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An Update on Anxiety Disorders

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1 An Update on Anxiety Disorders
in Primary Care, Part 1: Diagnosis, Presentation, & Evidence-Based Psychological Intervention C. Alec Pollard, Ph.D. Professor of Family & Community Medicine Saint Louis University Director, Anxiety Disorders Center Saint Louis Behavioral Medicine Institute

2 Most Prevalent Psychiatric Disorders in Medical Settings
Anxiety Disorders Depression Alcohol/Drug Abuse Somatoform Disorders Goldman, Wise, & Brody (1998)

3 Risks of Failure to Identify Anxiety Disorders in Primary Care:
Continued psychological deterioration Psychiatric comorbidity Family conflict/dysfunction Vulnerability to medical illness, mortality Costs to society

4 Anxiety Symptoms

5 Primary Symptoms of the Major Anxiety Disorders
1. Panic attacks 2. Fear/Avoidance a. of panic/symptom attacks b. of social situations/ performance c. of other, specific situations 4. Obsessions, compulsions 5. Worry 6. Flashbacks, nightmares, etc. DISORDER Panic Disorder 2. Phobia a. Agoraphobia b. Social Phobia c. Specific Phobia 4. Obsessive-Compulsive Disorder 5. Generalized Anxiety Disorder 6. Posttraumatic Stress Disorder

6 A Note on Mixed Anxiety & Depression
Subclinical levels of both disorders Combination = clinical syndrome More common in primary care

7 Other Signs of Anxiety Disorders

8 Physical Complaints/Conditions Associated with Specific Anxiety Disorders
COMPLAINT/CONDITION 1. Attacks of nerves, anxiety, etc. 2. concern: fainting, loss of bladder/bowel control, vomiting 3. blushing, trembling, sweating 4. difficulty urinating, bladder infection 5. chapped, red skin 6. actual fainting 7. hypertension 8. sleep difficulties 9. sexual problems 10. fatigue CONSIDER 1. Panic Disorder w/ Agor. 2. Agoraphobia w/o panic 3. Social Phobia 4. Social Phobia 5. OCD 6. Blood/Injec/Injur. Phobia 7. anxiety 8. anxiety, especially GAD 9. anxiety 10. anxiety

9 Management of Anxiety Disorders in Primary Care
Education about the disorder & treatment options Education about local (e.g., support groups, programs?) and national resources: - Anxiety Disorders Association of America (www.adaa.org) - International Obsessive-Compulsive Disorder Foundation (www.ocfoundation.org) - National Center for PTSD (www.ncptsd.va.gov) Crisis intervention when needed Provide treatment in-house or refer to specialty care

10 Evidence-Based Psychosocial Intervention for Anxiety Disorders
Cognitive Behavior Therapy - Education about treatment model - Cognitive therapy to address misappraisals of threat - Coping skills - Systematic exposure to feared situations - Family/environmental intervention (as needed) - Relapse prevention Future Directions - Drugs/behavioral procedures to enhance learning in CBT - Psychological interventions to address treatment ambivalence

11 Advantages & Disadvantages of CBT (vs medication)
- takes more effort/time - less accessible Advantages: - Fewer side effects - Superior long-term outcome

12 An Update on Anxiety Disorders in Primary Care, Part 2: Pharmacological Treatment
Eric Nolan, M.D. Adult Psychiatrist Chief Fellow Division of Child Psychiatry Washington University in St. Louis

13 A Common Presentation…
36yo female presents to her PCP’s office with the chief complaint of poor concentration and difficulty sleeping for the past several years Stay at home mother of a 4 year old boy and a 6 month old girl Husband works 60+ hours/week as a laborer when he is able, but work is hard to come by

14 A Common Presentation…
On further questioning, you find out that she feels overwhelmed frequently, and “worries about everything” She feels unable to manage the household because she feels “scatterbrained” and is always worried about “what’s going to happen next”

15 A Common Presentation…
When you probe further about her sleep, she says that once she falls asleep, she is “perfect” However, it can take up to 2-3 hours for her to do so She also feels fatigued “most of the day”

16 In the Office… You have identified what you believe to be anxiety
You note a moderate amount of impairment—enough to present to a PCP with these symptoms as the primary complaint You feel that this warrants treatment, but which type—psychotherapy, medication, or both?

17 Pharmacological Treatment
SSRI’s SNRI’s Mirtazapine, bupropion Benzodiazepines Buspirone TCA’s

18 Fluoxetine (Prozac) First of this group Most well-studied in adults
Starting dose of 20mg/day, max 60mg/day Common side effects: activation, +/- weight gain, sexual side effects FDA indications for OCD, Panic DO

19 Sertraline (Zoloft) Second SSRI to obtain approval
Starting dose 50mg/day, up to 200mg/day Common side effects: sedation, sexual side effects, LESS ACTIVATING than fluoxetine Indicated for treatment of PTSD, OCD, Panic DO, social phobia (social anxiety disorder)

20 Paroxetine (Paxil) Approved around the same time as sertraline
Starting dose of 20mg/day, max 60mg/day Most active serotonin inhibitorleast well-tolerated Common side effects: sedation, weight gain, sexual side effects, anti-cholinergic side effects Indicated for treatment of OCD, Panic DO, PTSD, social phobia (social anxiety DO), GAD

21 Citalopram (Celexa)/ Escitalopram (Lexapro)
Most recent additions to the SSRI’s Starting doses: Citalopram 20mg/day, max 60mg/day Escitalopram 10mg/day, max 30mg/day Very well-tolerated due to less potent activation of 5HT receptor Side effects are uncommon Indicated for treatment of GAD

22 Venlafaxine (Effexor XR)
First SNRI Starting dose mg/day, max 300mg daily Commonly used to treat co-morbid anxiety and depression Effective for anxiety at HIGHER doses (>150mg/day) Common side effects: dizziness, diaphoresis, headache, monitor for elevations in BP Indicated for treatment of MDD

23 Duloxetine (Cymbalta)
Newest SNRI Starting dose 30mg/day, max 120mg/day Commonly used to treat anxiety associated with pain syndromes Common side effects: diaphoresis, headaches, insomnia (usually dose-related) Indicated for treatment of GAD, fibromyalgia, chronic musculoskeletal pain

24 Mirtazapine (Remeron)/ Bupropion (Wellbutrin)
Not indicated for treatment of anxiety disorders Some retrospective data suggests there may be some utility for bupropion in anxiety disorders, but the data is not sufficient at this time to warrant use as primary pharmcotherapeutic agent

25 Benzodiazepines Act at the GABA-A receptor (same as alcohol)
Very effective in the treatment of anxiety HOWEVER: must be very judicious in their use Different benzodiazepines carry different sets of risk Long-acting benzodiazepines: Clonazepam (Klonopin), diazepam (Valium) Short-acting benzodiazepines: Lorazepam (Ativan), alprazolam (Xanax)

26 Benzodiazepines Consider severity of symptoms in deciding whether or not to start a benzodiazepine Benzodiazepines should NEVER be used as monotherapy for treatment of an anxiety disorder May start at low-dose concurrently with an SSRI, with the goal that as SSRI becomes effective over 4-6 weeks, benzodiazepine may be decreased/discontinued

27 Buspirone (Buspar) 5HT-1A receptor partial agonist Mild anxiolytic
Often used with SSRI’s for treatment of mild anxiety Efficacy is debated Starting dose is 15mg/day, max 60mg/day No potential for abuse/dependence No common side effects Indicated in treatment of GAD

28 Children and Elderly: Other Considerations
These medications are generally considered safe in children and the elderly However, there is less data to support their use BLACK BOX WARNING for SSRIs/SNRIs in children and adolescents General rule: “start low, go slow” More susceptible to side effects

29 Conclusions Many AD sufferers still do not receive evidence-based treatment. Most who do receive evidence-based treatment obtain significant improvement in symptom relief and functioning. Both drug and cognitive behavioral therapies are effective, but each has limitations and strengths. Combined approach is superior for some patients, especially the more severe. CBT improves long-term outcome and can reduce relapse if initiated during drug discontinuation.

30 Related Readings American Psychiatric Association. (1995). Diagnostic and Statistical Manual of Mental Disorders IV: Primary Care Version. Washington DC: APA Press. Kroenke et al. (2007). Anxiety disorders in primary care: Prevalence, impairment, comorbidity, & detection. Annals of Internal Medicine, 146, 317. Stein. M. B. (2003). Attending to anxiety disorders in primary care. Journal of Clinical Psychiatry, 64 (suppl 15), 35. Sullivan et al. (2007). Design of the coordinated anxiety learning and management (CALM) study: Innovations in collaborative care for anxiety disorders. General Hospital Psychiatry, 29, 379. ZoberiK., & Pollard, C.A. (2010). Treating anxiety without SSRIs. Journal of Family Practice, 59, 313.

31 Contact Information Address 1129 Macklind Ave St. Louis, MO 63110 Phone: , Ext. 424 Fax: Website:


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