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

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

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

4. Anxiety Symptoms

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

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

7. Other Signs of Anxiety Disorders

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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