7/13/2015 OBJECTIVES. 1. Presenter 2. Subject 3. DSM-IV vs DSM-5. What is Anxiety. Evaluation Tools. SSRIs SNRIs Benzo s. Others.

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7/13/25 OBJECTIVES ANXIETY 1 Presenter 2 Subject 3

Define Diagnosis What is Anxiety 2 QUESTIONS &

Hallmark Features Medication Plan of Care Questions

1 7/13/25 OBJECTIVES ANXIETY 1 Presenter 2 Subject 3 DSM-IV vs DSM-5 Differential Diagnosis Introduce Define Diagnosis What is Anxiety 2 QUESTIONS & ANSWERS Resources Evaluation Tools Effectiveness Hallmark Features Medication Plan of Care Questions Other Information SSRIs SNRIs Benzo s Case study Overview Others 3 4 1

7/13/25 Brain and the Neurotransmittors What is Anxiety?

Neurocognitive models of anxiety propose a common amygdala-prefrontal circuitry that underlies dysfunctional biases in emotion processing C GABA Aliquam ultrices elit sed lacus consequat, vel

resolve a situation Negative impact Address spectrum---to debilitating, paralysis Treatment indicated Intensity of anxiety Triggers of anxiety S/S that manifest A NOREPINEPHRINE Mauris justo felis,

demands on healthcare services Anxiety is a fluid state requiring in-depth assessment to tease out symptoms and determine diagnosis for best treatment In 20, National Institute of Mental Health

2 7/13/25 Brain and the Neurotransmittors What is Anxiety? Feeling of dread or uncomfortable anticipation with psychological, physical, cognitive, and behavioral features or diffuse, unpleasant, vague sense of apprehension accompanied by autonomic symptoms Neurocognitive models of anxiety propose a common amygdala-prefrontal circuitry that underlies dysfunctional biases in emotion processing C GABA Aliquam ultrices elit sed lacus consequat, vel sagittis odio vulputate B SEROTONIN Fusce pharetra sem non mauris auctor dapibus id ac eusimod adopiscing Motivational Certain amount of anxiety is good and makes us more productive Awesome We act to resolve a situation Negative impact Address spectrum---to debilitating, paralysis Treatment indicated Intensity of anxiety Triggers of anxiety S/S that manifest A NOREPINEPHRINE Mauris justo felis, lacinia vitae lectus sed, adpiscing scelerisque nisi More form article 6 Anxiety Disorders Diagnosis Anxiety is a significant health problem, often causing functional impairments and placing heavy demands on healthcare services Anxiety is a fluid state requiring in-depth assessment to tease out symptoms and determine diagnosis for best treatment In 20, National Institute of Mental Health declared anxiety as the most common mental health problem in the United States Lifetime Prevalence of 15-20% Family Burden Frequently present with co-morbidities Often Undetected and Undertreated DSM-5: Diagnostic and Statistical Manual of Mental Disorders fifth edition Separation Anxiety Excessive distress -separation Predominantly in childhood Excessive worry about loss Nightmares Panic Disorder Reluctance or refusal Being alone Recurrent unexpected panic Worrying about panic attacks Sleep away from home attacks NO other reason for attacks Selective Mutism Agoraphobia Fear of public transportation Fear of standing in line Failure to speak in certain situations Fear of open places Fear of crowds Interferes with achievements Fear of enclosed places Fear of being outside of home Lack of knowledge alone Generalized Anxiety Specific Phobias Out of proportion Excessive anxiety or worrying Object or situation Impairment Difficult to control Immediate reaction Animal, natural environment, Restlessness, keyed up, easily fatigued, mind going blank, Active avoidance blood-injection-injury, situational, irritability, muscle tension, sleep changes other Impairment 07 Social Anxiety Others Possible scrutiny by others Out of proportion Substance/Medication Induced Anxiety D/O Negative evaluation Impairment Anxiety D/O due to Another Medical Condition 08 Avoidance of social events Not attributed to other Other Specified Anxiety D/O 7 2

3 7/13/25 Demonstration Hallmark Symptoms Which diagnosis is the participant exhibiting? GENERALIZED ANXIETY Excessive & occurring more days than not for over 6 months SOCIAL ANXIETY D/O Exposure to scrutiny by others in social situations PANIC DISORDER Recurrent unexpected panic attacks abrupt surge from calm to panic SPECIFIC PHOBIA Out of proportion and specific in nature AGORAPHOBIA Situational, escape may not be available, may lead to panic 9 10 Who develops GAD? General Anxiety Disorder Common characteristics of the GAD patient Female yrs Smokes tobacco Separated or divorced Single parent Survivor of abuse Lives alone Only about 1/3 of patients with GAD seek psychiatric treatment The most effective treatment is a combination of psychopharmacology, psychotherapuetic, and supportive approaches Usually the patient seeks out the PCP for treatment of the somatic symptoms of GAD Anywhere from 50-90% of patients with GAD have another mental health condition---mdd, dysthymia, and substance abuse disorders

7/13/25 Prior to pharmacological treatment: Psychopharmacology Prescribing an anxiolytic to patients should not always be prescribed on the first visit Several factors need to be considered along

arcu, accumsan SIDE EFFECTS g a b ACCIDENTAL OVERDOSE SSRI S Selective Serotonin Reuptake Inhibitors SNRI S Selective Norepinephrine Reuptake Inhibitors COST f c AGE OF PATIENT PERSONAL PREFERENCE e

4 7/13/25 Prior to pharmacological treatment: Psychopharmacology Prescribing an anxiolytic to patients should not always be prescribed on the first visit Several factors need to be considered along with a treatment plan for this long term disorder COMORBIDITY Others drugs prescribed Duis arcu tortor, suscipit eget, imperdiet nec, imperdiet iaculis, ipsum Sed aliquam ultrices mauris Integer ante arcu, accumsan SIDE EFFECTS g a b ACCIDENTAL OVERDOSE SSRI S Selective Serotonin Reuptake Inhibitors SNRI S Selective Norepinephrine Reuptake Inhibitors COST f c AGE OF PATIENT PERSONAL PREFERENCE e d RISK OF SELF HARM OTHERS Anxiolytics, Beta Blockers, TCAs, mood stabilizers, atypical antipsychotic BENZODIAIPINES Lorazepam, diazepam, alprazolam, clonazepam, etc SSRIs SNRIs fluoxetine sertraline venlafaxine duloxetine desvenlafaxin e paroxetine citalopram levomilnacipran milnacipran reboxetine escitalopram fluvoxamine mirtazapine*

5 7/13/25 Benzodiazepines Benzos should not be offered for treatment of GAD EXCEPT as a short term measure for an acute crisis Others lorazepam diazepam Betablockers TCAs buspirone alprazolam clonazepam Mood stabilizers pregabalin gabapentin clorazepate oxazepam clonidine nefazadone COMPLEMENTARY AND ALTERNATIVE TREATEMNTS SCREENING TOOLS Most treatments require time and commitment from patient The GAD-7 offer clinicians concise, self-administered screening and diagnostic tools for mental health disorders, which have been field-tested in office practice CBT (Cognitive Behavioral Therapy) More effective for long term treatment Corrects dysfunctional beliefs and The screeners are quick and user-friendly, improving the recognition rate of anxiety and facilitating diagnosis and treatment eliminate unhelpful avoidance behaviors EMDR (Eye Movement Desensitization and Reprocessing) Self-Help Internet options Journaling Beck Anxiety Inventory Self reporting GAD-7 Seven question tool used specifically for anxiety Stress & Relaxation Techniques Guided Imagery, Yoga VANDERBILT ADHD DIAGNOSTIC SCALE Meditation SPENCE CHILDREN S ANXIETY SCALE HAMILTON ANXIETY RATING SCALE (HAM-A) This tool requires about minutes One of the first Acupuncture rating scales used to diagnose anxiety 07 KAVA Mixed results HOSPITAL ANXIETY AND DEPRESSION SCALE Sensitive and specific tool in identifying pathological anxiety and helps identify people who have medical conditions that may stimulate anxiety

7/13/25 OTHER Neuroimaging Predictors Pre-treatment

in anxiety disorders, PTSD, and OCD Case Study Cultural

the Horizon PET (positron emission tomography) Easily done

imaging) Measure brain activation in response to cognitive

computed tomography) Pre-treatment cerebral perfusion during

prescriptions Access to mental health treatment is worse

pricey, with 45% of the untreated citing cost as a barrier

6 7/13/25 OTHER Neuroimaging Predictors Pre-treatment neuroimaging measure do help predict treatment effectiveness in anxiety disorders, PTSD, and OCD Case Study Cultural Considerations Anxiety in Children & Adolescents Genetics On the Horizon PET (positron emission tomography) Easily done but least effective fmri (functional magnetic resonance imaging) Measure brain activation in response to cognitive and/or affective tasks SPECT (single photon emission computed tomography) Pre-treatment cerebral perfusion during provocation FIVE FACTS ABOUT MENTAL HEALTH IN USA QUESTIONS? Mental health dollars go toward out patient treatment and prescriptions Access to mental health treatment is worse than other types of medical services Mental health care is pricey, with 45% of the untreated citing cost as a barrier Attitudes about mental health services are another big barrier to care Recently states cut $18 billion dollars from their mental health budgets

7/13/25 References HAM-A American Psychiatric Association (23) Diagnostic and Statistical Manual of Mental Disorders, 5 th edition Washington, DC: American Psychiatric Association Garner, M, Mohler,

7 7/13/25 References HAM-A American Psychiatric Association (23) Diagnostic and Statistical Manual of Mental Disorders, 5 th edition Washington, DC: American Psychiatric Association Garner, M, Mohler, H, Stein, DJ, Mueggler, T, & Baldwin, DS, (2009) Research in Anxiety Disorders: From the Bench to the Bedside European Neuropsychopharmacology (2009) doi: 1016/jeuroneuuro20091 Kliff, SA (22, December 17) Seven facts about America s mental health-care system The Washington Post p A13 Lavoie, JAA(23) Eye of the Beholder: Perceived Stress, Coping Style, and Coping Effectiveness Among Discharged Psychiatric Patients Archives of Psychiatric Nursing 27(23) doi: 1016/japnu230 McGrandles, A & Duffy, T (22) Assessment and Treatment of Patients with Anxiety Nursing Standard 26(35) McGrandles, A & McCaig, M (20) Diagnosis and Management of Anxiety in Primary Care Nurse Prescribing 8(7) Mohr, C & Schneider, S (23) Anxiety Disorders European Child & Adolescent Psychiatry 22(Suppl 1) S17-S22 doi:101007/s The Hamilton Anxiety Rating Scale (HAM-A) is a widely used and wellvalidated tool for measuring the severity of a patient's anxiety It should be administered by an experienced clinician The major value of HAM-A is to assess the patient's response to a course of treatment, rather than as a diagnostic or screening tool Sadock, JB & Sadock, V A (2007) Kaplan & Sadock s Synopsis of Psychiatry (10 th ed) New York: Lippincott, Williams, & Wilkins Shin, LM, Davis, FC, VanElzakker, MB, Dahlgren, MK & Dubois, S J (23) Neuroimaging Predictors of Treatment Response in Anxiety Disorders Biology of Mood & Anxiety Disorders 3(15) doi:101186/ Stahl, SM (24) Stahl s Essential Psychopharmacology: Prescriber s Guide (5 th ed) New York: Cambridge University Press

Index. Note: Page numbers of article titles are in boldface type.

Index. Note: Page numbers of article titles are in boldface type. Index Note: Page numbers of article titles are in boldface type. A Age as factor in selective mutism, 623 as factor in social phobia, 623 Agoraphobia, 593 600 described, 594 596 DSM-V changes related to,