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The Anxious Patient A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1,2 A Presentation for SOMC Medical Education Kendall L. Stewart,

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Presentation on theme: "The Anxious Patient A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1,2 A Presentation for SOMC Medical Education Kendall L. Stewart,"— Presentation transcript:

1 The Anxious Patient A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1,2 A Presentation for SOMC Medical Education Kendall L. Stewart, MD, MBA, DFAPA March 18, 2011 1 This is problem-oriented learning with numerous links to supporting resource material. 2 Please let me know how I can improve my service to you on your evaluation, in person or on Facebook.

2 Why should you learn about these disorders? They are the most common mental disorders. These disorders are frequently missed, ignored or mistreated.missed These disorders cause substantial distress and impairment. 1 Patients with these disorders over-utilize other medical services. 2,3 Many physicians still lump these disorders and minimize them as “nerves.” These disorders can usually be effectively treated.effectively treated 1 Significant distress and/or impairment are required to make a psychiatric diagnosis. 2 Anxiety and depression are frequently masked by physical complaints. 3 One of my elderly patients never talked about her anxiety, only the “burning in my head.”

3 What are some of the physical manifestations of anxiety? Diarrhea Dizziness or light- headedness Hyperhidrosis Hyperreflexia Hypertension Palpitations Pupillary mydriasis Restlessness Syncope Tachycardia Tingling in the extremities Tremors 1,2,3 Upset stomach (“butterflies”) Urinary frequency, hesitancy, urgency 1 Most tremors are worsened by anxiety. 2 I admitted a man from the ED who developed a significant conduction disturbance. 3 I unexpectedly experienced panic when undergoing MR imaging.

4 What are some of the mental manifestations of anxiety? Apprehension Vigilance Scanning Shame Confusion Distortion of perception Decreased concentration Poor recall Impaired association Selective inattention False assumption 1,2 1 Anxious patients always assume the worst. 2 One of my patients noted, “You don’t look so good.”

5 What is a clinical decision tree for diagnosing the anxiety disorders? “Normal” Anxiety Disorders Anxiety 2 o to Gen Med Cond Substance- Induced Anxiety Anxiety Assoc With Another Mental Disorder Etc. Gen Anxiety DisorderEtc. Acute Stress Disorder PTSD OCD Social Phobia Specific Phobia Agoraphobia Panic Disorder Adjustment Disorders Hypoglycemia Hypothyroidism CHF Pulmonary Embolism COPD Caffeine Alcohol Stimulants Anesthetics Sedatives Mood Disorder Cognitive Disorder Dissociative Disorder 1 These categories form an excellent conceptual algorithm for evaluating psychiatric symptoms in clinical practice.

6 What is the difference between normal and pathologic anxiety? It is often impossible to tell. Whether the anxiety or fear promotes adaptation or causes impairment must be considered. Whether a given distress is judged normal or pathologic depends on one’s resources, psychological defenses, and coping mechanisms. 1,2 psychological defenses “Is this more than the usual ups and downs of life?” will often point the physician in the right direction. 1 Strong emotion of any sort impairs your ability to think clearly and act rationally. 2 One of my patients came out of the restroom to find the atrium door locked. The sign on my door may have discouraged potential rescuers. All she needed to do was turn the deadbolt and walk out.

7 What specific diagnoses are included in this category? Panic disorder without agoraphobia Panic disorder with agoraphobia Agoraphobia without a history with panic disorder Specific phobia Social phobia Obsessive-compulsive disorder Posttraumatic stress disorder Acute stress disorder Generalized anxiety disorder Anxiety disorder due to a [GMC] Anxiety disorder NOS 1Anxiety disorder NOS 1 Always remember to ask about caffeine.

8 What is the epidemiology of anxiety? This in one of the most common groups of psychiatric disorders. One in four persons has diagnosable anxiety disorder. The 12-month prevalence rate is 17.7%. The prevalence of these disorders decreases with higher socioeconomic status.socioeconomic status

9 What is the biological basis of anxiety? 1,2 1 Kaplan & Sadock, 2008 2 These observations are true for all of the anxiety disorders. Autonomic Nervous System –Increased sympathetic tone in anxious patients Neurotransmitters –Norepinephrine –Serotonin –γ- aminobutyric acid (GABA) Brain-Imaging Studies –Some patients with anxiety disorders have functional or anatomical changes. Genetic Studies –Some genetic component clearly contributes to the development of anxiety disorders. Neuroanatomical Considerations –The locus ceruleus and raphe nuclei project to the limbic system. –The limbic system contains a high concentration of GABA A receptors.limbic system –The frontal cerebral cortex is connected with the parahippocampal region, the cingulate gyrus, and the hypothalamus.

10 What about anxiety due to another medical condition? Anxiety commonly accompanies many different general medical conditions. general medical conditions These underlying conditions cause anxiety via the noradrenergic and perhaps the serotonergic systems. Paroxysmal bouts of anxiety should make clinicians suspicious. The clinical features can be identical to those of the primary anxiety disorders. Primary anxiety disorders generally have their onset before age 35. Anxiety symptoms may persist after the primary disorder is treated. The underlying disorder should be treated first, but the anxiety may need to be addressed separately. 1,2 1 If you decide up front that the patient is a crock, this will set you up for some serious mistakes. 2 One of my “crock” patients presented to the ED with the history of a dilated pupil.

11 What about substance-induced anxiety disorders? This is a common consequence of recreational and prescription drug abuse.drug abuse You must think about it and ask about it every time. Don’t forget about caffeine. The associated clinical features may vary with the substance involved. 1,2 Cognitive impairments in comprehension, calculation and memory usually disappear when the substance is discontinued. The differential diagnosis includes –Primary anxiety disorders –Anxiety due a general medical condition (for which the patient may be receiving the implicated drug) –Mood disorders –Personality disorders –Malingering Removal of the offending substance is the preferred treatment 1 People who take a lot of speed become overtly paranoid. 2 I evaluated a patient at a MHC who was convinced that the FBI was landing UFOs in his backyard.

12 What about mixed anxiety- depressive disorder? These are patients that don’t meet full criteria for either a mood or an anxiety disorder. They are particularly common in primary care practices.primary care On careful examination, they often are depressed. The accompanying anxiety is misleading. For this reason, the syndrome is controversial. This combination of symptoms leads to considerable functional impairment. Up to 2/3 of depressed persons are also anxious and up to 9/10 of panic patients experience depression. If this emerges as a specific diagnosis, it may affect about 1% of the population. The serotonergic drugs are helpful for both the anxiety and depression. 1,2 1 These “mixed syndromes” can be very challenging. Unfortunately, few of your patients will have read the book. 2 When in doubt, treat for depression. It is very hard to get patients off benzodiazepines.

13 Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008 1Concise Textbook of Clinical Psychiatry, Third Edition Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007 2The Massachusetts Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005First Aid© for the Psychiatry Clerkship, Second Edition Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 2009 3Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007Lange Q&A: Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000Dealing With Anxiety: A Practical Approach to Nervous Patients,” 1,2 Please note that you must master all of the information in a basic neurology textbook and a basic psychiatry textbook to do well on the comprehensive, standardized final examination.

14 Where can you find evidence-based information about mental disorders? Explore the site maintained by the organization where evidence-based medicine began at McMaster University Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health Download this presentation and related presentations and white papers at Learn more about Southern Ohio Medical Center and the job opportunities there at Review the exceptional medical education training opportunities at Southern Ohio Medical Center

15 How can you contact me? 1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 1 Speaking and consultation fees benefit the SOMC Endowment Fund.

16  Safety  Quality  Service  Relationships  Performance   Safety  Quality  Service  Relationships  Performance  Are there other questions? Carolyn Arnett, DO OUCOM 1993 Jason Cheatham, DO OUCOM 2002

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