1. PIPC ® Psychiatry In Primary Care ANXIETY DISORDERS Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College of Virginia at the Virginia Commonwealth University Richmond, Virginia

2. PIPC ® Goals Effectively recognize, diagnose and treat mental illness in primary care Bring the psychiatry skills and knowledge base of the primary care physician on par with other medical specialty knowledge bases

3. Outline PIPC 1 –Introduction –PIPC ® Interview –MAPS-O ® –Mood Disorders –Suicide

4. Outline PIPC 2 –Anxiety Disorders PIPC 3 –Neurotransmitters –The 3 Phases and the 5Rs –Medications –Cases and Discussion

5. MAPS-O ®

6. Mood Disorders Anxiety Disorders Psychotic Disorders Substance Abuse Other

7. MAPS-O ® Mood Disorders Major Depression, Dysthymia, Bipolar Disorder Anxiety Disorders Psychotic Disorders Substance Abuse Other

8. MAPS-O ® Mood Disorders Anxiety Disorders GAD, Panic Disorder, PTSD, OCD, Phobias (Social/Specific) Psychotic Disorders Substance Abuse Other

9. MAPS-O ® Mood Disorders Anxiety Disorders Psychotic Disorders Schizophrenia, Schizoaffective Substance Abuse Other

10. MAPS-O ® Mood Disorders Anxiety Disorders Psychotic Disorders Substance Abuse Alcohol, Cocaine, Nicotine, Other Psychoactive Substances Other

11. MAPS-O ® Mood Disorders Anxiety Disorders Psychotic Disorders Substance Abuse Other “Organic”: Stroke, Dementia, HIV, TBI Other Psych: Personality Disorders, ADHD, Somatization,Eating Disorders

14. ANXIETY DISORDERS

15. Normal vs. Pathological Anxiety A biological warning system that is activated by perceived danger Distressing and usually associated with bodily discomfort Normal levels prepare one for a protective response High levels can be disorganizing, counter– productive, and cause impairment Abnormal when disproportionate to the potential for harm or when it occurs in situations reasonably deemed to be harmless

16. Importance Of Anxiety Disorders as a Group Are the most common mental disorders –lifetime prevalence for any AD is 24.9% Tend to be chronic (more chronic and non-remitting than major depression) Have substantial comorbidity Carry a burden of distress and impairment similar to chronic medical disorders

17. Comorbidity Comorbidity is the rule –Depressive disorders (50-70%) –Substance abuse –Other anxiety disorders –Comorbidity predicts: chronicity, disability, increased suicide risk, and poorer treatment response

18. Risk Factors Female gender: F:M~2:1 (except OCD M=F) Family history: Odds ratios 4-6 Trauma (abuse, assault, accidents, etc.) Stressful Life Events (unemployment, illness, death of loved one, marital conflict, etc.)  Note: These are the same risk factors seen in Major Depression - whenever you consider someone at increased risk for depression, they are also at increased risk for an AD

19. Somatic Symptoms and Mental Disorders # of SymptomsMood D/O (%)Anxiety D/O (%) 0-121 2-3127 4-52313 6-84430 > 96048

21. Medical Mimics of Anxiety Anxiety Disorder Secondary to … Substances - Pseudoephedrine, nicotine, caffeine, marijuana, LSD, cocaine, MDMA (ecstasy), herbal supplements. Withdrawal of ETOH, opiates or benzodiazepines. Medical Disorders – Cardiac arrhythmias (SVT), congestive heart disease, hyperthyroidism, vertigo, congenital adrenal hyperplasia, hypoglycemia, pheochromocytoma, Medications – Stimulants, theophylline, others.

22. Anxiety Disorders Generalized Anxiety Disorder (GAD) Panic Disorder Posttraumatic Stress Disorder (PTSD) Obsessive Compulsive Disorder (OCD) Phobias –Specific –Social

23. Anxiety Disorders - Symptoms “Angst” Fears Worry Increased startle RestlessnessEasily fatigued IrritabilityHypervigilence Muscle tensionPalpitations ObsessionsCompulsions Shortness of breathChoking Fear of losing control or dying Difficulty concentrating (“mind goes blank”) Sleep disturbance (classically initial insomnia)

24. Generalized Anxiety Disorder GAD Excessive anxiety for 6 months (more days than not) Difficult to control the worry (a “worrier”) Associated with 3 or more of the following: – Restlessness – Easily fatigued – Difficulty concentrating – Irritability – Muscle tension – Sleep disturbance (initial insomnia, fragmented)

25. Generalized Anxiety Disorder GAD Common, chronic Uncontrollable, pervasive anxiety Psychological Sx (e.g. excessive worry) Somatic Sx (e.g. muscle tension) Psychiatric comorbidity common –Depression –Other Anxiety Disorders –Substance Abuse

26. GAD – Questions Have you frequently been worried or anxious about a number of things in your daily life? –Do people say you worry about things too much? –Do you think your anxiety is unrealistic or excessive? Is it hard for you to control or stop your worrying?

27. GAD – Questions Now I’m going to ask you about physical symptoms that often go along with anxiety and nervousness? – …feel restless, fidgety, jittery, keyed up – …get tired easily? – …feel irritable? – …feel tension, aches, or soreness in your muscles – …have problems falling asleep or staying asleep

28. Panic Disorder Common, often chronic Panic attacks + agoraphobia Psychiatric comorbidity common –Depression –Other anxiety disorders –Substance Abuse High medical utilization

29. Panic Attack: 4 or more Fear of DyingFear of Losing Control SweatingDerealization TremblingNausea SOBChoking feeling ParathesiasHot flashes Chest Pain

30. Panic – Medical Presentations Cardiac Panic Pulmonary Panic GI Panic Neurological Panic (vertigo) Panic exacerbating medical illness

31. Panic Disorder – Questions: Have you had a sudden rush of intense feat, anxiety, or discomfort that come on from out of the blue for no apparent reason or in situations where you did not expect them to occur? Do you worry a lot about having more of them? Have you changed your behavior since these attacks began?

32. Panic Disorder – Questions: Think back to last attack you had. When was it? Where were you at the time? Would most of the symptoms ever come on quickly, within ten minutes after the attack began? Did you experience of the following? –…feel your heart racing, pounding, fluttering, or skipping beats?

33. Panic Disorder – Questions: –…sweat? –…tremble or shake? –…have trouble catching your breath, or feel like you were being smothered? –…feel like you were choking? –…have chest pain, pressure, tightness, or discomfort? –…feel nauseated, sick to your stomach, or like you might have diarrhea?

34. Panic Disorder – Questions: –…feel dizzy, light-headed, unsteady, or like you might faint? –…feel like things around you were unreal, like you were in a dream, like part of your body were unreal or detached from you… –…fear you were going crazy or might lose control? –…fear you might die? –…feel numb or tingling in your fingers or feet? –…have hot flashes?

35. Agoraphobia – Questions Some people have very strong fears of being in certain places or in certain situations. Do any of the following make you feel very fearful, anxious or nervous? –Being away from home? –Standing in long lines? –Being in wide open spaces like a park?

36. Agoraphobia – Questions –Being in crowded places like a movie theater, supermarket, shopping mall, church, restaurant, etc. ? –Being on a bridge or in a tunnel? –Traveling in a bus, train or plane? –Driving in a car? –Being home alone?

37. Agoraphobia – Questions I know it’s difficult to describe, but what about [ ] that worries you? What do think will happen to you? What are you afraid of?

38. Posttraumatic Stress Disorder PTSD Common, following life-threatening, overwhelming experiences Symptom categories: –Reexperiencing –Avoidance –Increased arousal

39. PTSD – Stressor Criteria Questions: Have you ever seen or experienced a traumatic event in which your life was actually in danger or you thought your life was in danger? Have you ever witnessed an event in which someone else’s life seemed to be in danger? How did you react to the trauma? –Were frightened or horrified? –Did you feel helpless and out of control?

40. PTSD – Re-experiences Questions: Do memories about the [ ] still bother you? –Do you see images of the trauma? –What about dreams? –What about flashbacks where you relive the event? –Are there things that remind you of the [ ] that get you upset? –Do the reminders make you tremble, break you in a sweat, hyperventilate or have a racing heart?

41. PTSD – Avoidance Questions: Do you try to block out thoughts or feelings related to the [ ]? –Do you try to avoid activities, situations, or places that remind you of the [ ]? –Are there aspects of the [ ] that you can’t recall? –Since the [ ] have you lost interest in some things you used to enjoy? –…do you feel distant and cut off from people? –…have you lost the ability to feel certain emotions? –Has the [ ] changed how you feel about the future?

42. PTSD – Hyperarousal Questions: Since the trauma have you… –..problems sleeping? –…more irritable or lost your temper more easily? –…problems concentrating? –…been on the alert, always keeping your guard up with an eye out for possible trouble? –..been kind of jumpy and easily startled by everyday ordinary noises?

43. Obsessive Compulsive Disorder OCD Obsessions: persistent ideas, thoughts, impulses, or images that are experienced as intrusive, inappropriate, and increase anxiety Compulsions: repetitive behaviors or mental acts that are aimed at preventing or reducing the anxiety and distress caused by the obsessions

44. Obsessive Compulsive Disorder OCD Not frequently diagnosed in primary care setting. Patients are often secretive about this and have increased shame. Starts early in life, adolescence or early adulthood.

45. OCD – Questions: Some people are bothered by recurrent thoughts or impulses that seem inappropriate or do not make sense, but they keep repeating over and over and are difficult to get out of your mind. Examples: that you are contaminated by germs; thoughts you might hurt someone you didn’t want to; that you'd yell obscenities in public…

46. OCD – Questions: What about intrusive images? Describe what it is like? How often does it happen? What do you do to deal with this? Do you try to ignore or get rid of these thoughts/images and them out of your mind? Do you tell yourself things or imagine certain other images in order to neutralize or counteract the unpleasant thought or image?

47. OCD – Questions: Some people are bothered by having to do something over and over that they can’t resist when they try. For example: –Wash hands –Checking the doors, windows or stove –Counting things excessively –…rituals that always have to be in a particular order, and if the wrong way you have to start all over again.

48. Social Phobia (Social Anxiety Disorder) Common, potentially disabling Intense fear of embarrassment Avoidance of social interactions Rarely recognized in Primary Care

49. Social Phobia - Questions: Some people have very strong fears of being watched or evaluated by others. Do you worry that you might do or way something that would embarrass you in front of others, or that other people might think badly of you? Do you think you are much more anxious than other people? …what about the situation bothers you?

50. Specific Phobia A marked, excessive fear provoked by the presence or anticipation of a specific object or situation Generally, the phobic object is either avoided or endured with intense anxiety and distress Five subtypes: 1. Animal 2. Natural environment (storms, heights, water) 3. Blood-Injection-Injury (MDs, hospitals, dentists) 4. Situational (public transportation, flying, enclosed spaces) 5. Other (space, loud noises)

51. Specific Phobia - Questions: Some people have very strong fears of certain objects or situations. Such as: –Heights –Being near household pets –Spiders, bugs, snakes, mice or rats –Seeing blood, getting an injection –Being in water –Storms –Flying in an airplane

52. Specific Phobia - Questions: Whenever you are exposed to or even think of being exposed to [ ] do you immediately get anxious or nervous? Do you think you are more afraid and worried about [ ] you should be? To what degree do you avoid the [ ]?

54. Health care-related phobias Examples of health care-related phobias –needles –the sight of blood or open wounds –pain –anesthesia –dental procedures Effectively treated with systematic desensitization

55. CASE

56. 39 year old woman 18 month history of spells where she gets acutely nauseated, cramping abdominal pain, sweating and feels light-headed She also gets exceedingly scared and overwhelmed when these occur They last 10 minutes on average and are getting worse She is taking Paxil 20 mg with little change

57. Panic Attacks Panic comes as a somatic disorder –GI, Cardiac, Pulmonary, Vertiginous In what disorders can panic attacks occur? –Panic d/o, GAD, PTSD, OCD, Phobias, Major Depression, Substance induced What questions help figure out panic? –Triggered, Phobic avoidance, the “scat”

58. Panic Attack  Panic Disorder DiagnosisSpontaneousSituationalAnticipatoryAutonomic Arousal Phobic Avoidance Panic Disorder ++++/-+++ + Agora- phobia +/- ++++++++ Specific Phobia -++ +++ Social Phobia +/-+++++ +++ PTSD +/-+++/-++++ GAD +/- +

59. 39 year old woman Triggered by cars Raped 18 months ago in her car at a ATM (she told no one) Had Sx of PTSD –Reexperiences, Avoidance, Hyperarousal Increased EtOH consumption Long history of dysthymia Trauma in childhood

60. MAPS-O ® Mood DisordersDysthymia Anxiety DisordersPTSD* (Panic Attacks) Psychotic DisordersNone Substance AbuseAlcohol (Ab)use OtherNo Organic Defer “Other Psych” (Eating d/o, Personality d/o)