The Anxiety Disorders
A Patient-Centered, Evidence-Based Diagnostic
and Treatment Process1
Kendall L. Stewart, MD, MBA, DLFAPA
September 20, 2013
1 This
is problem-oriented learning with numerous links to supporting resource material.
Why should you learn about these
disorders?
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They are the most common mental disorders.
These disorders are frequently missed, ignored or mistreated.
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.
1 Significant
distress and/or impairment are required to make a psychiatric diagnosis.
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.”
2 Anxiety
What are some of the physical
manifestations of anxiety?
• Diarrhea
• Dizziness or lightheadedness
• Hyperhidrosis
• Hyperreflexia
• Hypertension
• Palpitations
• Pupillary mydriasis
1 Most
•
•
•
•
•
•
Restlessness
Syncope
Tachycardia
Tingling in the extremities
Tremors1,2,3
Upset stomach
(“butterflies”)
• Urinary frequency,
hesitancy, urgency
tremors are worsened by anxiety.
admitted a man from the ED who developed a significant conduction disturbance.
3 I unexpectedly experienced panic when undergoing MR imaging.
2I
What are some of the mental
manifestations of anxiety?
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Apprehension
Vigilance
Scanning
Shame
Confusion
Distortion of perception
Decreased concentration
Poor recall
Impaired association
Selective inattention
False assumption1,2
1 Anxious
2 One
patients always assume the worst.
of my patients noted, “You don’t look so good.”
What clinical algorithm1,2 will assist you in
making a correct anxiety diagnosis?
Anxiety
“Normal”
Anxiety
Anxiety
Disorders
Anxiety 2o to
Gen Med Cond
SubstanceInduced
Anxiety
Anxiety Assoc
With Another
Mental Disorder
Specific Phobia
Social Anxiety Disorder
Panic Disorder
COPD
Sedatives
Pulmonary Embolism
Anesthetics
CHF
Stimulants
Dissociative Disorder
OCD
Hypothyroidism
Alcohol
Cognitive Disorder
Adjustment Disorders
PTSD
Hypoglycemia
Caffeine
Mood Disorder
Etc.
Etc.
Etc.
Etc.
Etc.
Agoraphobia
Gen Anxiety Disorder
1 These
categories form an excellent conceptual algorithm for evaluating psychiatric symptoms in clinical
practice.
2Always remember to ask about caffeine.
What is the difference between normal
and pathologic anxiety?
• It is often impossible to tell at the time.
• Consider whether the anxiety or fear promotes adaptation
or causes impairment.
• Consider the trigger, the duration and the degree of
impairment.
• Whether a given distress is judged normal or pathologic
depends on one’s resources, psychological defenses, and
coping mechanisms.1,2
• “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.
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.
2 One
What disorders are included in the
Anxiety Disorders category?
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Separation Anxiety Disorder
Selective Mutism
Specific Phobia
Social Anxiety Disorder (Social Phobia)
Panic Disorder
Panic Attack Specifier (not a diagnosis)
Agoraphobia
Generalized Anxiety Disorder
Substance/Medication-Induced Anxiety Disorder
Anxiety Disorder Due to Another Medical Condition
Other Specified Anxiety Disorder
Unspecified Anxiety Disorder
What disorders are included in the
Obsessive-Compulsive category?
Obsessive-Compulsive Disorder
Body Dysmorphic Disorder
Hoarding Disorder
Trichotillomania (Hair-Pulling Disorder)
Excoriation (Skin-Picking) Disorder
Substance/Medication-Induced Obsessive-Compulsive
and Related Disorder
• Other Specified Obsessive-Compulsive and Related
Disorder
• Unspecified Obsessive-Compulsive and Related
Disorder
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What disorders are included in the
Trauma- and Stressor-Related category?1,2
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Posttraumatic Stress Disorder
Acute Stress Disorder
Adjustment Disorders
Other Specified Trauma- and Stressor-Related
Disorder
• Unspecified Trauma- and Stressor-Related
Disorder
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1A
2If
number of us are concerned about diagnosis inflation.
you would like to read more about this concern, read Saving Normal by Allen Frances.
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.
Lifetime Prevalence
of Anxiety Disorder
35%
30%
25%
20%
15%
10%
5%
0%
Men
Women
What is the biological basis of
anxiety?1,2
•
Autonomic Nervous System
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Neurotransmitters
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Some genetic component clearly contributes to the development of anxiety
disorders.
Neuroanatomical Considerations
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1
Some patients with anxiety disorders have functional or anatomical changes.
Genetic Studies
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Norepinephrine
Serotonin
γ- aminobutyric acid (GABA)
Brain-Imaging Studies
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Increased sympathetic tone in anxious patients
The locus ceruleus and raphe nuclei project to the limbic system.
The limbic system contains a high concentration of GABAA receptors.
The frontal cerebral cortex is connected with the parahippocampal region, the
cingulate gyrus, and the hypothalamus.
Kaplan & Sadock, 2008
observations are true for all of the anxiety disorders.
2These
What about Anxiety Disorder Due to
Another Medical Condition?
• Anxiety commonly
accompanies many different
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.
1 If
youtremors
decide up
that the
Most
arefront
worsened
by patient
anxiety.is
• 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
a crock, this will set you up for some serious mistakes.
significant
with the history
conduction
of a dilated
disturbance.
pupil.
3 I unexpectedly experienced panic when undergoing MR imaging.
2 One
I admitted
of my “crock”
a man from
patients
the ED
presented
who developed
to the ED
a
What about Substance/MedicationInduced Anxiety Disorder?
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This is a common consequence of
recreational and prescription 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.
1 Most
tremors
are aworsened
by
People
who take
lot of speed
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
anxiety.
become overtly paranoid.
admitted
a
man
from
the
ED
who
a significant
disturbance.
evaluated a patient at a MHC whodeveloped
was convinced
that theconduction
FBI was landing
UFOs in his backyard.
3 I unexpectedly experienced panic when undergoing MR imaging.
2I
What about patients who present with
mild mixed anxiety and depression?
• 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.
• On careful examination, they
often are depressed; the
accompanying anxiety is
misleading.
• This controversial presentation
is not a separate diagnosis.
• 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.1,2,3
1 These
Most tremors
“mixed are
syndromes”
worsenedcan
by be
anxiety.
very challenging.
2 When
I admitted
in doubt,
a man
treat
from
forthe
depression.
ED who developed
It is very ahard
significant
to get patients
conduction
off benzodiazepines.
disturbance.
3A
I
unexpectedly
number of these
experienced
patients will
panic
report
when
definite
undergoing
benefit
MR
from
imaging.
one of the SSRIs.
What treatment options are available?
• Medication
• Non-medication
• Antidepressants
interventions
• Benzodiazepines
• No treatment
• Atypical antipsychotics
• Distractions
• Buspirone (Buspar)
• Sensory override strategies
• Antihistamines
• Meditation
• Progressive relaxation
exercises
• Cognitive behavioral
therapy
1 Most
tremors are worsened by anxiety.
admitted a man from the ED who developed a significant conduction disturbance.
3 I unexpectedly experienced panic when undergoing MR imaging.
2I
What practical guidelines should you follow
when prescribing medication for anxiety?
• Make the correct diagnosis first;
the treatment differs.
• Fix the problem that is causing
the anxiety if you can.
• Try every reasonable
nonmedical intervention first
unless the severity of the
symptoms will not allow that.
• The SSRIs and SNRIs are
currently considered the
medications of first choice for
most anxiety disorders.
• If you need to block panic
attacks immediately,
clonazepam (Klonopin) is the
go-to drug.
1 Most
• Use benzodiazepines for only a
brief period of time before
tapering—if possible.
• Encourage exposure and
cognitive therapy from the start;
pills are rarely the answer by
themselves.
• Support your patients in their
management of their chronic
illnesses.
• Use the atypical antipsychotic
medications and
anticonvulsants for anxiety
ONLY as a last resort and after a
psychiatric consultation.
tremors are worsened by anxiety.
admitted a man from the ED who developed a significant conduction disturbance.
3 I unexpectedly experienced panic when undergoing MR imaging.
2I
What problems will you face when
prescribing antidepressants?
Problem
Solution
Your anxious patients may become even
more anxious after starting the drug.
Lower the starting dosage, reassure
them and counsel patience.
Your patients may complain of
unpleasant side effects.
If possible, recommend persistence and
completion of an adequate trial.
Your patients may need immediate
blockage of panic attacks.
Don’t hesitate to add clonazepam
(Klonopin) and taper it later.
Your patients may want to try the same Agree to try it. This is a very good idea.
drug a family member took with benefit.
Your patients may not want to take ANY
medication long term.
1 Most
The rare PRN use of benzodiazepines
makes some sense. PRN SSRIs do not.
tremors are worsened by anxiety.
admitted a man from the ED who developed a significant conduction disturbance.
3 I unexpectedly experienced panic when undergoing MR imaging.
2I
What problems might you face when
prescribing benzodiazepines?
Problem
Solution
You may not be comfortable prescribing
benzodiazepines at all.
Refer the patient to a more flexible,
mature and experienced provider.
You may not feel comfortable
prescribing benzodiazepines long-term.
Seek a consultation from a psychiatrist.
Your patient may insist that you
prescribe when you don’t agree.
Refer to a colleague BEFORE anyone
gets mad.
You may discover that your patient is
abusing your medication.
Confront them respectfully, then taper
and discontinue the medication.
You may need to taper the medication.
Warn about relapse, rebound,
withdrawal and taper slowly.
tremorsconclude
are worsenedthat
by anxiety.
You
may
the benefits of
Document your unsuccessful attempts
I admitted a man from the ED who developed a significant conduction disturbance.
I unexpectedlyuse
experienced
panic when
long-term
outweigh
theundergoing
risks. MR imaging.to taper and monitor carefully.
1 Most
2
3
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Treatment Process
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Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of my problems and
concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
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Review my laboratory data and other
available records.
Tell me what diagnoses you have made.
Reassure me.
Outline your recommended treatment plan
while making sure that I understand.
Repeatedly invite my clarifying questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any additional
questions I may have.
Make a follow up appointment.
Communicate with my other physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
1
How can you access the OU-HCOM
psychiatry flash cards online?
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• Please post your feedback or suggestions on the Quizlet
site.
Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition, 2013
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third
Edition, 2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical
Psychiatry, 2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts General Hospital Handbook of
Neurology, 2011
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship,
Third Edition, 2011
Klamen, D, and Pan, P, Psychiatry PreTest Self-Assessment and Review,
Thirteenth Edition, 2012
Blitzstein, Sean, Lange Q&A Psychiatry, 2011
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home,
Work and School, 2010
Where can you find evidence-based
information about mental disorders?
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Explore the site maintained by the organization where
evidence-based medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the
specialties of your choice here.
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 here.
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 here.
How can you contact me?
Kendall L. Stewart, MD, MBA, DLFAPA
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
StewartK@somc.org
KendallLStewartMD@yahoo.com
www.somc.org
www.KendallLStewartMD.com
Are there other questions?1,2
Justin Greenlee, DO
Director
Family Medicine
Residency
 Safety  Quality  Service  Relationships Performance 
Thomas Carter, DO
Director
Emergency Medicine
Residency
1Learn
2Learn
more about Southern Ohio Medical Center.
more about our Family Medicine and Emergency Medicine Residencies.