1. Anxiety Overview October 2011

2. Introduction to Harvest Healthcare Experience. Education. Excellence. Harvest is a leading full-service behavioral health provider, specializing in the delivery of progressive and innovative consultative behavioral health services for patients and residents residing in skilled nursing, rehabilitation, and assisted living facilities. Our multidisciplinary team of highly skilled professionals work together to offer a broad menu of services including but not limited to 24-hour prescriber on-call services and hospitalization support, comprehensive cognitive assessments, documentation review, OBRA compliance support and customized educational programs designed for the individual needs of your facility.

3. Objectives This presentation on anxiety was developed for the continuing education of healthcare providers. At the conclusion of this presentation, participants will have a basic understanding of anxiety including symptoms and management. Mental health professionals should be consulted for management of patients with anxiety.

4. Introduction to Anxiety Anxiety is also known as’ angst’ or ‘worry’ It is a psychological and physiological state characterized by somatic, emotional, cognitive and behavioral components. Anxiety can create feelings of fear, worry, uneasiness, and dread. Anxiety is considered a normal reaction to a stressor and can help by motivating action but when it becomes excessive it may become an anxiety disorder.

5. Description Anxiety is a generalized mood condition that can often occur without an identifiable trigger. Anxiety is related to situations perceived as uncontrollable or unavoidable. Anxiety and fear differ: fear is short lived, present focused, geared toward a specific threat and facilitation escape from threat. Anxiety is long acting, future focused, broadly focused towards a diffuse threat and promoting caution while approaching a potential threat.

6. Physical Effects Heart palpitations Muscle weakness Tension Fatigue Nausea Chest Pain Shortness of Breath Stomach Aches Headaches Increased Blood Pressure and Pulse Sweating Pale skin Trembling Pupillary Dilation

7. Panic Attacks The most intense form of anxiety. Often thought of as heart attack. Sense of dread or panic may exist Panic attacks usually come without warning with irrational fear and a perception of danger that is very real to the person. A person experiencing a panic attack will often feel as if he or she is about to die or pass out.

8. Emotional Effects of Panic Feelings of apprehension or dread Trouble concentrating Feeling tense or jumpy Anticipating the worst Irritability Restlessness Watching (and waiting) for signs (and occurrences) of danger Feeling like your mind’s gone blank Nightmares/bad dreams Obsessions about sensations Déjà vu A trapped in your mind feeling Feeling like everything is scary

9. Cognitive Effects of Panic Thoughts about suspected danger – Such as fear of dying: “may fear that chest pains (sign of anxiety) are a deadly heart attack or the shooting pains in your head (another physical symptom of anxiety) are the result of a tumor or aneurysm. – May feel an intense fear of dying or more frequent thoughts that won’t go away

10. Behavioral Effects of Panic Withdrawal from situations where unpleasant effects of anxiety have been experienced Changes in sleeping patterns Nail biting Increased motor tension, such as foot tapping

11. Causes of Anxiety The exact cause is not fully known, but a factors such as genetics, brain chemistry and environmental factors contribute. Genetics: some research suggests that family history plays a role in the development of anxiety. Brain chemistry: abnormal levels of certain neurotransmitters in the brain. Neurotransmitters are special chemical messengers that help move information from nerve cell to nerve cell. If the neurotransmitters are out of balance, messages cannot get through the brain properly. This can alter the way the brain reacts in certain situations, leading to anxiety.

12. Causes of Anxiety Trauma and stressful events, such as abuse, the death of a loved one, divorce, changing jobs or schools, may lead to anxiety. Anxiety also may become worse during periods of stress. The use of and withdrawal from addictive substances, including alcohol, caffeine, and nicotine, can also worsen anxiety.

13. Types of Anxiety: DSM IV Panic disorder with agoraphobia Panic disorder without agoraphobia Obsessive-compulsive disorder (OCD) Phobias Post-traumatic stress disorder Acute Stress disorder Generalized anxiety disorder (GAD) Anxiety Disorder not otherwise specified Anxiety Disorder due to known physical causes

14. Diagnostic Criteria for GAD A. At least 6 months of "excessive anxiety and worry" about a variety of events and situations. Generally, "excessive" can be interpreted as more than would be expected for a particular situation or event. B. There is significant difficulty in controlling the anxiety and worry. If someone has a very difficult struggle to regain control, relax, or cope with the anxiety and worry, then this requirement is met. C. The presence for most days over the previous six months of 3 or more of the following symptoms: 1. Feeling wound-up, tense, or restless 2. Easily becoming fatigued or worn-out 3. Concentration problems 4. Irritability 5. Significant tension in muscles 6. Difficulty with sleep

15. Diagnostic Criteria for GAD D. The symptoms are not part of another mental disorder. E. The symptoms cause "clinically significant distress" or problems functioning in daily life. F. The condition is not due to a substance or medical issue Mental health care provider will collect history and current medical information Blood and other diagnostic tests may be ordered to rule out medical causes of symptoms History may be obtained from family or caregivers Anxiety scales may be used

16. Treatment of Anxiety In general anxiety disorders are treated with medication, specific types of psychotherapy or both Treatment choices depend on the problem and the person’s preference Before treatment begins, a careful diagnostic evaluation needs to be done to determine whether a person’s symptoms are caused by an anxiety disorder or a physical problem.

17. Treatment of Anxiety If an anxiety disorder is diagnosed, the type of disorder or the combination of disorders that are present must be identified. Coexisting conditions: – depression – substance abuse. Sometimes alcoholism, depression, or other coexisting conditions have such a strong effect on the individual that treating the anxiety disorder must wait until the coexisting conditions are brought under control.

18. Medication Medication will not cure anxiety disorders, but it can keep them under control while the person receives psychotherapy. Medication should be prescribed by mental health specialists, who can either offer psychotherapy themselves or work as a team with psychologists, social workers, or counselors who provide psychotherapy. The principal medications used for anxiety disorders are antidepressants, anti-anxiety drugs, and beta-blockers to control some of the physical symptoms.

19. Psychotherapy Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor, to discover what caused an anxiety disorder and how to deal with its symptoms. Cognitive-behavioral therapy (CBT) is very useful in treating anxiety disorders. The cognitive part helps people change the thinking patterns that support their fears, and the behavioral part helps people change the way they react to anxiety- provoking situations.

20. Thought Provoking Questions Can you describe the difference between generalized anxiety and panic? When a patient is presenting with acute anxiety, what should you do? How can you refer a patient for a psychiatric evaluation?