Treatment of Anxiety Disorders Controlled Substance Workshop. Shonda Phelon MSN, FNP-BC, APMHNP-BC MNA Convention 2011
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1 Treatment of Anxiety Disorders Controlled Substance Workshop Shonda Phelon MSN, FNP-BC, APMHNP-BC MNA Convention 2011
2 Term used to describe both symptoms and disorders Occurs normally Very common symptom in multiple disorders Difference between Fear and Anxiety real or perceived threat Adaptive value : helps to plan and prepare for threat moderate levels enhance learning and performance Maladaptive when chronic / severe
3 Symptoms include : physiological symptoms of activated sympathetic nervous system (increased heart rate, increased respiration, sweating etc.) cognitive component (awareness of being frightened) behavioral components (urge to escape)
4 Panic disorder with or without agoraphobia Agoraphobia without panic disorder Specific phobias Social phobia Obsessive compulsive disorder Posttraumatic stress disorder Acute stress disorder Generalized anxiety disorder Anxiety disorder due to a general medical condition Substance-induced anxiety disorder Anxiety disorder not otherwise specified
5 Some amount of anxiety is normal and is associated with optimal levels of functioning. Only when anxiety begins to interfere with social or occupational functioning is it considered abnormal.
6 Fear Panic Anxiety Anxiety Disorder
7 CNS equilibrium is determined by a balance between excitatory and inhibitory neurotransmission Excitation -> Glutamate is prototypical NT. Inhibition -> GABA is prototypical NT. Inhibition via GABA is primarily mediated by the ionotropic GABA-A receptor. GABA binding to GABA-A results in an increase in neuronal Cl - conductance and subsequent neuronal hyperpolarization.
8 Anxiety disorders: >25% of population A psychological disorder characterized by unrealistic fear and anxiety. Panic disorder Panic Disorder: generalized anxiety obsessive compulsive behavior A disorder characterized by episodes of intense fear accompanied by symptoms such as shortness of breath and irregularities in heartbeat.
9 General characteristics Prevalence and age of onset Comorbidity with other disorders Treatment
10
11 The psychoanalytic viewpoint Classical conditioning to many stimuli The role of unpredictable and uncontrollable events A sense of mastery: immunizing against anxiety
12 Genetic factors A functional deficiency of GABA Neurobiological differences between anxiety and panic
13
14
15 Prevalence and age of onset Comorbidity with other disorders Biological causal factors The role of Norepinephrine and Serotonin
16 Copyright 2004 Allyn and Bacon
17
18 Genetic factors Cognitive and behavioral causal factors Interoceptive fears
19
20 Brain Mechanisms MRI reveals lower activity in frontal cortex during panic attack in panic subjects compared to controls Decreased frontal activity may inhibit one s ability to control reactions to panic inducing stimuli
21 Anticipatory anxiety: A fear of having a panic attack; may lead to the development of agoraphobia. Agoraphobia: An unrealistic and intense fear of being away from home or other protected places. In severe cases people will not leave home!
22 Perceived control and safety Anxiety sensitivity as a vulnerability factor for panic Safety behaviors and the persistence of panic Cognitive biases and the maintenance of panic
23
24 Panic disorder Panic versus anxiety Agoraphobia Agoraphobia without panic
25 Medications Behavioral and cognitive-behavioral treatments
26
27 Phobias 1. Specific phobias 2. Social phobia 3. Agoraphobia
28 Psychosocial causal factors Genetic and temperamental causal factors Preparedness and the nonrandom distribution of fears and phobias Treating specific phobias
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30 General characteristics Fear of being in social situations in which one will be embarrassed or humiliated
31
32 Interaction of psychosocial and biological causal factors Social phobias as learned behavior Social fears and phobias in an evolutionary context Preparedness and social phobia
33
34
35 Characteristics of OCD Types of compulsions Types of obsessions Treatment
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37 Obsessions- repetitive unwanted ideas that the person recognizes are irrational Compulsions- repetitive, often ritualized behavior whose behavior serves to diminish anxiety caused by obsessions Affects 2-3% of general population
38 Genetic influences Abnormalities in brain function The role of serotonin
39 Examples of obsessions: Concern for order and constancy Cleanliness (body or living space) Forbidden sexual thoughts Examples of compulsions: Hand washing Checking Collecting Repeating behaviors (in and out of a door) Arranging things Cleaning
40
41 Acute Stress Disorder Added to DSM-IV in 1994 symptoms 2 days to 4 weeks following traumatic event PTSD Added to DSM-III in 1980 symptoms beyond 4 weeks delayed onset
42 Critical Components Symptoms occurs AFTER a traumatic stressor Response involves intense fear, helplessness, or horror Re-experiencing of the event and numbing response Increased Arousal Interference in Social and Occupational Functioning
43
44 Intrusive Thoughts distressing recollections dreams flashbacks psychological trigger reactions physiological trigger reactions
45 Avoidance Behaviors avoid thoughts, feelings or discussions avoid activities, places memory blocks anhedonia (without pleasure) numb alexithymia (emotions unknown) feeling of doom
46 Hyperarousal Symptoms sleep disturbance anger problems concentration startle response on guard hypervigilence
47 All ages Both genders Across Cultures and ethnic groups
48 Natural Earthquakes Floods Fires Hurricanes Human induced War Violent Crimes Motor Vehicle Accidents
49 Alcoholism 75% for Vietnam Veterans with PTSD Depression 77% of firefighters with PTSD also have depression Generalized Anxiety Panic Attacks
50
51 Assessment Nonpharmacologic Medication Therapy
52 Hypersensitivity and Allergies Use of alcohol and other CNS depressants Drug abuse and dependence All current prescribed medication
53 Cognitive behavioral therapy Counseling Biofeedback techniques Meditation
54
55 Historically barbiturates were used to treat severe cases of anxiety (not seem much anymore) Benzodiazapines (valium, ativan, librium) had less severe side effects Other GABA agonists Gabapentin Serotonin agonists Tricyclic Antidepressants
56 Antidepressants-First Line -SSRI s -Tricyclics Benzodiazepines -Klonopin GABA Agonists -Gabepentin
57 Serotonin's involvement in impulse control via orbitofrontal cortex and basil ganglia (both receive SE input) SSRIs are most effective (Zoloft and Paxil ) Serotonin antagonists worsen symptoms (Trazodone) Tricyclic Antidepressants very helpful in OCD There is controversy as to how lone Benzodiazepines should be used. They are not the Mainstay of treatment!
58 Librium introduced in 1957 s Mother s little helper Valium came out in 1970 s and quickly became the top selling drug Xanax introduced in 1986 and again became top selling drug SSRI s began to replace some chronic benzo use for anxiety
59 General characteristics Differ in action, duration, drug-drug interactions & side effects based on differences in absorption rate, lipid solubility & metabolism. Indications/uses include anxiety d/o, panic d/o, mania, seizure d/o, phobias, insomnia, alcohol withdrawal, muscle spasm, agitation, catatonia, akathisia hospital use (IV/IM) in sedation for procedures Side effects sedation, cognitive impairment, anterograde amnesia respiratory depression at high dose or with alcohol may worsen obstructive sleep apnea symptoms disinhibition in susceptible individuals
60 alprazolam (Xanax) short/mid chlordiazepoxide (Librium) long clonazepam (Klonopin) mid-long clorazepate (Tranxene) long diazepam (Valium) long estazolam (ProSom) mid flurazepam (Dalmane) long lorazepam (Ativan) short-mid oxazepam (Serax) short-mid temazepam (Restoril) mid triazolam (Halcion) short (used in Procedures)
61 Abuse and dependence Risk of abuse is small in individuals who are not abusing other substances Withdrawal symptoms and physical dependence are not in themselves problematic if reductions are done gradually to minimize symptoms use of longer acting agents to minimize between-dose breakthrough and avoiding PRN dosing are helpful symptoms of withdrawal may represent breakthrough of the underlying anxiety disorder needing to increase the dose (tolerance) not generally an issue at therapeutic doses
62 Partial agonist at the serotonin 1a receptor. Relieves anxiety without producing sedation, impairment of motor skills, or memory loss. Does not induce withdrawal symptoms upon discontinuation. Does not act immediately works best with chronic anxiety Can take up to 1-2 weeks to become effective. Pharmacokinetics: Rapidly absorbed orally. Rapid first-pass effect. Elimination half-life = 2-4 hrs. Metabolism is primarily hepatic.
63 Based on the idea that our thoughts cause or feelings and behaviors Uses in-vivo exposure with Anxiety Disorders Uses Exposure/Response Prevention with OCD Uses exposure and cognitive restructuring with Social Anxiety Disorder Has proven very useful in weaning patients off benzodiazepines
64 Medication may correct an underlying biological abnormality. CBT may correct maladaptive behavior or cognitions. Neither helps everyone---research has shown combination therapy is best.
65 Sources for evidence regarding combined therapy Literature search for databases (e.g., Medline, PsycINFO) using keywords (e.g., anxiety and disorder and social and phobia and combined or pharmacotherapy or psychotherapy ) Results consisted of: Articles comparing treatment approaches + Provides details of research methods and analysis - Difficult to compare results across different studies Meta-analytic studies + Synthesizes research by transforming results from diff. studies into a common metric (effect size) - No gold standard; exclusionary criteria my bias conclusions Literature reviews + Allows for gross comparison of different studies - Exclusionary criteria may bias conclusions
66 The only thing that helps me is Xanax Refuses to try other meds even as an adjucnt Refuses inpatient treatment to regulate medications (even if it s free!) Refuses Cognitive Behavioral Therapy Calls in for frequent refills Usually short on meds at follow-up Often asks to go up on dose without attempting alternative therapies.
67
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