Anxiety and PTSD. Dr. Joseph Polimeni Psychiatrist University of Manitoba

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1 Anxiety and PTSD Dr. Joseph Polimeni Psychiatrist University of Manitoba 1

Disclosure: Joseph Polimeni Financial Interest or Affiliation Commercial Enterprise(s) Ownership or partnership Employment Investments (mutual funds excluded)

2 Disclosure: Joseph Polimeni Financial Interest or Affiliation Commercial Enterprise(s) Ownership or partnership Employment Investments (mutual funds excluded) Advisory board or similar committee Clinical trials or studies Honoraria or other fees (e.g., travel support) Research grants Patents Other (specify) Speaker s Bureau 2

3 Learning Objectives At the end of this symposium the learner will be able to: List the main pharmacotherapeutic and psychotherapeutic treatment options for Panic Disorder/Agoraphobia. List the main pharmacotherapeutic and psychotherapeutic treatment options for Generalized Anxiety Disorder. List the main pharmacotherapeutic and psychotherapeutic treatment options for Social Anxiety Disorder. List the main pharmacotherapeutic and psychotherapeutic treatment options for PTSD. 3

4 Forward, Stop, Backwards 4

5 It is better to run away 100 times than be eaten once 5

6 Mismatch Theory Radiation, Divorce, Unemployment 6

7 Anxious Emotions Alert to Danger (They are only a warning light and not the actual danger) - Suffering is evolutionarily adaptive - Environmental Mismatch -Genetic variation -Disease 7

8 Depression and anxiety are mostly due to threats to social standing (and attachments) 8

9 Threats to Social Standing (as well as attachments and our reputation as cooperators) were very dangerous in the ancestral environment. 9

10 Anxiety Disorders Physical Threats Social Threats Hierarchal status Attachments 6. Generalized Anxiety Disorder (GAD) 10

Emotions Love, comradery, sexual attraction, mirth and laughter, happiness, anger, jealousy, revenge, dysphoria, sadness, anxiety, fear, boredom, adoration, pride, spirituality.

11 Emotions Love, comradery, sexual attraction, mirth and laughter, happiness, anger, jealousy, revenge, dysphoria, sadness, anxiety, fear, boredom, adoration, pride, spirituality. Emotions place the organism in a state that makes certain evolutionarily desirable behaviors more probable. Emotions reflect a complex stimulus-response paradigm All emotions are irrational (because they are unthinking reflexes) Frontal cortex modulates the intensity of emotions 11

12 Why drugs and talk therapy compliment each other 12

13 Anxiety presents in a few common ways Depression is contending with loss Anxiety is contending with threat of loss Life is complicated and therefore we are often dealing with stresses with both elements. Brains are complicated and therefore anxiety (or depression) can manifest in different ways. Normal anxiety, GAD Panic Disorder (agoraphobia) Social Anxiety Disorder (Social phobia) PTSD 13

14 Causes of Depression and Anxiety Hierarchal status (job loss, flunking exams) Attachments (divorce, break-up) Physical threats Genetic variation (Bipolar II Disorder) Early childhood trauma (borderline personality disorder) Disease (hypothyroidism, hyperthyroidism) 14

15 Panic Disorder (Agoraphobia alone is uncommon) TABLE 1. DSM-IV criteria for panic attack A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 min 1. Palpitations, pounding heart, or accelerated heart rate 2. Sweating 3. Trembling or shaking 4. Sensations of shortness of breath or smothering 5. Feeling of choking 6. Chest pain or discomfort 7. Nausea or abdominal distress 8. Feeling dizzy, unsteady, lightheaded, or faint 9. Derealization (feelings of unreality) or depersonalization (being detached from oneself) 10. Fear of losing control or going crazy 11. Fear of dying 12. Paresthesias (numbness or tingling sensations) 13. Chills or hot flushes 15

16 Social Anxiety Disorder Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation), being observed (e.g., eating or drinking), or performing in front of others (e.g., giving a speech). The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (e.g., be humiliated, embarrassed, or rejected) or will offend others. The social situation(s) almost always provoke fear or anxiety. (Note: in children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failure to speak in social situations.) The social situation(s) are actively avoided or endured with marked fear or anxiety. The fear or anxiety is out of proportion to the actual threat posed by the social situation. (Note: Out of proportion refers to the sociocultural context.) The fear, anxiety, or avoidance is persistent, typically lasting six or more months The fear, anxiety, and avoidance cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. 16

17 Generalized Anxiety Disorder core symptoms Uncontrollable and excessive worry about day-today matters such as finances, family, work, or health Worry about the impact of worrying i.e. they may be concerned that worry will damage their health or they may think that negative things will occur if they do not worry enough. These individuals report more worry about the future than patients with other anxiety problems GAD worry is chronic, exaggerated and impairs functioning 17

18 Generalized Anxiety Disorder (GAD): DSM-5 Diagnostic Criteria Excessive anxiety and worry present most of the time for > 6 months Difficult to control worry Associated with (at least 3 items adults; 1 item - children): Restlessness Being easily fatigued Concentration difficulties Irritability Muscle tension Sleep disturbance Anxiety, worry or physical symptoms cause clincially significant distress or functional impairment Not due to medication or substance or medical condition Disturbance not better explained another mental disorder 18

19 Generalized Anxiety Disorder (GAD) Prevalence: 1-year: 1%-4% Lifetime: approx. 6% Children: 3% Adolescents: 10.8% More frequent in Caucasians, elderly, and women (2-3x more likely) Age of onset: variable and may be bimodal: Children and adolescents: ages Adults: 31 (median), 32.7 (mean) Substantial economic costs Frequently under-recognized <1/3 of patients adequately treated Diagnosis and treatment in children complicated by previous designation of Overanxious Disorder of Childhood and its possible differentiation of childhood GAD from GAD in adults Painful physical symptoms in 60%-94% of patients (initial reason for presentation to physician in 72% of cases) 6. Generalized Anxiety Disorder (GAD) 19

20 Most Patients with GAD do NOT Present with Anxiety as the Primary Complaint Only 13% had anxiety as primary complaint 20

21 Actual Presentation May not be Worry Physical symptoms can be the main avenue through which GAD patients express their distress (known as somatization) Common presenting physical complaints include: - Insomnia - Muscle tension, trembling, twitching, aching, soreness - Cold, clammy hands - Dry mouth - Sweating - Nausea or diarrhoea - Urinary frequency - Tachycardia, palpitations - Dizziness, light-headedness - Breathing difficulties - Numbness, tingling - Hot or cold flushes 21

22 GAD: A Common Comorbid Condition GAD is one of the most common conditions that occurs comorbidly with other disorders 91% of patients with GAD have 1 additional diagnosis 1 GAD occurs comorbidly with many medical and psychiatric conditions, including: Major depression 1-4 Panic disorder 1-3 Social phobia 1 Specific phobia 1 Post-traumatic stress disorder 2 Chronic pain conditions 4 Chronic fatigue syndrome 2 Gastrointestinal disease 5 Irritable bowel syndrome 2,5 Hypertension 2 Heart disease 2 Comorbid psychiatric disorders are related to a poorer prognosis 22

23 Work Impairment in GAD and Other Chronic Conditions Days Work Impairment in Past Month 23

24 GAD Course of Illness Chronic Waxing and waning of symptoms 1 Low rates of remission over long term 1,2 Intermittent exacerbations Exaggerated response to stress 1,3 Symptom overlap with medical and psychiatric disorders 3 Many are undiagnosed 4 Episodes may be more persistent with age 5 Duration: Mean yrs (ECA) Poorer outcomes in patients with psychiatric comorbidities 6 24

25 GAD-7: Generalized Anxiety Disorder 7-item Scale 25

26 Main Points of Treating GAD 1. Treat based on comorbidity 2. SSRI s/snris are first line 3. Benzodiazepines are not evil 4. Buspirone and Pregabalin can be considered 5. Antipsychotics are not the cure for everything but have a place in treating GAD 6. In cases of treatment resistance, carefully review the diagnosis 26

27 Medications approved by Health Canada for GAD Venlafaxine Paroxetine E-citalopram Duloxetine Buspirone Note: Benzodiazepines have been approved for treatment of anxiety disorders not specifically GAD All other Meds are Off-label use in the treatment of GAD Katzman et al. BMC Psychiatry

28 Katzman et al. Canadian Clinical Practice Guidelines for Anxiety. BMC Psychiatry

29 SSRI s/snris Are First Line Ecitalopram, Venlafaxine have strong evidence in treating GAD Gelenberg JAMA month RCT with Venlalfaxine Lenze JAMA week RCT in older adults with ecitalopram But, pick your favorite based on patient s side effect profile. Start low, go slow, aim high. 29

30 Can J Psychiatry

31 Antidepressants vs. Benzodiazepines in Treating GAD Berney et al 2008 reviewed the literature and found that there were 22 RCTs comparing ADs to BZDs. None of them showed superiority of ADs over BZDs in the treatment of GAD. They concluded that there has been a shift in prescribing ADs instead of BZDs for GAD without any evidence to support this shift. 31

32 Risk of Fractures Not Just With Benzodiazepines 1. Bolton JM, Metge C, Lix L, et al. Fracture risk from psychotropic medications: a population-based analysis. J Clin Psychopharmacol. 2008;28(4): Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009;169(21): Wagner AK, Ross-Degnan D, Gurwitz JH, et al. Effect of New York State regulatory action on benzodiazepine prescribing and hip fracture rates. Ann Intern Med. 2007;146(2):

33 Antipsychotics Are Not the Cure for Everything, But Have a Place Atypical Antipsychotics- may have utility in people GAD + Bipolar disorder GAD + borderline personality disorder Zahreddenni et al. Current Clinical Pharmacotherapy Opinion

34 Generalized Anxiety Disorder Overview of Psychological Strategies CBT (preventing worry behaviors, problem solving, allaying guilt and anger, imagery exposure, psycheducation) Mindfulness-based strategies (meditation, acceptance of emotions, focus on here and now, Buddhist principles ) Relaxation Therapies (progressive muscle relaxation) Psychodynamic psychotherapy Motivational Interviewing 34

35 CBT vs. Medication for GAD Only three controlled studies were found that examined the relative and combined effects of CBT vs. medication (buspirone, diazepam, venlafaxine), with mixed results In a recent meta-analysis, CBT plus medication was generally more effective than CBT plus placebo at posttreatment, but not at follow-up for the treatment of GAD (Hofmann et al., 2009) 35

36 PTSD Haunted by an Experience

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41 Which criterion of DSM-IV ACUTE stress Disorder and PTSD was removed in DSM-5? A. Persistent avoidance of places that remind the person of the traumatic event. B. The person's response involved intense fear, helplessness, or horror. C. Persistent symptoms of increased arousal (not present before the trauma). D. Persistent re-experiencing of the trauma (e.g., nightmares, intrusive thoughts)

42 PTSD Criteria (DSM-5) A. Exposure to actual or threatened a) death, b) serious injury, or c) sexual violation, in one or more of the following ways: 1. directly experiencing the traumatic event(s) 2. witnessing, in person, the traumatic event(s) as they occurred to others 3. learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental 4. experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work-related. American Psychiatric Association, DSM-5

43 PTSD core symptoms Re-experiencing the trauma Intrusion Symptoms (distressing memories, flashbacks, nightmares) Hyperarousal (panic attacks, anxiety, poor concentration, startle reflex, irritable, insomnia) Active Avoidance Negative mood and Cognitions (depressed mood, emotional numbing, anger, guilt, pessimism) Greater than 1 month

44 DSM-5 Acute Stress Disorder PTSD Criteria Greater than 3 days and less than 1 month.

45 Prevalence of traumatic events in US General Population Husarewycz N, El-Gabalawy R, Logsetty S, Sareen J. Gen Hosp Psych, 2014

Pre-Trauma Factors Female sex Low IQ Prior trauma exposure Prior mental disorder

Severity of trauma Physical injury Post-Trauma Factors High heart rate Low Social

Peritraumatic dissociation Acute stress disorder Disability PTSD Sareen J.

46 Pre-Trauma Factors Female sex Low IQ Prior trauma exposure Prior mental disorder Personality factors Genetics Trauma Factors Perceived fear of death Assaultive trauma Severity of trauma Physical injury Post-Trauma Factors High heart rate Low Social support Financial stress Pain severity Intensive care unit stay Traumatic brain injury Peritraumatic dissociation Acute stress disorder Disability PTSD Sareen J. Can J Psychiatry 2014 Sareen et al. Depression and Anxiety 2013 Bryant et al. JAMAPsychiatry 2013 Brewin et. Al JCCP 2000

women is PTSD (~20%) Cambodian refugees in US, 20 years later 3 12-month prevalence 62% Combat veterans 30-50% Van Ameringen et al.

47 DSM-IV PTSD Prevalence Canadian general Population Lifetime 9.2% US general population Lifetime 6.8% (se 0.4) in NCS-R Female:Male ~ 2:1 Prevalence higher in some US subpopulations 2 to 3X in American Indians on reservations 2 Most prevalent disorder in women is PTSD (~20%) Cambodian refugees in US, 20 years later 3 12-month prevalence 62% Combat veterans 30-50% Van Ameringen et al NCS-R, National Comorbidity Survey Replication; 1 Kessler RC et al. Arch Gen Psychiatry. 2005;62: ; 2 Beals J et al. Arch Gen Psychiatry. 2005;62:99-108; 3 Marshall G et al. JAMA. 2005:294:

48 Prevention and Treatment 1. Pharmacological interventions in the acute stage of injury have not shown efficacy in reducing PTSD (but being drunk during the trauma helps!). 2. Group based Critical Incident Stress Debriefing does not have evidence of reducing PTSD. 3. Cognitive-behavioral therapy (CBT), and Exposure therapy (systematic desensitization) are more efficacious than citalopram or waiting list in preventing PTSD (however, access for CBT is difficult).

49 4. Treatment approach for a person with PTSD should consider comorbidity 5. EMDR - Eye Movement Desensitization Reprocessing What is effective in EMDR is not new, and what is new is not effective 6. SSRIs and SNRIs are the first line treatment. 7. Management of insomnia is crucial with zopiclone, trazodone, quetiapine, prazosin. (minimize benzodiazepines)

50 Questions

Anxiolytics and anxiety disorders. MUDr. Vítězslav Pálenský Dept. of Psychiatry, Masaryk University, Brno

Anxiolytics and anxiety disorders MUDr. Vítězslav Pálenský Dept. of Psychiatry, Masaryk University, Brno Anxiety disorders 1. Panic disorders and agoraphobia 2. Specific phobia and social phobia 3. Obsessive