1. Charles Hart Enzer, M.D. 5599 Kugler Mill Road Cincinnati, OH 45236-2035 513-281-0074 Email: cenzer@gmail.com WebSite: homepages.uc.edu/~enzerchcenzer@gmail.comhomepages.uc.edu/~enzerch Child - Adolescent - Adult - Family – Psychiatry Anxiety -- Rational Evaluation Leads to Rational Management Objectives: Appreciate that Anxiety may not be a disorder Rapid Assessment for Anxiety Disorders Learn the Hierarchy of the Differential Diagnosis of Anxiety Disorders "Prescribing Is So Easy, Understanding People So Hard." Kafka, Franz. (1917) A Country Doctor. The Penal Colony, Stories and Short Pieces

2. “Patient Has Anxiety” What is Your Next Step? Click to Add Text

3. What Is the Treatment for Anxiety? What Does Hunger Tell Me? –Eat Food What Does Thirst Tell me? –Drink? What Does Tiredness Tell Me –Get Some Rest What Does Anxiety Tell Me Galvanize to Action Symptoms are Not Enough for Diagnosis –Impairment Is Required

4. Normal Fear vs Normal Anxiety Normal Fear Physiologic and Emotional Response to Recognized Sources of Danger Basic Survival Mechanism –Pain –Threat of Danger One of Innate Emotions Promotes Fight or Escape/Avoidance Ready To Cope with Present Danger(s) Normal Anxiety Apprehension, tension, or uneasiness from anticipation of danger Normal reaction to stress –Galvanize to Action Ready To Cope With Upcoming Negative Event(s)

5. - Pathologic Anxiety - When Anxiety Interferes with Effectiveness And/or when Anxiety Interferes with Achievement And/or when Anxiety Interferes with Satisfactions And/or when Anxiety Interferes with Emotional Comfort Mood Condition That Occurs Without An Identifiable Triggering Stimulus Anxiety + Impairment

6. - Pathologic Anxiety - Anxiety Disorders Double the Death Rate The Suicide Rate of Some Anxiety Disorders is the Same as the Suicide Rate for the Depressive Disorders

7. Decision Tree for Anxiety Learning to Think Like A Psychiatrist Apprehensive Anticipation Future Danger and/or Misfortune Accompanied by Feeling of Dysphoria and/or Somatic Tension Focus of Anticipated Danger May be Internal or External Anxiety:

8. Symptoms of Anxiety, Fear, Avoidance or Increased Arousal Due to the Direct Physiological Effect of a General Medical Condition Yes Anxiety Disorder due to a General Medical Condition 293.89 Due to the Direct Physiological Effect of a Substance (Drug, Alcohol, Caffeine, Medication) Substance Induced Anxiety Disorder 291.8, 292.89 No Yes No

9. Recurrent, Unexpected Panic Attacks Plus 1 Month of Worry, Concern about Attacks or Change in Behavior Anxiety about Being in Places from which Escape Might be Difficult or Embarrassing in the Event of Having a Panic Attack Panic Disorder With Agoraphobia 300.21 Yes Panic Disorder Without Agoraphobia 300.01 No

10. Agoraphobia [Anxiety about Being in Places from Which Escape is Difficulty and/or Embarrassing Anxiety about Separation for Attachment Figure – Onset in Childhood Fear of Humiliation or Embarrassment in Social or Performance Situations Social Phobia 300.23 Separation Anxiety Disorder 309.21 Agoraphobia without History of Panic Disorder 300.22 No Yes No

11. Fear Cued by Object or Situation Obsessions or Compulsions 6-Month Period of Excessive Anxiety or Worry Plus Associated Symptoms Generalized Anxiety Disorder 300.02 Obsessive Compulsive Disorder 300.3 Specific Phobia 300.29 No Yes No Occurs Exclusively During a Mood or Psychotic Disorder No Yes See Mood or Psychotic Disorders

12. Acute Stress Disorder 308.3 Anxiety in Response to a Severe Traumatic Event Posttraumatic Stress Disorder 309.81 Reexperiencing of Event, Increased Arousal with Avoidance of Stimulus Associated with Traumatic Event Duration of More than One Month No Yes No Yes

13. Anxiety that Does not Meet Criteria for One of the Above Anxiety Disorders and Develops in Response to a Stressor Clinically Significant Symptoms that Do not Meet Criteria for a Specific Anxiety Disorder Anxiety Disorder not Otherwise Specified 300.00 Adjustment Disorder with Anxiety 309.24 No Yes No No Anxiety Disorder (Symptoms of Fear, Anxiety or Avoidance that Are not Clinically Significant) No

14. Think Like a Psychiatrist Since the era Rudolf Ludwig Karl Virchow (13 October 1821 – 5 September 1902), mere symptom treatment represents a scientifically untenable position in all areas of medicine, psychiatry included Looking alike, primary and secondary psychiatric symptoms are etiologically diverse They demand serious differential diagnostic effort Secondary psychiatric symptoms caused by undetected medical illness will not respond to psychotherapy Secondary psychiatric symptoms may be aggravated by psychotropic medications

15. Think Like a Psychiatrist A survey of 4500 psychiatric patients in different times and geographical locations, showed 30 - 50% of patients suffered from previously undiagnosed significant medical abnormalities. About 30% of the physical illnesses produced symptoms showing direct relation to the psychopathology of the patient –Predisposing to the Mental Disorders –Precipitating the Mental Disorders –Perpetuating the Mental Disorders

16. Anxiety from Medical Disorders Cardiovascular Disorders Acute Anemias Arrhythmias Congestive Heart Failure Pulmonary Embolism Endocrine Disorders Hyperadrenocorticism Hyperthyroidism Hypoglycemia Pheochromocytoma Metabolic Disorders Porphyria Vitamin B12 Deficiency Neurologic Disorders Encephalitis Neoplasms Vestibular Dysfunction Pain Respiratory Disorders Chronic Obstructive Pulmonary Disease Hyperventilation Pneumonias

17. Substance-Induced Anxiety Disorder Sedative, or Hypnotic, or Anxiolytic Adverse Reaction to Medications ePocrates Hand Held = #301 ePocrates Online Alternative Drugs = #86 ePocrates Online Drugs = #266 www.pdr.net = #603www.pdr.net Drugs of Abuse During Intoxication or Withdrawal Alcohol Amphetamine Amphetamine-like Caffeine Cannabis Cocaine Hallucinogen Phencylcline Phencylcline-like

18. Managing Anxiety 1.Suspend Moral Judgment 2.Examine Comprehensively 3.Inform about the Findings 4.Make Recommendations 5.Provide Specific Treatments when Indicated Doctoring: Sequence is Crucial

19. Managing Anxiety Disorders Rational Evaluation 1.Consider Anxiety Secondary to Medical Condition 2.Consider Anxiety Secondary to Substance(s) 3.Decision Making Tree to Sort out the 50+ Disorders 4.5 – 45 Seconds Evaluation for Suicide 5.Use Medications On Label Only for Specific Disorder 6.When Will it be Reasonable to Expect a Response 7.For Treatment Failure, Psychiatric Consultation

20. Managing Anxiety Disorders Rational Treatment The Hippocratic Oath We Do Not Promise to Cure We Do Not Promise to Treat We Promise Not to Harm

21. Managing Anxiety Disorders Rational Treatment 1.Review the Advantages of Medical Psychotherapy 2.Review the Advantages of Medication 3.Use Medication On Label Only for Specific Disorder 4.Review the Counter-Indications 5.Review the Cautions 6.Review the Adverse Effects 7.Review the Approved Duration of Treatment

22. Managing Anxiety Disorders Rational Treatment The Shorter the Half-life The Greater the Addictiveness The Faster the Onset The Greater the Addictiveness Sedatives Hypnotics Anxiolytics

23. Managing Anxiety Disorders Choosing a Psychiatric Consultant The Psychiatrist is Curious The Psychiatrist is Thorough The Psychiatrist Enjoys Working with Patients Who Have Failed Treatment

24. Now, Go Forth: 1.Learn 2.Practice 3.Learn 4.Practice 5...... And Do No Harm