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ECPSLLC.COM O (843) 856 6998 F (843) 856 6997. Anxiety Spectrum Updates 2012 Ricardo J. Fermo, MD Medical Director East Cooper Psychiatric Solutions,

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1 ECPSLLC.COM O (843) F (843)

2 Anxiety Spectrum Updates 2012 Ricardo J. Fermo, MD Medical Director East Cooper Psychiatric Solutions, LLC 1073 B. Johnnie Dodds Blvd. Mount Pleasant, South Carolina Diplomate of the American Board of Psychiatry and Neurology Diplomate of American Board of Child and Adolescent Psychiatry

3 FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST Abbott Laboratories AstraZeneca Bristol Myer-Squibb Cephalon Eli Lilly & Co. Forest Laboratories, Inc. GalaxoSmithKline Janssen Research Jazz Pharmaceuticals Mallinckrodt Merck Novartis Palmlabs Pfizer, Inc. Sanofi Aventis Sepacor Inc. Shire Pharmaceuticals Somaxon Pharmaceuticals Sunovion Pharmaceuticals Inc. Takeda UCB Pharma Inc. Wyeth Pharmaceuticals ECPSLLC.COM

4 Learning Objectives Review updates on the epidemiology of Anxiety Provide a summary of the disease state (s) Discuss diagnostic criteria for various anxiety disorders Treatment/Goals – Discuss evidence-based approaches for treatment-Anxiety ECPSLLC.COM




8 Stress and anxiety are the same thing. True False

9 The causes of stress are essentially the same for everyone. True False

10 Anxiety is the most common mental illness in the US: – True – False

11 Men are twice as likely to have Generalized Anxiety then Woman? » True » False

12 What percentage of people with mental illnesses improve if they receive treatment? 25% to 45% 50% to 70% 70% to 90%

13 Anxiety as a Normal and an Abnormal Response Some amount of anxiety is “ normal ” and is associated with optimal levels of functioning. Only when anxiety begins to interfere with social or occupational functioning is it considered “ abnormal. ”

14 ANXIETY DISORDERS Anxiety is a normal reaction to stress and can actually be beneficial in some situations. Fear and anxiety are part of life anxiety can become excessive, and while the person suffering may realize it is excessive they may also have difficulty controlling it and it may negatively affect their day-to-day living. Most common of emotional disorders Affects more than 40 million Americans The most prevalent psychiatric disorders

15 The Fear and Anxiety Response Patterns Fear Panic Anxiety Anxiety Disorder

16 Definition of Anxiety Anxiety is a feeling of apprehension or fear. The source of this uneasiness is not always known or recognized, which can add to the distress you feel. Anxiety disorders are a group of psychiatric conditions that involve excessive anxiety.

17 Anxiety Facts Most common mental illness in the U.S. with 18 million of the adult (ages 18-54) U.S. population affected. Anxiety disorders cost more than $42 billion a year. More than $22 billion are associated with the repeated use of healthcare services, as those with anxiety disorders seek relief for symptoms that mimic physical illnesses. Anxiety is highly treatable (up to 90% of cases), but only one-third of those who suffer from it receive treatment People with an anxiety disorder are three-to-five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than non-sufferers. Depression often accompanies anxiety disorders 2003 Anxiety Disorders Association of America

18 Anxiety Facts Anxiety disorders are the most common mental illness in the U.S., affecting 40 million adults in the United States age 18 and older (18% of U.S. population). Anxiety disorders are highly treatable, yet only about one- third of those suffering receive treatment. Anxiety disorders cost the U.S. more than $42 billion a year, almost one-third of the country's $148 billion total mental health bill, according to "The Economic Burden of Anxiety Disorders," a study commissioned by ADAA (The Journal of Clinical Psychiatry, 60(7), July 1999). More than $22.84 billion of those costs are associated with the repeated use of health care services; people with anxiety disorders seek relief for symptoms that mimic physical illnesses.

19 Anxiety disorders in the U.S. cost more than $42 billion each year. 1/3 of the total amount spent on mental health care

20 Anxiety Disorders One-quarter of the U.S. population experiences pathologic anxiety in their lifetime People with an anxiety disorder are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than those who do not suffer from anxiety disorders. Anxiety disorders develop from a complex set of risk factors, including genetics, brain chemistry, personality, and life events. Anxiety and Depression It's not uncommon for someone with an anxiety disorder to also suffer from depression or vice versa. Nearly 70 % of those diagnosed with depression are also diagnosed with an anxiety disorder. Presenting problem for 11% of patients visiting primary care physicians 90% of patients with anxiety present with somatic complaints

21 Anxiety Nervousness and fear are common human emotions. Adaptive at lower levels; disabling at high levels. Physicians must recognize the difference between pathological anxiety and anxiety as a normal or adaptive response.

22 Definition of Anxiety Diffuse, unpleasant, vague sense of apprehension Often accompanied by autonomic symptoms such as headache, perspiration, heart palpitations, chest tightness, stomach discomfort and restlessness Presentation depends on perception of stress, personal resources, psychological defenses, and coping mechanisms

23 Pathological Anxiety Anxiety that is excessive, persistent, easily triggered. Degree of the person’s fear is out-of-proportion to actual danger. Disrupts the person’s life and functioning. Creates intense discomfort. Doesn’t respond to rational reassurance. in pathological anxiety, attention is focused also on the person's response to the threat.

24 Features of Pathologic Anxiety Autonomy: no or minimal environmental trigger Intensity: exceeds patient ’ s capacity to bear the discomfort Duration: symptoms are persistent Behavior: anxiety impairs coping and results in disabling behaviors

25 Etiology Neurophysiology – Central noradrenergic systems– in particular, the locus coeruleus is the major source of adrenergic innervation – GABA neurons from the limbic system – Serotoninergic systems and neuropeptides Cognitive-Behavioral Formulations Developmental (Psychodynamic) Formulations

26 Common Medical Conditions Associated with Anxiety Disorders Endocrine: thyroid dysfunction, hyper adrenalism Drug Intoxication: caffeine, cocaine Drug Withdrawal: alcohol, narcotics Hypoxia: CHF, angina, anemia, COPD Metabolic: acidosis, hyperthermia Neurological: seizures, vestibular dysfxn




30 Lifetime Prevalence of Common Psychiatric Disorders Kessler RC, et al. Arch Gen Psychiatry. 1994;51(1): Kessler RC, et al. Arch Gen Psychiatry. 1995;52(12): DSM-IV-TR *In menstruating women % 14.1% 13.3% 7.8% 5.1% 3.5% 2.5% Major depressive disorder 1 Social anxiety disorder 1 Posttraumatic stress disorder (PTSD) 2 Generalized anxiety disorder (GAD) 1 Panic disorder 1 Obsessive-compulsive disorder (OCD) 3 Alcohol dependence 1 Prevalence (%) Prevalence 29 of 45

31 40 million American adults age 18 years and older (about 18%)

32 Generalized Anxiety Disorder Obsessive-Compulsive Disorder (OCD) Panic Disorder Post-Traumatic Stress Disorder (PTSD) Social Phobia (or Social Anxiety Disorder) Specific Phobia Each anxiety disorder has different symptoms, but all the symptoms cluster around excessive, irrational fear and dread.

33 Explaining anxiety disorders Learning perspective Biological perspective

34 Learning perspective Fear conditioning – One bad event can lead to classical conditioning of fear Stimulus generalization – Fear may broaden: fear of heights  fear of airplanes

35 Learning perspective Reinforcement can help maintain fears. – Avoiding or escaping the feared situation reduces anxiety, so the avoiding or escaping behavior is reinforced

36 Learning perspective Observational learning – We learn our fears by watching and listening to others

37 Biological perspective We are biologically prepared to fear threats faced by ancestors – Spiders – Snakes – Darkness

38 Biological perspective Genes – Some people seem genetically predisposed to particular fears and high anxiety

39 Biological perspective 35 year old identical twins who independently developed claustrophobia and fear of water

40 Biological perspective Physiology – Brain scans of people with OCD  unusually high activity in certain parts of the frontal lobes

41 Physiology – Generalized anxiety, panic attacks, and OCD are linked with overarousal in brain areas linked with impulse control and habitual behaviors – People cannot “ turn off ” these thoughts.

42 Physical Reaction to Anxiety Auditory and Visual Stimuli: sights and sounds are processed first by the thalamus, which filters the incoming cues and shunts them either directly to the amygdala or to the other parts of the cortex. Olfactory and tactile stimuli: Smells and touch sensations Bypass the thalamus altogether, Taking a shortcut directly to the Amygdala. Smells, therefore, Often evoke stronger memories Or feelings than do sights or Sounds.

43 Physical Reaction to Anxiety Thalamus: The hub for sights and sounds, The thalamus breaks down Incoming visual ques by size, Shape and color, and auditory Cues, by volume and Dissonance, and then signals The appropriate part of the Cortex. Cortex: It gives raw sights and sounds meanings, enabling the brain to become conscious of what it Is seeing or hearing. One region, the prefrontal cortex, may be vital to turning off the anxiety response once a threat has passed.

44 Physical Reaction to Anxiety Amygdala: emotional core of the brain, the amygdala has the primary role of triggering the fear response. information that passes through the amygdala is tagged with emotional significance. Bed Nucleus of Stria Terminalis: unlike the Amygdala, which sets off an immediate burst of fear, the BNST perpetuates the fear response, causing the longer term unease typical of anxiety.

45 Physical Reaction to Anxiety Locus Ceruleus: It receives signals from the amygdala and is responsible for initiating many of the classic anxiety responses: rapid heartbeat, increased blood pressure, sweating and pupil dilation. Hippocampus: This is the memory center, vital to storing the raw information coming in from the senses along with the emotional baggage attached to the data during their trip through the amygdala.

46 Generalized Anxiety Disorder: Biological Causal Factors Genetic factors A functional deficiency of GABA Neurobiological differences between anxiety and panic

47 Relationship Between Arousal (anxiety) and Performance Yerkes-Dodson Law

48 Three Components of Anxiety Physical Psychological (Cognition and emotion) Behaviours

49 The Physical Component  Trembling, twitching,Shaking  Dizziness  Numbness/Tingling  Backache, headache  Muscle tension  Shortness of breath, hyperventilation  Fatigability  Startle response  Difficulty swallowing  Autonomic hyperactivity:  Flushing and pallor  Tachycardia, palpitation  Sweating  Cold hands  Diarrhea  Dry mouth (xerostomia)  Urinary frequency  Blurred Vision


51 The Psychological Component  Anxious Thoughts  Anxious Predictions  Anxious Beliefs and Interpretations  Difficulty in Attention and Memory  Mental Images  Unreality/Detachment  Hypervigilance  Insomnia  Decreased libido  Lump in the throat

52 The Behavioural Component  Avoidance of Situations and Activities  Subtle Avoidance Strategies, Safety Signals, and Overprotective Behaviours  Alcohol, Drug, and Medication Use

53 1. Generalized Anxiety Disorder (GAD) 2. Panic Disorder (PD) with Agoraphobia (AG) 3. PD without Agoraphobia 4. Specific Phobia (SP) 5. Social Phobia (SoP) 6. Obsessive Compulsive Disorder (OCD) 7. Post traumatic Stress Disorder (PTSD) 8. Acute Stress Disorder (ASD) 9. Substance-Induced Anxiety disorder (SIAD) 10. Anxiety disorder due some medical illness Anxiety Disorders - DSM-IV Dual Diagnosis Disorders

54 Anxiety disorders Continuous anxietyEpisodic anxiety In defined situation Mixed patternIn any situation Panic disorder with agoraphobia Panic disorder Phobic anxiety disorder Simple phobia Social phobia Agoraphobia Generalized anxiety disorder

55 Epidemiology Overall, anxiety disorders are among the most prevalent of psychiatric disorders. Age; Earlier onset than depression Sex factor; More in females Frequency (Prevalence): 18 %of general population 28% (life time prevalence) Strong genetic component

56 Shared features of anxiety disorders Substantial proportion of aetiology is stress related. Difference with Psychosis - free of delusions and hallucinations, good insight - Reality testing is intact. Symptoms are ego dystonic (distressing) Disorders are enduring or recurrent. Demonstrable organic factors are absent Note: Hierarchy of Diagnosis Precedence: Psychosis >Depression >Anxiety

57 Risk Factors/Etiology  Psychodynamic theory posits that anxiety occurs when instinctual drives arc thwarted (dissatisfied).  Behavioral theory states that anxiety is a conditioned response to environmental stimuli originally paired with a feared situation.  Cognitive approach: Selective attention and catastrophic thinking  Biologic theories implicate various neurotransmitters (especially: gamma-aminobutyric acid [GABA], norepinephrine, and serotonin) and various CNS structures (especially reticular activating system and limbic system).  Other theories: Social and personality factors.

58 The Psychodynamic Approach to Anxiety Anxiety is a signal that the ego is having a hard time mediating between reality, id and superego. Different anxiety disorders are the result of different defense mechanisms used to cope. – Phobia - displacement – OCD - reaction formation, undoing – PTSD - denial, repression Attachment Theories : Bowlby – disturbances in parent-child bond leads to “anxious attachment” and a vulnerability to anxiety disorders later in life.

59 The Behavioural Approach to Anxiety (learning theory)  Behavioral theories:- anxiety is a conditional response to specific environmental stimuli followed by its generalization, displacement, or transference.  It may be learned through identification and imitation of anxiety pattern in parents (social learning theory).  Mowrer (1948) Avoidance learning (learned behaviour) 1) classical (respondent) conditioning 2) negative reinforcement

60 The Cognitive Approach to Anxiety Individuals misperceive and misinterpret internal and external stimuli.  Selective attention and catastrophic thinking  Cognitive Appraisal (perceive threat)  Stimulus--->Appraisal---> Response  evaluation of stimulus based on memories, beliefs, and expectations.. Albert Ellis identified basic irrational assumptions: It is necessary for humans to be loved by everyone It is catastrophic when things are not as one wants them to be If something is dangerous, a person should be terribly concerned and dwell on the possibility that it will occur One should be competent in all domains to be a worthwhile person The idea is, when these assumptions are applied to everyday life, GAD may develop. Aaron Beck :Those with GAD hold unrealistic silent assumptions that imply imminent danger: Any strange situation is dangerous A situation/person is unsafe until proven safe

61 The Biological Approach to Anxiety  Genetic Component  family and twin studies suggest a genetic component in most anxiety disorders  panic disorder shows the strongest genetic component and generalized anxiety disorder the least.  Neurotransmitter abnormalities - the release of catecholamine (NA, DA) is increased. - decrease level of GABA (GABA inhibit CNS irritability). - serotonin decrease causes anxiety; increased dopaminergic activity is associated with anxiety.  Activity in the temporal cerebral cortex is increased.  The locus ceruleus, a brain center of noradrengic neurons, is hyperactive in anxiety disorders, especially panic attacks.  Elevated responsiveness in the amygdala, part of the fear circuit of the limbic system.  HPA axis dysregulation  Serotonin and basal ganglia abnormalities in OCD  Hormonal theory of PTSD

62 Other theories: Social factors – Early life adversity – Stressful events especially those involving threat – Lack of support network Personality factors – Some personality traits predispose to certain anxiety disorders – avoidant, perfectionist

63 Anxiety Disorders 24.9% (lifetime prevalence) Major Depressive Disorder 16.2% (lifetime prevalence) Up to 60% Overlap The lifetime prevalence of depression is 60% in patients with social anxiety disorder Depression-Anxiety Comorbidity Brown TA, et al. J Abnorm Psychol 2001;36: Kessler RC, et al. JAMA 2003;289: Kessler RC, et al. Arch Gen Psychiatry 1994;51:8-19. The lifetime prevalence of depression is 57% in patients with panic disorder

64 1. Wittchen HU, et al. Arch Gen Psychiatry. 1994;51: Magee WJ, et al. Arch Gen Psychiatry. 1996;53: DSM-IV-TR™. Washington, DC: American Psychiatric Association; MDDGAD Anhedonia Depressed mood Suicidal ideation Feelings of worthlessness Appetite disturbance Fear/avoidance of social situations Blushing Trembling/shaking SAD Low self- esteem Agitation Irritability Sleep disturbance Fatigue Pain Worry Anxiety Muscle tension Dry mouth Difficulty concentrating GI complaints Interpersonal sensitivity Palpitations Sweating Depression and Anxiety Disorders Commonly Occur Together 62%* (GAD + MDD 1 ) 37%* (SAD + MDD 2 ) *Lifetime prevalence of MDD among individuals with lifetime diagnoses of each anxiety disorder.

65 Screening and Diagnosis Measurement-Based Care Screening – GAD-7, LSAS, PTSD, YBOC – Detect depression (PHQ-9, QIDS, CUDOS, Zung) – Rule out bipolarity (MDQ, WHO CIDI 3.0) Diagnosis – DSM-IV overview – Comorbidity Suicide Assessment Symptom Tracking – HAM-A (physician) – CGI-A

66 Generalized Anxiety Disorder (GAD) GAD affects 6.8 million adults, or 3.1% of the U.S. population. Women are twice as likely to be affected as men. Obsessive-Compulsive Disorder (OCD) 2.2 million, 1.0% Equally common among men and women. The median age of onset is 19, with 25 percent of cases occurring by age 14. One-third of affected adults first experienced symptoms in childhood. Generalized Anxiety Disorder (GAD) GAD affects 6.8 million adults, or 3.1% of the U.S. population. Women are twice as likely to be affected as men. Obsessive-Compulsive Disorder (OCD) 2.2 million, 1.0% Equally common among men and women. The median age of onset is 19, with 25 percent of cases occurring by age 14. One-third of affected adults first experienced symptoms in childhood. Hoarding is the compulsive purchasing, acquiring, searching, and saving of items that have little or no value. Panic Disorder 6 million, 2.7% Women are twice as likely to be affected as men. Very high comorbidity rate with major depression. Posttraumatic Stress Disorder (PTSD) 7.7 million, 3.5% Women are more likely to be affected than men. Rape is the most likely trigger of PTSD: 65% of men and 45.9% of women who are raped will develop the disorder. Childhood sexual abuse is a strong predictor of lifetime likelihood for developing PTSD. Social Anxiety Disorder 15 million, 6.8% Equally common among men and women, typically beginning around age 13. According to a 2007 ADAA survey, 36% of people with social anxiety disorder report experiencing symptoms for 10 or more years before seeking help. Specific Phobias 19 million, 8.7% Women are twice as likely to be affected as men. Panic Disorder 6 million, 2.7% Women are twice as likely to be affected as men. Very high comorbidity rate with major depression. Posttraumatic Stress Disorder (PTSD) 7.7 million, 3.5% Women are more likely to be affected than men. Rape is the most likely trigger of PTSD: 65% of men and 45.9% of women who are raped will develop the disorder. Childhood sexual abuse is a strong predictor of lifetime likelihood for developing PTSD. Social Anxiety Disorder 15 million, 6.8% Equally common among men and women, typically beginning around age 13. According to a 2007 ADAA survey, 36% of people with social anxiety disorder report experiencing symptoms for 10 or more years before seeking help. Specific Phobias 19 million, 8.7% Women are twice as likely to be affected as men. Related Illnesses Many people with an anxiety disorder also have a co-occurring disorder or physical illness, which can make their symptoms worse and recovery more difficult. It’s essential to be treated for both disorders. Related Illnesses Many people with an anxiety disorder also have a co-occurring disorder or physical illness, which can make their symptoms worse and recovery more difficult. It’s essential to be treated for both disorders.

67 generalized anxiety disorder (GAD)

68 Generalized Anxiety Disorder Excessive uncontrollable worry about everyday things. This constant worry affects daily functioning and can cause physical symptoms. GAD can occur with other anxiety disorders, depressive disorders, or substance abuse.

69 Generalized Anxiety Disorder The focus of GAD worry can shift, usually focusing on issues like job, finances, health of both self and family; but it can also include more mundane issues such as, chores, car repairs and being late for appointments. The intensity, duration and frequency of the worry are disproportionate to the issue

70 Generalized Anxiety Disorder Characterized by at least 6 months of persistent and excessive anxiety and worry


72 GAD Epidemiology 5% prevalence in community samples 2:1 female/male ratio Age of onset is frequently in childhood or adolescence Chronic but fluctuating course of illness (worsened during stressful periods)

73 Generalized Anxiety Disorder (GAD) Patients with GAD suffer from severe worry or anxiety that is out of proportion to situational factors. Must last most days for at least 6 months Described as “ worriers ” or “ nervous ”

74 GAD Symptoms include: – Muscle tension – Restlessness – Insomnia – Difficulty concentrating – Easy fatigability – Irritability – Persistent anxiety (rather than discrete panic attacks)

75 GAD Diagnostic Criteria Excessive anxiety and worry that occurs more days than not for 6 months Difficult to control the worry 3 out of 6 symptoms Anxiety caused significant distress or impairment in function Not attributed to another organic cause

76 GAD Treatment Cognitive Behavioral Therapy Other Psychotherapies Pharmacotherapy – Antidepressants – Benzodiazepines – Buspirone

77 Common Causes There is no one cause for anxiety disorders. Several factors can play a role – Genetics – Brain biochemistry – Overactive "fight or flight" response Can be caused by too much stress – Life circumstances – Personality People who have low self-esteem and poor coping skills may be more prone Certain drugs, both recreational and medicinal, can lead to symptoms of anxiety due to either side effects or withdrawal from the drug. In very rare cases, a tumor of the adrenal gland (pheochromocytoma) may be the cause of anxiety.

78 Symptoms of Anxiety Anxiety is an emotion often accompanied by various physical symptoms, including: Twitching or trembling Muscle tension Headaches Sweating Dry mouth Difficulty swallowing Abdominal pain (may be the only symptom of stress especially in a child)

79 Additional Symptoms of Anxiety Sometimes other symptoms accompany anxiety: Dizziness Rapid or irregular heart rate Rapid breathing Diarrhea or frequent need to urinate Fatigue Irritability, including loss of your temper Sleeping difficulties and nightmares Decreased concentration Sexual problems

80 Generalized anxiety disorder Person is continually tense, apprehensive, and in a state of CNS arousal.

81 Generalized anxiety disorder Tense and jittery Worried bad things will happen Muscular tension Agitation Sleeplessness

82 Generalized anxiety disorder Person cannot identify the cause of the anxiety, and therefore can ’ t avoid or deal “ Free floating anxiety ”

83 Generalized anxiety disorder Worry about things that are not too likely to happen Worry more intensely

84 Generalized Anxiety Disorder Generalized anxiety disorder (GAD) is characterized by unrealistic or excessive worry (generalized free-floating persistent anxiety) about every day events/problems with symptoms of muscle and psychic tension, causing significant distress/functional impairment.

85 What is Gen. Anxiety Disorder ?  Anxiety Disorders are characterized by persistent fear and anxiety that occurs too often, is too severe, is triggered too easily or lasts too long.  Compared with others with anxiety disorders, persons with GAD have a better ability to maintain normal work and social relationships in spite of their distress.  The “What if?” disorder

86 DSM-IV Diagnostic Criteria for Generalized Anxiety Disorder A. Excessive anxiety or worry is present most days during at least a six-month period and involves a number of life events. B. The anxiety is difficult to control. C. At least three of the following: 1. Restlessness or feeling on edge. 2. Easy fatigability. 3. Difficulty concentrating. 4. Irritability. 5. Muscle tension. 6. Sleep disturbance. D. The focus of anxiety is not anticipatory anxiety about having a panic attack, as in panic disorder. E. The anxiety or physical symptoms cause significant distress or impairment in functioning. F. Symptoms are not caused by substance use or a medical condition, and symptoms are not related to a mood or psychotic disorder.

87 Diagnostic criteria of GAD- SUMMARY Excessive Worry About Work Family and Children Health Finances Minor Matters Worry occurs most days (for at least 6 months) Difficult to control worry Associated with disturbed sleep, irritability, restlessness, poor concentration, fatigue, muscle tension

88 Clinical Features of Generalized Anxiety Disorder A. Other features often include insomnia, irritability, trembling, muscle aches and soreness, muscle twitches, sweaty hands, dry mouth, and a heightened startle reflex. Patients may also report palpitations, dizziness, difficulty breathing, urinary frequency, dysphagia, light-headedness, abdominal pain, and diarrhea. B. Patients often complain that they “can't stop worrying,” which may revolve around valid concerns about money, jobs, marriage, health, and the safety of children. C. Chronic worry is a prominent feature of generalized anxiety disorder, unlike the intermittent terror that characterizes panic disorder.

89 D. Mood disorders, substance- and stress-related disorders (headaches, dyspepsia) commonly coexist with GAD. Up to one-fourth of GAD patients develop panic disorder. Excessive worry and somatic symptoms, including autonomic hyperactivity and hypervigilance, occur most days. E. About 30-50% of patients with anxiety disorders will also meet criteria for major depressive disorder. Drugs and alcohol may cause anxiety or may be an attempt at self-treatment. Substance abuse may be a complication of GAD.

90 Differential Diagnosis of Generalized Anxiety Disorder A.Substance-Induced Anxiety Disorder: Substances such as caffeine, amphetamines, or cocaine can cause anxiety symptoms. Alcohol or benzodiazepine withdrawal can mimic symptoms of GAD. These disorders should be excluded by history and toxicology screen. B. Panic Disorder, Obsessive-Compulsive Disorder, Social Phobia, Hypochondriasis and Anorexia Nervosa 1. Many psychiatric disorders present with marked anxiety, and the diagnosis of GAD should be made only if the anxiety is unrelated to the other disorders. 2. For example, GAD should not be diagnosed in panic disorder if the patient has excessive anxiety about having a panic attack, or if an anorexic patient has anxiety about weight gain.

91 C. Anxiety Disorder Due to a General Medical Condition. Hyperthyroidism, cardiac arrhythmias, pulmonary embolism, congestive heart failure, and hypoglycemia, may produce significant anxiety and should be ruled out as clinically indicated. D. Mood and Psychotic Disorders 1. Excessive worry and anxiety occurs in many mood and psychotic disorders. 2. If anxiety occurs only during the course of the mood or psychotic disorder, then GAD cannot be diagnosed.

92 Course and prognosis Course is chronic; symptoms may diminish as the patient get older. With time, secondary depression may develop. This is not uncommon if the condition is left untreated.

93 Treatment of Generalized Anxiety Disorder The combination of pharmacologic therapy and psychotherapy is the most successful form of treatment.

94 I. Pharmacotherapy of Generalized Anxiety Disorder:, Fluoxetine

95 A.Antidepressants 1. SSRIs and Venlafaxine a. The onset of action of antidepressants is much slower than the benzodiazepines, but they have no addictive potential and may be more effective. An antidepressant is the agent of choice when depression coexists with anxiety. b. The side-effect profile for GAD patients is similar to that seen with depressive disorders. 2. Tricyclic antidepressants are also effective in treating GAD, but adverse effects limit their use.

96 Treatment Options Antidepressant Medications – Selective Serotonin Reuptake Inhibitors (SSRI) – Serotonin and Norepinephrine Reuptake Inhibitors (SNRI) – Norepinephrine-dopamine Reuptake Inhibitors – Mixed Selective Serotonin Reuptake Inhibitors and Receptor Blockers – Tricyclic Antidepressants (TCA) – Monoamine Oxidase Inhibitors (MAOI) Nonpharmacological Therapy – Psychotherapy  Cognitive Behavioral Therapy (CBT)  Interpersonal Therapy (IPT)  Biofeedback?  Exposure Response Treatment  Trauma Focused CBT  DBT

97 Alternative Treatments Acupuncture Aromatherapy Breathing Exercises Exercise Meditation Nutrition and Diet Therapy Vitamins Self Love

98 Factors to Consider in Choosing an Medications for Anxiety Patient preference Nature of prior response to medication Relative efficacy and effectiveness Safety, tolerability, and anticipated side effects Co-occurring psychiatric or general medical conditions Potential drug interactions Half-life Cost

99 B. Buspirone a. Buspirone is an effective treatment for GAD. It lacks sedative effects. Tolerance to the beneficial effects of buspirone does not seem to develop. There is no physiologic dependence or withdrawal syndrome.

100 C. Benzodiazepines 1. Benzodiazepines can almost always relieve anxiety if given in adequate doses, and they have no delayed onset of action. 2. Benzodiazepines have few side effects other than sedation. Tolerance to their sedative effects develops but not to their antianxiety properties. 3. Drug dependency becomes a clinical issue if the benzodiazepine is used regularly for more than 2-3 weeks. A withdrawal syndrome occurs in 70% of patients, characterized by intense anxiety, tremulousness, dysphoria, sleep and perceptual disturbances and appetite suppression. 4. Slow tapering of benzodiazepines is crucial (especially those with short half-lives).

101 Comparison of Benzodiazepines BZNSedationAnxiolyticHalf lifeLipid soluDose Diazepam hHigh5 mg od Alprazolam hLow0.5 mg qid Clonazapam hLow0.5 mg bid Lorazepam hMed1 mg tid Chlordiazepx hMed15 mg bid

102 II. Non-Drug Approaches to Anxiety 1. Patients should stop drinking coffee and other caffeinated beverages, and avoid excessive alcohol consumption. 2. Patients should get adequate sleep, with the use of medication if necessary. Moderate exercise each day may help reduce the intensity of anxiety symptoms. 3. Psychotherapy a. Cognitive behavioral therapy, with emphasis on relaxation techniques and instruction on misinterpretation of physiologic symptoms, may improve functioning in mild cases. b. Supportive or insight oriented psychotherapy can be helpful in mild cases of anxiety.

103 GOOD SLEEP HYGENE No sleeping during the day (If you have to no longer than 30 mins) Don’t lay in bed if not sleepy Get out of bed if unable to sleep No milk during the evening No caffeine No Nicotine No Alcohol Warm baths, no showers No exercising before going to bed but exercise in the morning Sleep at the same time every night Wake up at the same time every morning Make sure bed and pillow is comfortable, primarily for sleep with appropriate room temp (Cool about 60 degrees), noise free (some sleep better with white noise). Remember Cool, dark and quiet) Jot down all of your concerns and worries Avoid “Over the counter” sleep aides Don’t over sleep Set your body clock (wake up to light) Develop a bedtime routine No TV in bed ECPSLLC.COM

104 Other Psychological managements:  Education about nature of disorder  Progressive muscle relaxation  Structured problem solving  Graded exposure to difficult situations  Support (guidance, advice, development of coping strategies)  Counselling  Stress management (relaxation, meditation, exercise regimens that improve stress recovery)

105 Combination Maximize benefit by affecting multiple neurotransmitters Could increase adherence and lower drop-out rates Could target side effects of first agent (eg, insomnia, fatigue, sexual dysfunction) Papakostas G. J Clin Psychiatry. 2009;70(S6):16-25.


107 social anxiety disorder

108 Social Anxiety Disorder 15 million, 6.8% Equally common among men and women, typically beginning around age 13. (According to a 2007 ADAA survey, 36% of people with social anxiety disorder report experiencing symptoms for 10 or more years before seeking help. Comorbity exisits


110 Social Phobia General characteristics Fear of being in social situations in which one will be embarrassed or humiliated

111 Social Phobia Interaction of psychosocial and biological causal factors – Social phobias as learned behavior – Social fears and phobias in an evolutionary context – Preparedness and social phobia

112 Social Phobia Interaction of psychosocial and biological causal factors – Genetic and temperamental factors – Perceptions of uncontrollability – Cognitive variables

113 Social phobias Shyness to the extreme Persistent, irrational fear linked to presence of others Fear of being scrutinized or negatively evaluated by others

114 Social phobias Person with social phobia may avoid – Speaking – Eating out – Going to parties – Anything in the presence of others

115 CONCERN Very Under diagnosed and Therefore undertreated. Can cause severe impairment in social, occupational and academic functioning Can Lead to Avoidant Behavior

116 . DIAGNOSIS Fear or avoidance of social or performance situations Situations avoided, or endured with anxiety or distress Patients recognize symptoms as excessive or unreasonable Very distressing or disabling

117 Feared/Avoided Situations Public speaking/performing Eating, drinking, writing, working while being observed by others Social events Dating Meeting new people Being center of attention Using public bathroom

118 Common Somatic Complaints Blushing Sweating Trembling Palpitations Stuttering Shaking

119 Transient Low interference Low avoidance Chronic High interference High avoidance Avoidant personality disorder Shyness Generalized SAD Spectrum of Social Discomfort Nongeneralized SAD

120 Treatment Goals Eliminate anxiety/phobic avoidance Eliminate functional disability Treat associated comorbidities Choose therapy that is tolerable for the long term

121 Social Phobia: Treatment Antidepressants, SSRI ’ s and MAOI ’ s High potency benzodiazepines Low doses of beta blockers are helpful for public speaking (if only an occasional event); this alleviates the autonomic symptoms Psychotherapy-cognitive restructuring

122 Treatment Medication Management Psychotherapy Combined Medication Management and Psychotherapy Practice Practice Practice!

123 Social Effects of Anxiety Depression – Not as involved with family and friends the way you used to be – Lowered quality of relationships – Low energy – Lack of motivation to do the things you once looked forward to doing Unable to convey the person that you are Fear and avoidance of situations where previous attacks occurred

124 r/liebowitz/ r/liebowitz/

125 Social Phobia/Anxiety Social anxiety disorder, also known as social phobia, is an intense fear of social situations. This fear arises when the individual believes that they may be judged, scrutinized or humiliated by others. Individuals with the disorder are acutely aware of the physical signs of their anxiety and fear that others will notice, judge them, and think poorly of them. In extreme cases this intense uneasiness can progress into a full blown panic attack.

126 Social Phobia/Anxiety Common anxiety provoking social situations include: – public speaking – talking with people in authority – dating and developing close relationships – making a phone call or answering the phone – interviewing – attending and participating in class – speaking with strangers – meeting new people – eating, drinking, or writing in public – using public bathrooms – driving – shopping

127 Specific Disorder Facts Generalized Anxiety Disorder – Women are twice as likely to be afflicted than men. – Very likely to exist along with other disorders. Obsessive Compulsive Disorder – It is equally common among men and women. – One third of afflicted adults had their first symptoms in childhood. Panic Disorder – Women are twice as likely to be afflicted than men. – Occurs with major depression in very high rates Anxiety Disorders Association of America

128 Obsessive-Compulsive Disorder

129 Obsessive-Compulsive Disorder (OCD) 2.2 million, 1.0% Equally common among men and women. The median age of onset is 19, with 25 percent of cases occurring by age 14. One-third of affected adults first experienced symptoms in childhood. Obsessive-Compulsive Disorder (OCD) 2.2 million, 1.0% Equally common among men and women. The median age of onset is 19, with 25 percent of cases occurring by age 14. One-third of affected adults first experienced symptoms in childhood. Hoarding is the compulsive purchasing, acquiring, searching, and saving of items that have little or no value. Hoarding is the compulsive purchasing, acquiring, searching, and saving of items that have little or no value.

130 Obsessive-Compulsive Disorder Characterized by uncontrollable obsessions and compulsions which the sufferer usually recognizes as being excessive or unreasonable. Obsessions are recurring thoughts or impulses that are intrusive or inappropriate and cause the sufferer anxiety: – Thoughts about contamination, for example, when an individual fears coming into contact with dirt, germs or "unclean" objects; – Persistent doubts, for example, whether or not one has turned off the iron or stove, locked the door or turned on the answering machine; – Extreme need for orderliness; – Aggressive impulses or thoughts, for example, being overcome with the urge to yell 'fire' in a crowded theater

131 Obsessive-Compulsive Disorder Compulsions are repetitive behaviors or rituals performed by the OCD sufferer, performance of these rituals neutralize the anxiety caused by obsessive thoughts, relief is only temporary. – Cleaning. Repeatedly washing their hands, showering, or constantly cleaning their home; – Checking. Individuals may check several or even hundreds of times to make sure that stoves are turned off and doors are locked; – Repeating. Some repeat a name, phrase or action over and over; – Slowness. Some individuals may take an excessively slow and methodical approach to daily activities, they may spend hours organizing and arranging objects; – Hoarding. Hoarders are unable to throw away useless items, such as old newspapers, junk mail, even broken appliances In order for OCD to be diagnosed, the obsessions and/or compulsions must take up a considerable amount of the sufferers time, at least one hour every day, and interfere with normal routines.

132 Obsessive-Compulsive Disorder Obsessions- repetitive unwanted ideas that the person recognizes are irrational Compulsions- repetitive, often ritualized behavior whose behavior serves to diminish anxiety caused by obsessions

133 Obsessive-Compulsive Disorder Prevalence and age of onset Characteristics of OCD Types of compulsions Comorbidity with other disorders

134 Common Examples of OCD Common Obsessions: Common Compulsions: Contamination fears of germs, dirt, etc. Washing Imagining having harmed self or others Repeating Imagining losing control of aggressive urges Checking Intrusive sexual thoughts or urgesTouching Excessive religious or moral doubtCounting Forbidden thoughtsOrdering/arranging A need to have things "just so"Hoarding or saving A need to tell, ask, confessPraying

135 OCD is not OCPD Obsessive-Compulsive Disorder is different from obsessive compulsive personality disorder (OCPD) OCPD: a pervasive pattern of preoccupation with orderliness, perfectionism and control that begins by early adulthood

136 Obsessive-Compulsive Disorder: Psychosocial Causal Factors Psychoanalytic viewpoint Behavioral viewpoint The role of memory Attempting to suppress obsessive thoughts

137 Obsessive-Compulsive Disorder: Biological Causal Factors Genetic influences Abnormalities in brain function The role of serotonin

138 OCD Treatment Serotonin reuptake inhibitors Clomipramine, a serotonergic tricyclic antidepressant Psychotherapy: exposure and response prevention

139 Panic Disorder


141 Epidemiology of Panic Disorder Panic disorder has a lifetime prevalence of % 2:1 female/male ratio ? Of true gender difference versus men tend to self-medicate with alcohol and are less likely to seek treatment. Onset is late teens through third decade of life.

142 Panic Disorder With and Without Agoraphobia Panic disorder Panic versus anxiety Agoraphobia Agoraphobia without panic

143 Panic Disorder Prevalence and age of onset Comorbidity with other disorders Biological causal factors The role of Norepinephrine and Serotonin

144 Panic Attack Discrete episodes of intense anxiety Sudden onset Peak within 10 minutes Associated with at least 4 of the 13 other somatic or cognitive symptoms of autonomic arousal

145 Panic Attack Symptoms Cardiac: palpitations, tachycardia, chest pain or discomfort Pulmonary: shortness of breath, a feeling of choking GI: nausea or abdominal distress Neurological: trembling and shaking, dizziness, lightheadedness or faintness, paresthesias

146 Panic Attack Symptoms Autonomic Arousal: sweating, chills or hot flashes Psychological: – Derealization (feeling of unreality) – Depersonalization (feeling detached from oneself) – Fear of losing control or going crazy – Fear of dying

147 Panic Disorder A syndrome characterized by recurrent unexpected panic attacks (at least 4 in one month) Attacks are followed for at least one month with: – Concern about having another attack – Worry about implications of the attack – Behavior changes because of the attacks

148 Agoraphobia Complication of panic disorder Means “ fear of the market ” Anxiety or avoidance of places or situations from which escape might be difficult, embarrassing, or help may be unavailable. Restricts daily activities

149 Agoraphobia – The patient may avoid crowds, restaurants, highways, bridges, movie theaters etc. – In its most severe form, the patient may become dependent on companions to face situations outside the home. – Some individuals become homebound.

150 Differential Diagnosis of Panic Disorder Not due to another anxiety disorder Not due to effects of a general medical condition – Cardiovascular disease – Pulmonary disease – Neurological disease – Endocrine disease – Drug intoxication or withdrawal – Other (lupus, infections, heavy metal poisoning, uremia, temporal arteritis)

151 Panic Disorder: Costs 200,000 normal coronary angiograms/yr in the U.S. at a cost of 600 million dollars: 1/3 of these patients have panic disorder ½ of patients referred for non-invasive testing for atypical chest pain and who have normal tests have panic disorder 1/3 patients undergoing work-up for vestibular disorder with c/o dizziness have panic disorder

152 Panic Disorder: Comorbidity Panic disorder patients have an increased personal and family history of other anxiety, mood and substance abuse disorders. Major depression is a co-morbid diagnosis in 1/3 of cases presenting for treatment Untreated patients have high risk of suicide

153 Panic Disorder: Treatment About 80% of patients will respond to treatment Antidepressant medications are effective – Serotonin reuptake inhibitors (SSRI) are first line therapy – Tricyclic antidepressants (TCA) and monoamine oxidase inhibitors (MAOI ’ s) are also used.

154 Panic Disorder: Treatment Sedative-Hypnotics: benzodiazepines are ideally used in the short term before an antidepressant has had time to work Cognitive Behavioral Therapy (CBT): helps patients overcome a learned pattern of catastrophically misinterpreting the physical symptoms associated with panic attacks.

155 Panic Disorder The abrupt onset of an episode of intense fear or discomfort, which peaks in approximately 10 minutes, and includes at least four of the following symptoms: A feeling of imminent danger or doom The need to escape Palpitations Sweating Trembling Shortness of breath or a smothering feeling A feeling of choking Chest pain or discomfort Nausea or abdominal discomfort Dizziness or lightheadedness A sense of things being unreal, depersonalization A fear of losing control or "going crazy" A fear of dying Tingling sensations Chills or hot flushes

156 Panic Disorder There are three types of Panic Attacks: 1. Unexpected - the attack "comes out of the blue" without warning and for no discernable reason. 2. Situational - situations in which an individual always has an attack, for example, upon entering a tunnel. 3. Situationally Predisposed - situations in which an individual is likely to have a Panic Attack, but does not always have one. An example of this would be an individual who sometimes has attacks while driving.

157 Panic and the Brain

158 Panic Disorder Genetic factors Cognitive and behavioral causal factors Interoceptive fears

159 Panic Disorder: The Cognitive Theory of Panic

160 Perceived control and safety Anxiety sensitivity as a vulnerability factor for panic Safety behaviors and the persistence of panic Cognitive biases and the maintenance of panic

161 Treating Panic Disorder and Agoraphobia Medications Behavioral and cognitive-behavioral treatments

162 Post-traumatic stress disorder (PTSD)


164 Post Traumatic Stress Disorder (PTSD) Patients with PTSD have experienced a trauma and develop disabling symptoms in response to the event. Symptoms usually begin within 3 months of the trauma Syndrome can occur at any age

165 Definition of Trauma The person experienced, witnessed or learned of an event that involved actual or threatened death, serious injury, or threat of harm to self or others The person ’ s response involved intense fear, helplessness or horror

166 Diagnosis of PTSD Symptoms must be > one month duration and include: – Re-experiencing symptoms – Avoidance symptoms – Emotional numbing – Hyperarousal symptoms

167 Re-experiencing Symptoms There are recurrent, intrusive thoughts of the event (can ’ t not think about it) Dreams (nightmares) about the event Acting or feeling the event is recurring, or sense of living the event (flashbacks) Psychological or Physiological Distress upon exposure to reminders or cues of the event.

168 Avoidance/Numbing Symptoms Avoid thoughts, feelings, places or people that arouse memories of the event Being unable to recall important parts of the event Decrease interest in activities Feeling detached or estranged from others Decreased range of affect Sense of foreshortened future

169 Hyperarousal Symptoms Patient experiences at least two of the following: – Insomnia (falling or staying asleep) – Irritability or outbursts of anger – Decreased concentration – Hypervigilance – Increased/exaggerated startle response

170 Post-Traumatic Stress Disorder Critical Component – Symptoms occurs AFTER a traumatic stressor

171 Types of Traumas Natural – earthquakes – floods – fires Human induces – war – crimes of violence

172 Types of Trauma Sexual abuse Rape Physical abuse Severe motor vehicle accidents Robbery/mugging Terrorist attack Combat veteran Natural disasters Being diagnosed with a life threatening illness Sudden unexpected death of family/friend Witnessing violence (including domestic violence) Learning one ’ s child has life threatening illness

173 Co-Morbid Diagnoses Alcoholism – 75% for Vietnam Veterans with PTSD Depression – 77% of firefighters with PTSD also have depression Generalized Anxiety Panic Attacks

174 Symptoms Categories Intrusive – distressing recollections – dreams – flashbacks – psychological trigger reactions – physiological trigger reactions

175 Symptoms Categories Avoidance – avoid thoughts, feelings or discussions – avoid activities, places – memory blocks – anhedonia (without pleasure) – numb – alexithymia (emotions unknown) – feeling of doom

176 Symptom Categories Hyperarousal Symptoms – sleep disturbance – anger problems – concentration – startle response –“ on guard ” hypervigilence

177 Diagnoses Acute Stress Disorder – new to DSM-IV (1994) – symptoms 2 days to 4 weeks following traumatic event PTSD – new to DSM-III (1980) – symptoms beyond 4 weeks – delayed onset

178 Post-Traumatic Stress Disorder Exposure to traumas such as a serious accident, a natural disaster, or criminal assault can result in PTSD. When the aftermath of a traumatic experience interferes with normal functioning, the person may be suffering from PTSD. Symptoms of PTSD are: – Reexperiencing the event, which can take the form of intrusive thoughts and recollections, or recurrent dreams; – Avoidance behavior in which the sufferer avoids activities, situations, people,and/or conversations which he/she associates with the trauma; – A general numbness and loss of interest in surroundings; – Hypersensitivity, including: inability to sleep, anxious feelings, overactive startle response, hypervigilance, irritability and outbursts of anger.

179 Specific Disorder Facts Posttraumatic Stress Disorder

180 Who Is Vulnerable? All ages Both genders Across Cultures and ethnic groups

181 PTSD Treatment Psychotherapies – Exposure-based cognitive behavioral therapy – Psychotherapy aimed at survivor anger, guilt and helplessness (victimization) Pharmacological treatment targets the reduction of prominent symptoms – SSRI ’ s are first line therapy – Atypical antipsychotics are being increasingly used

182 Specific Phobia

183 Specific Phobias 19 million, 8.7% Women are twice as likely to be affected as men. Specific Phobias 19 million, 8.7% Women are twice as likely to be affected as men. Related Illnesses Many people with an anxiety disorder also have a co-occurring disorder or physical illness, which can make their symptoms worse and recovery more difficult. It’s essential to be treated for both disorders. Related Illnesses Many people with an anxiety disorder also have a co-occurring disorder or physical illness, which can make their symptoms worse and recovery more difficult. It’s essential to be treated for both disorders.

184 Epidemiology of Specific Phobias Lifetime prevalence is 10% of the population Age of onset varies with subtype – Childhood onset for phobias of animals, natural environments blood and injections – Bimodal distribution (childhood and mid-twenties for situational phobias

185 Phobic Disorders Phobias 1.Specific phobias 2.Social phobia 3.Agoraphobia

186 Specific Phobias

187 Psychosocial causal factors Genetic and temperamental causal factors Preparedness and the nonrandom distribution of fears and phobias Treating specific phobias

188 Specific Phobia Marked and persistent fear that is excessive and unreasonable of a specific object or situation Exposure to the phobic stimulus will provoke an anxiety response

189 Phobia Subtypes Animals or insects Natural environment– storms, water, heights Blood, injury, injection, medical procedure Situational flying, driving, enclosed places Having a phobia of a specific subtype increased the chances of having another phobia within that subtype

190 Specific Phobia Treatments Flooding-exposing the person to the feared stimulus Exposure therapy works to desensitize the patient using a series of gradual, self-paced exposures to the phobic stimulus; uses relaxation, hypnosis, breathing control and other cognitive approaches Benzodiazepines or Beta blockers are useful acutely

191 Specific Phobia: Treatment Example: Fear of Flying – Visualize a plane. Look at a plane in the sky. Drive by an airport. Go to a museum that has planes. Same museum—visualize going inside. Go inside. Go to airport and watch planes take off and land. Visualize yourself on a plane flying. Omnimax theater experience. The real thing.


193 Treatment of Anxiety Disorders Medications Specific types of psychotherapy Comorbidities History

194 How to Get Help for Anxiety Disorders See our MD See A Clincian Support Groups CBT Cut Caffiene, Alcohol, Drugs, Cold Medicaations Internet Family Support Systems

195 Role of Research in Improving the Understanding and Treatment of Anxiety Disorders Role of Genes Enviormental factors Physical and psychological stress Diet Brain imaging technology Neurochemical techniques – Amygdala and Hippocampus Developing Medications and behavioral therapies

196 PSYCHIATRIC MANAGEMENT Establish and maintain a therapeutic alliance Complete the psychiatric assessment Evaluate the safety of the patient Establish the appropriate setting for treatment Evaluate the functional impairment and quality of life Coordinate the patient’s care with the other clinicians Monitor the patient’s psychiatric status Integrate measurements into psychiatric management Enhance treatment adherence Provide education to the patient and the family ECPSLLC.COM

197 Monitor psychiatric status and safety. Monitor the patient for changes in destructive impulses to self and others. Be vigilant in monitoring changes in psychiatric status, including major depressive symptoms and symptoms of potential comorbid conditions. Consider diagnostic reevaluation if symptoms change significantly or if new symptoms emerge.

198 PE History of the present illness and current symptoms Psychiatric history, including symptoms of mania Treatment history with current treatments and responses to previous treatments General medical history History of substance use disorders Personal history (e.g., psychological development, response to life transitions, major life events) Social, occupational, and family histories Review of the patient’s medications Review of systems Mental status examination Physical examination Diagnostic tests as indicated

199 Items to Monitor Throughout Treatment Symptomatic status, including functional status, and quality of life Degree of danger to self and others Signs of “switch” to mania Other mental disorders, including alcohol and other substance use disorders General medical conditions Response to treatment Side effects of treatment Adherence to treatment plan

200 American Psychiatric Association. Am J Psychiatry. 2000;157(4 suppl):1-45. Selection of Treatment: Make Your First Choice Count! Aim for remission of symptoms – Choose agents with proven efficacy – Use optimal dose Minimize dropout – Consider efficacy/tolerability/safety profile – Maximize adherence Prevent relapse/recurrence – Achieve remission of symptoms! – Adequate duration

201 Summary and Take-Home Messages Patients can have a high rate of nonadherence with SSRIs due to adverse events First few weeks of therapy are critical Monitor medication compliance during this time period Choose a medication that is effective and generally well tolerated across indications

202 Antidepressant Therapy Time Adverse Events Therapeutic Effect Onset of Adverse Events and Efficacy Adapted from American Psychiatric Association. Am J Psychiatry. 2000;157(Suppl 4):1-45. Bull SA, et al. Ann Pharmacother. 2002;36:

203 Side effects of antidepressant medications 1. Selective serotonin reuptake inhibitors a. Gastrointestinal b. Activation/insomnia c. Sexual side effects d. Neurological e. Falls f. Effects on weight g. Serotonin syndrome h. Drug interactions i. Discontinuation syndrome

204 Side effects of antidepressant medications 2. Serotonin norepinephrine reuptake inhibitors Venlafaxine, Desvenlafaxine, Duloxitine Nausea Dry mouth Sweating Agitation Sedation Weight Sexual Dysfunction Elevated Blood Pressure

205 Side effects of antidepressant medications 4. Tricyclic antidepressants – a. Cardiovascular effects – b. Anticholinergic side effects – c. Sedation – d. Weight gain – e. Neurological effects – f. Falls. – g. Medication interactions

206 Side effects of antidepressant medications 5. Monoamine oxidase inhibitors – a. Hypertensive crises – b. Serotonin syndrome – c. Cardiovascular effects – d. Weight gain – e. Sexual side effects – f. Neurological effects

207 Buspar Nausea Dizziness

208 Psychotherapy. Specific psychotherapies – Cognitive and behavioral therapies – Interpersonal psychotherapy – Psychodynamic psychotherapy – Problem-solving therapy – Marital therapy and family therapy – Group therapy Implementation Combining psychotherapy and medication

209 Complementary and alternative treatments a. St. John’s wort b. S-adenosyl methionine c. Omega-3 fatty acids d. Folate e. N-Acetyl Cysteine f. Acupuncture G. Yoga

210 Assessing response and adequacy of treatment

211 Potential Reasons for Treatment Nonresponse Inaccurate diagnosis Unaddressed co-occurring medical or psychiatric disorders, including substance use disorders Inappropriate selection of therapeutic modalities Inadequate dose of medication or frequency of psychotherapy Pharmacokinetic/pharmacodynamic factors affecting medication action Inadequate duration of treatment Nonadherence to treatment Persistent or poorly tolerated side effects Complicating psychosocial and psychological factors Inadequately trained therapist or poor “fit” between patient and therapist

212 Treatment Should Be Discontinued Gradually Most antidepressants need to be tapered Gradually taper dose (  1 dosage level per week) 1 Longer-term treatment may require slower taper 1,2 Discontinuation symptoms are possible soon after stopping drugs with short half-lives 1,2 Counsel patients on possible discontinuation symptoms, including: – Agitation, anorexia, diarrhea, dizziness, dry mouth, insomnia, nausea, nervousness, sensory disturbances, somnolence, and sweating 1 1.EFFEXOR XR ® (venlafaxine HCl) Prescribing Information. 2.American Psychiatric Association. Am J Psychiatry. 2000;157(4 suppl):1-45.

213 Considerations in the Decision to Use Maintenance Treatment Risk of recurrence Severity of episodes Side effects experienced with continuous treatment Patient preferences Number of prior episodes; presence of comorbid conditions; residual symptoms between episodes Suicidality; psychotic features; severe functional impairments

214 SPECIFIC CLINICAL FEATURES INFLUENCING THE TREATMENT PLAN Psychiatric Factors Demographic and Psychosocial Variables Co-occurring psychiatric disorders Demographic and Psychosocial Variables Treatment Implications of Co-occurring General Medical Conditions

215 Co-occurring psychiatric disorders – Dysthymic disorder – Affective disorders – Dementia – Substance use disorders – Personality disorders – Eating disorders

216 Treatment Implications of Co-occurring General Medical Conditions 1. Hypertension 2. Cardiac disease 3. Stroke 4. Parkinson’s disease 5. Epilepsy 6. Obesity 7. Diabetes 8. Sleep apnea 9. Human immunodeficiency virus and hepatitis C infections 10. Pain syndromes 11. Obstructive uropathy 12. Glaucoma

217 Unmet Needs in Anxiety Underdiagnosed therefore untreated Faster improvement Fewer side effects and better tolerability Greater efficacy Long term efficacy Source: Datamonitor, Stakeholder Insight: MDD, Q1.2; Adult population figures from and MDD prevalence rates applied.

218 National Survey Dispels Notion that Social Phobia is the Same as Shyness social phobia is not simply shyness that has been inappropriately medicalized social phobia affects a minority of youth and only a fraction of those who consider themselves to be shy the greater disability that youth with social phobia experience and the greater likelihood that they will have another disorder they are not more likely to be getting treatment compared to their peers, questioning the notion that these youth are being unnecessarily medicated.

219 About half of adults with an anxiety disorder had symptoms of some type of psychiatric illness by age 15, a NIMH-funded study shows. Results from a small clinical trial suggest that it might be possible, using computer-based training, to help children with anxiety shift their attention away from threat. Normal human shyness is not being confused with the psychiatric anxiety disorder known as social phobia, according to an NIMH survey comparing the prevalence rates of the two among U.S. youth.

220 Anxiety as a personality trait appears to be linked to the functioning of two key brain regions involved in fear and its suppression, according to an NIMH-funded study. Differences in how these two regions function and interact may help explain the wide range of symptoms seen in people who have anxiety disorders. The study was published February 10, 2011 in the journal, Neuron.

221 Youth with obsessive compulsive disorder (OCD) who are already taking antidepressant medication benefit by adding a type of psychotherapy called cognitive behavior therapy (CBT), according to an NIMH-funded study published September 21, 2011, in the Journal of the American Medical Association.

222 Anxiety Linked to Smarts in Brain Study Tendency to worry may have evolved along with intelligence in humans, researchers say

223 Health Tip: When Your Child is Stressed Stress is a fact of life, and children are no less immune than their parents. How can you recognize if your child is "stressed out?" The American Academy of Pediatrics mentions these possible warning signs: Having physical problems, such as stomach ache or headache. Appearing agitated, tired or restless. Seeming depressed and unwilling to talk about his or her feelings. Losing interest in activities and wanting to stay at home. Acting irritable or negative. Participating less at school, possibly including slipping grades. Exhibiting antisocial behavior (stealing or lying), avoiding chores or becoming increasingly dependent on his or her parents.

224 Mental Stress May Be Harder on Women's Hearts Researchers Find Blood Flow to Women's Hearts Doesn't Increase in Face of Stress

225 Psychoeducation: Perhaps one of the most difficult aspects of coping with Social Phobia is simply understanding what it is, where it came from, why it's so hard to change, and how it keeps coming back with a vengeance. Psychoeducation involves you and your therapist working together to develop a better way to understand your Social Phobia, and subsequently, how to work with it. Cognitive Restructuring: As discussed earlier, individuals with Social Phobia frequently hold negative beliefs about themselves and others, which often show up as unhelpful thoughts in social situations. Cognitive restructuring is an important component of CBT, and it involves working with your therapist to identify these thoughts and look for patterns within them. As you become skilled at noticing these thoughts, you then develop strategies for gaining flexibility in your thinking and considering more helpful ways of looking at your experiences. In Vivo Exposure: In vivo (real life) exposure is another core element of CBT for Social Phobia. You and the therapist identify situations that you avoid because of Social Phobia, and then gradually enter these situations while accepting your anxiety and allowing it to naturally dissipate. While this step probably sounds quite intimidating, it is important to know that exposure is done at a very gradual, planned pace, and that your therapist will support you throughout the process. Many clients report exposure practices as being among the most useful elements in their treatment. Interoceptive Exposure: Some individuals with Social Phobia are fearful not only of social situations, but also of the anxious physical sensations (such as blushing, shaking, sweating, etc.) that can accompany them. Interoceptive exposure practices deliberately bring about these sensations through such activities as wearing a warm sweater to induce sweating in social situations. Just as exposure to feared situations leads to reductions in situational fear, exposure to feared sensations will lead to a reduction in anxiety over experiencing these feelings in social situations. Social Skills Training: In the midst of a tense social situation, many people with Social Phobia fear that they do not have the necessary social skills to successfully navigate the exchange. While this may be due to negative self-talk and self-consciousness (rather than an actual lack of skill), many people find it helpful to discuss such topics as carrying on conversations, being assertive, and effective listening. Social skills training provides a chance to work on these areas in therapy.

226 Anxiety Disorder Association of American (ADAA) The ADAA brings together professionals from many disciplines including psychiatrists, psychologists, social workers, physicians, nurses, etc. Through networks, the ADAA increases awareness about anxiety disorders, provides education resources, offers access to care, and supports research.


228 Yoga Accupuncture Warm bath, soothing music, exercise, massage, stay away from caffeine, Alcohol?, balance diet, avoid eating to relieve stress, appropiate meal times Alternative and Supplemental Medication Books/Autotapes Podcast Meditation and Mindfullness


230 Concluding Thoughts — There is a clear and pressing need for faster, robust and well tolerated therapy/therapies. Thinking is rapidly changing and evolving – combination strategies from treatment initiation may be the new frontier for patients who need greater efficacy than antidepressant monotherapy. Personalized medicine may be needed to address genetic differences in depressed individuals to achieve and maintain remission.


232 EDUCATIONAL RESOURCES FOR PATIENTS AND FAMILIES Healthy Minds, Healthy Lives National Alliance on Mental Illness National Institute of Mental Health National Center for Complementary and Alternative Medicine Postpartum Support International

233 rx OCD cannot be prevented. However, early diagnosis and treatment can help reduce the time a person spends suffering from the condition



236 An Important Law- The Yerkes Dodson LawThe Yerkes Dodson Law

237 Another Bell Curve- Courtesy of Our Good Buddies Yerkes-Dodsen

238 Generalized Anxiety Disorder General characteristics Prevalence and age of onset Comorbidity with other disorders

239 Generalized Anxiety Disorder: Psychosocial Causal Factors The psychoanalytic viewpoint Classical conditioning to many stimuli The role of unpredictable and uncontrollable events A sense of mastery: immunizing against anxiety

240 Some Stats Andrews, Wahlberg, Montgomery (1993)

241 Employment

242 Depression

243 ANXIETY Galina Gerasimova Raeanne Perri Marisa Sevilla Joe Shen Grace Velasquez

244 Overview What is Anxiety? What are the different types of anxiety disorders? What are the causes? What are the symptoms? What are the treatments? Professional Resources available.

245 Anxiety Statistics Anxiety Disorders One-Year Prevalence (Adults) PercentPopulation Estimate* (Millions) Any Anxiety Disorder Panic Disorder Obsessive-Compulsive Disorder Post-Traumatic Stress Disorder Any Phobia Generalized Anxiety Disorder * Based on 7/1/98 U.S. Census resident population estimate of million, age 18-54

246 Allopathic Treatments Medications (Drug Therapy): Behavioral Therapy Cognitive Behavioral Therapy Psychodynamic Psychotherapy

247 Medications Buspirone: shown to be effective but usually takes 3- 4 weeks, particularly useful in elderly patients Benzodiazepines: include Xanax and Valium, act rapidly and successfully but can be addictive and loses effectiveness over time Side Effects: dizziness, headaches, nausea, impaired memory

248 Behavioral and Cognitive Therapy Teaches patient to react differently to situations and bodily sensations that trigger anxiety Teaches patient to understand how thinking patterns that contribute to symptoms Patients learn that by changing how they perceive feelings of anxiety, the less likely they are to have them Examples: Hyperventilating, writing down list of top fears and doing one of them once a week, spinning in a chair until dizzy; after awhile patients learned to cope with the negative feelings associated with them and replace them with positive ones

249 Psychodynamic Psychotherapy Psychodynamic therapy is a general name for therapeutic approaches which try to get the patient to bring to the surface their true feelings, so that they can experience them and understand them. Psychodynamic Psychotherapy uses the basic assumption that everyone has feelings held in the subconscious which are too painful to be faced. We then come up with defenses (such as denial) to protect us knowing about these painful feelings. Psychodynamic psychotherapy assumes that these defenses have gone wrong and are causing more harm than good, making you seek help. It tries to subdue them, with the intention that once you are aware of what is really going on in your mind the feelings will not be as painful. Takes an extremely long time and is labor intensive

250 Acupuncture Caused by the imbalance of chi coming about by keeping emotions in for too long Emotion effects the chi to move in an abnormal way: when fearful it goes to the floor, when angry the neck and shoulders tighten Redirects the chi into a balanced flow, releases tension in the muscles, increases flow of blood, lymph, and nerve impulses to affected areas Takes weekly sessions

251 Aromatherapy Calming Effect: vanilla, orange blossom, rose, chamomile, and lavender Reducing Stress: Lavender, sandalwood, and nutmeg Uplifting Oils: Bergamot, geranium, juniper, and lavender Essential Oil Combination: 3 parts lavender, 2 parts bergamot, and 1 part sandalwood

252 Exercise Benefits: symbolic meaning of the activity, the distraction from worries, mastery of a sport, effects on self image, biochemical and physiological changes associated with exercise, symbolic meaning of the sport Helps by expelling negative emotions and adrenaline out of your body in order to enter a more relaxed, calm state to deal with issues and conflicts

253 Meditation Cultivates calmness to create a sense of control over life Practice: Sit quietly in a position comfortable to you and take a few deep breaths to relax your muscles, next choose a calming phrase (such as “ om ” or that with great significance to you), silently repeat the word or phrase for 20 minutes

254 Nutrition and Diet Therapy Foods to Eat: whole grains, bananas, asparagus, garlic, brown rice, green and leafy veggies, soy products, yogurt Foods to Avoid: coffee, alcohol, sugar, strong spices, highly acidic foods, foods with white flour Keep a diary of the foods you eat and your anxiety attacks; after awhile you may be able to see a correlation East small, frequent meals

255 Vitamins B-Vitamins stabilize the body ’ s lactate levels which cause anxiety attacks (B-6, B-1, B-3) Calcium (a natural tranquilizer) and magnesium relax the nervous system; taken in combination before bed improves sleep Vitamin C taken in large doses also has a tranquilizing effect Potassium helps with proper functioning of adrenal glands Zinc has a calming effect on the nervous system

256 Self Love The most important holistic treatment of all Laugh: be able to laugh at yourself and with others; increases endorphin levels and decreases stress hormones Let go of frustrations Do not judge self harshly: don ’ t expect more from yourself than you do others Accept your faults

257 Additional Links Anxiety Screening Tools Anxiety Disorders Association of America (ADAA) Freedom From Fear ( National Institute of Mental Health ( U.S. Dept. of Health & Human Services ( e/stress/) e/stress/

258 What is Anxiety? According to Kaplan and Sadock Anxiety is “a diffuse, unpleasant, vague sense of apprehension, often accompanied by autonomic symptoms such as headache, perspiration, palpitations, tightness in the chest, mild stomach discomfort, and restlessness, as indicated by an inability to sit or stand still for long.”

259 Fear, Anxiety and Worry Normal emotional responses Clear adaptive purpose In anxiety disorders, these normal responses become excessive, persistent, easily triggered, and disruptive to the person’s life.

260 Major Anxiety Disorders Panic Disorder Generalized Anxiety Disorder Post Traumatic Stress Disorder Social Phobia Specific Phobia Obsessive Compulsive Disorder (OCD) Substance Induced Anxiety Disorder

261 Epidemiology of PTSD Prevalence is 1% in the general population, and can be as high as 25% in those who have experienced trauma In combat veterans, prevalence is 20% Very high prevalence in women who are victims of sexual trauma

262 PTSD Costs Patients with PTSD are frequent users of the health care system Patients usually present to primary care physicians with somatic complaints After panic disorder, PTSD is the most costly anxiety disorder

263 Social Phobia Fear of being exposed to public scrutiny Fear of behaving in a way which will be humiliating or embarrassing Symptomatic resemblance to panic disorder with anticipatory anxiety (person may be anxious/worrying far in advance of the event) Extensive phobic avoidance

264 Social Phobia Distinction: anxiety only occurs when the patient is subject to the scrutiny of others (public speaking, oral exam, eating in the cafeteria) Phobic stimulus is avoided or endured with intense anxiety Fear and avoidant behaviors interfere with person ’ s normal routine or cause marked distress

265 Epidemiology: Social Phobia Prevalence rates vary depending on study; overall range is 3 –13% of the population Onset in adolescence Prevalence greater in females, but greater for males in clinical samples Frequent comorbidity with depression and substance abuse

266 Obsessive Compulsive Disorder (OCD) Obsessions: recurrent, intrusive, unwanted thoughts (i.e. fear of contamination) Compulsions: behaviors or rituals aimed at reducing distress or preventing a dreaded event (i.e. compulsive handwashing)

267 OCD Symptoms Recurrent obsessions and/or compulsions are severe enough to consume more than one hour/day Person recognizes the obsession as a “ product of his/her own mind ”, rather than imposed from the outside, and that they are unreasonable or excessive

268 OCD Symptoms The obsessions are “ ego-dystonic ” (not enjoyable for the ego), as opposed to “ ego- syntonic ” (the ego likes it)

269 Common Obsessions Contamination Repeated doubts Order Aggressive or horrific images Sexual/pornographic imagery Scrupulosity

270 Obsessions and Common Compulsive Responses Contamination: cleaning, hand washing, showering Repeated doubts: checking, requesting or demanding reassurances from others, counting Order: checking, rituals, counting Aggressive or horrific images, checking, prayers, rituals Sexual/Pornographic imagery: prayer/rituals

271 Epidemiology of OCD Lifetime prevalence is 2-3% in the general population Mean age of onset is mid-twenties, although men may develop symptoms earlier Less than 5% of patients develop disease after age of 35 years Chronic course, stress can exacerbate symptoms

272 Substance Induced Anxiety Disorder Prominent symptoms of anxiety that are judged to be the direct physiological consequence of a drug or abuse, a medication or toxin exposure

273 Panic Attacks and Panic Disorder Panic Attacks Agoraphobia without a history of panic disorder Panic Disorder without agoraphobia Panic Disorder with agoraphobia

274 Post Traumatic Stress Disorder Characterized by the re-experiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma Symptoms present for at least one month If event just occurred and/or symptoms present for less than one month, a diagnosis of Acute Stress Disorder is given

275 Specific Phobia Clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidance behavior

276 Obsessive Compulsive Disorder Characterized by obsessions that cause marked anxiety or distress and/or compulsions that serve to neutralize anxiety

277 Substance Induced Anxiety Disorder Anxiety Disorder not otherwise specified

278 E 00 Separation Anxiety DisorderE 01 Panic DisorderE 02 AgoraphobiaE 03 Specific PhobiaE 04 Social Anxiety Disorder (Social Phobia)E 05 Generalized Anxiety DisorderE Substance-Induced Anxiety DisorderE 12 Anxiety Disorder Attributable to Another Medical ConditionE 13 Anxiety Disorder Not Elsewhere ClassifiedPanic Attack E 00 Separation Anxiety DisorderE 01 Panic DisorderE 02 AgoraphobiaE 03 Specific PhobiaE 04 Social Anxiety Disorder (Social Phobia)E 05 Generalized Anxiety DisorderE Substance-Induced Anxiety DisorderE 12 Anxiety Disorder Attributable to Another Medical ConditionE 13 Anxiety Disorder Not Elsewhere ClassifiedPanic Attack

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