Anxiety Disorders Through the Life Span

Transcription

1 Anxiety Disorders Through the Life Span U.S. Department of State 2017 Continuing Medical Education Joseph N. Rawlings, M.D. Regional Medical Officer/Psychiatrist U.S. Consulate General - Frankfurt 1

2 Defining Anxiety A feeling physical, emotional and behavioral responses to perceived threats Diffuse apprehension accompanied by physical symptoms headache, sweating, palpitations, chest tightness, stomach upset, restlessness Normal and necessary part of life 2

3 Anxiety vs. Fear Anxiety Threat is unknown, internal, vague or conflictual Fear Threat is known, external, definite threat 3

4 How Common? Most common mental disorders in adults and children Early onset: average age eleven ~18% of population More common in females than males Creswell C;Waite P. Evid Based Mental Health. 2016;19(3): NIMH data, accessed at: 4

5 Anxiety Common Conceptually easy to understand Often waxes and wanes like many chronic ills Functional impairment, decreased quality of life Treatable 5

6 Anxiety Common Conceptually easy to understand Often waxes and wanes like many chronic ills Functional impairment, decreased quality of life Treatable Why does treating anxiety sometimes make us anxious? 6

7 Anxiety Confounders Physical symptom presentation Overlap with mood diagnoses Patient expectations Concerns about malingering Increased risk of suicide* *Sareen J; Cox B; Afif T; et al. Anxiety Disorders and Risk for Suicidal Ideation and Suicide Attempts. Arch Gen Psychiatry. 2005;62(11):

8 Goals Normal developmental and maturity factors vs. anxiety What presents when? Symptoms and diagnosis Diagnoses commonly presenting to the HU Screening tools Management and treatment Case studies 8

9 Anxiety Presentation by Age Child/Adolescent Adult Geriatric Presenting Irritability Irritability Concentration/memory Complaint Somatic symptoms Somatic symptoms Somatic symptoms Poor sleep Poor sleep Poor sleep Fatigue Fatigue Context School Work, social settings Activities of daily living Burden School refusal Occupational disability Healthcare utilization Parental burden Interpersonal dysfunction Caregiver burden Healthcare utilization Dialogues Clin Neurosci Dec: 13(4):

10 Anxiety Prevalence by Age Dialogues Clin Neurosci Dec; 13(4):

11 Children and Anxiety 11

12 Developmental Considerations Stranger Anxiety 9 or 10 months Imaginary fears ( monsters ) peak 4 5 years Normal pre-school fears dissipate ~ 7-8 years Shonkoff JP, et. Al. Persistent Fear and Anxiety Can Affect Young Children s Learning and Development. National Scientific Council on the Developing Child. Harvard University Center on the Developing Child. (2010). Accessed via 12

13 Common Anxiety Presentations in Our Health Units 13

14 Common in Our Health Unit Encounters Separation Anxiety Social Anxiety Obsessive-Compulsive* Panic Generalized Anxiety Acute Stress* American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing * Obsessive-Compulsive and related disorders, as well as Trauma and Stressor related disorders, not classified with Anxiety Disorders. Included here for clinical relevance 14

15 Separation Anxiety Disorder Developmentally inappropriate excessive fear or anxiety concerning separation from those to whom the individual is attached Worry about losing attachment, untoward events, refusal to go to school, sleep away, not able to accept parents departure for work, etc. Four weeks duration in children Most common anxiety disorder in young children. Rare to see onset in adolescence American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing 15

16 Social Anxiety Disorder Worry about one or more social situations in which the individual is exposed to possible scrutiny by others Concern that may act in a way that makes the individual feel humiliated, embarrassed, rejected, Fear of being negatively evaluated Persistent avoidance of situations Present six months Median onset, age 13 American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing 16

17 Obsessive Compulsive Disorder Presence of obsessions, compulsions, or both Obsessions recurrent and persistent thoughts, urges, or images Attempt to suppress with other thought or action Compulsions Repetitive behaviors (like hand washing) or mental acts ( like counting) person feels driven to perform Median age onset: 19.5 years American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing 17

18 Panic Disorder Recurrent, unexpected abrupt surge of intense fear or discomfort, reaching peak in minutes Pounding heart, sweating, trembling/shaking, sensation of smothering, feeling of choking, chest pain, dizzy/faint, paresthesias, derealization/depersonalization, fear of loss of control or dying At least one attack followed by one month of persistent fear of recurrence Peak in adulthood, decline later in life American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing 18

19 Generalized Anxiety Disorder Excessive worry occurring more days than not for at least six months, about a number of events or activities Restless, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance Difficult to control worry and to keep thoughts from interfering with tasks at hand Often worry is about routine matters Median onset: age 30 American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing 19

20 Acute Stress Disorder Exposure to or threatened death, serious injury, or sexual violation, through Intrusive memories or dreams, dissociative reactions (flashbacks), avoidance, hyperarousal Symptoms begin immediately after event, persistence at least three days, up to one month American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing 20

21 Medical Mimics 21

22 Conditions that May Mimic or Increase Anxiety Symptoms Endocrine Hyperthyroidism, hypothyroidism, pheochromocytoma, Cushing s disease, Addison s disease, menopause Cardiovascular Acute coronary syndrome, arrhythmia, CHF, hypertension, hypotension, mitral valve prolapse Neurologic Epilepsy, cerebrovascular disease, Meniere s disease, multiple sclerosis, encephalitis, early dementia, migraine 22

23 Conditions that May Mimic or Increase Anxiety Symptoms (continuing) Metabolic Diabetes, porphyria Pulmonary Asthma, COPD, pulmonary embolism, pneumonia Other illnesses Anemia, UTI in elderly, irritable bowel syndrome, heavy metal poisoning, B-12 deficiency, electrolyte disturbances Medications Anticholinergics, steroids, stimulants, theophylline, nasal decongestants, SSRIs 23

24 Screening Tools 24

25 Anxiety Screening Tools Clinical interview or self-report screens Value of the screen documenting diagnosis educational tool Familiarity with screening terms for informal interviewing 25

26 GAD -7 Generalized Anxiety Disorder 7-Item Scale Over the last two weeks, how often have you been bothered by the following problems? Feeling nervous, anxious, or on edge Not being able to stop or control worry Worrying too much about different things Trouble relaxing Being so restless that it s hard to sit still Becoming easily annoyed or irritable Each of these scored as: 0: Not at all 1: Several days 2: Over half the days 3: Nearly every day Feeling afraid as if something awful might happen Spitzer RL, Kroenke K, Williams JB, Lowe B. A Brief Measure for Assessing Generalized Anxiety Disorder. Arch. Intern. Med. 2006;166:

27 GAD -7 Generalized Anxiety Disorder 7-Item Scale Scoring: 5: Mild anxiety 10: Moderate anxiety 15: Severe anxiety Spitzer RL, Kroenke K, Williams JB, Lowe B. A Brief Measure for Assessing Generalized Anxiety Disorder. Arch. Intern. Med. 2006;166:

28 GAD -7 Generalized Anxiety Disorder 7-Item Scale Scoring: 5: Mild anxiety 10: Moderate anxiety 15: Severe anxiety Score 10 or more: recommend further evaluation Spitzer RL, Kroenke K, Williams JB, Lowe B. A Brief Measure for Assessing Generalized Anxiety Disorder. Arch. Intern. Med. 2006;166:

29 GAD -7 Generalized Anxiety Disorder 7-Item Scale If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult Spitzer RL, Kroenke K, Williams JBW, Lowe B. A Brief Measure for Assessing Generalized Anxiety Disorder. Arch. Intern. Med. 2006;166:

30 Beck Anxiety Inventory Self-report, 21 item Useful in adolescents and adults More useful in patients with somatic focus Beck, AT. Epstein, N. Brown, G. Steer, RA. (1988). An Inventory for Measuring Clinical Anxiety: Psychometric Properties. Journal of Consulting and Clinical Psychology, 56, Leyfer, OT; Ruberg, JL; Woodruff-Borden, J (2006). Examination of the utility of the Beck Anxiety Inventory and its factors as a screener for anxiety disorders. Journal of Anxiety Disorders. 20 (4): Osman, A; Hoffman, J; Barrios, FX; Kopper, BA; Breitenstein, JL; Hahn, SK (April 2002). Factor structure, reliability, and validity of the Beck Anxiety Inventory in adolescent psychiatric inpatients. Journal of Clinical Psychology. 58 (4): Creamer M, Foran J, Bell R (1995). The Beck Anxiety Inventory in a nonclinical sample. Behav Res Ther. 33 (4):

31 Beck Anxiety Inventory Past month, including today Numbness and tingling Feeling hot Wobbliness in legs Unable to relax Fear of worst happening Dizzy or lightheaded Heart pounding/racing Unsteady Terrified or afraid Nervous Feeling of choking Hands trembling Shaky / unsteady Fear of losing control Difficulty in breathing Fear of dying Scared Indigestion Faint / lightheaded Face Flushed Hot or cold sweats Beck, AT. Epstein, N. Brown, G. Steer, RA. (1988). An Inventory for Measuring Clinical Anxiety: Psychometric Properties. Journal of Consulting and Clinical Psychology, 56,

32 Beck Anxiety Inventory Past month, including today 0: Not at all 1: Mildly - but it didn t bother me much 2: Moderately - it wasn t pleasant at times 3: Severely it bothered me a lot Beck, AT. Epstein, N. Brown, G. Steer, RA. (1988). An Inventory for Measuring Clinical Anxiety: Psychometric Properties. Journal of Consulting and Clinical Psychology, 56,

33 Beck Anxiety Inventory Scoring 0 9: Normal 10 18: Mild to moderate 19-29: Moderate to severe 30 63: Severe Steer RA, Ranieri WF, Beck AT, Clark DA (1993). Further Evidence for the Validity of the Beck Anxiety Inventory with Psychiatric Outpatients. Journal of Anxiety Disorders. 7:

34 Anxiety Management 34

35 Anxiety Management Identify Anxiety Symptoms Distress or functional impairment? Assess suicidality Differential Diagnosis Due to another medical or psych condition? Co-morbid with another diagnosis? Medication-induced? Drug related? Physical exam, labs needed? Can J Psychiatry, Principles of Diagnosis and Management of Anxiety Disorders. Vol 51, Suppl 2, July

36 Anxiety Management (continued) Identify Specific Anxiety Disorder Panic, specific phobia, OCD, Generalized, PTSD, etc. Comorbid Medical Diagnosis? benefits, risks of treatment and untreated anxiety Comorbid Psych Diagnosis? Substance abuse? Other anxiety or mood:? Single therapy to address both Psychological or pharmacologic treatment Patient preference Education Can J Psychiatry, Principles of Diagnosis and Management of Anxiety Disorders. Vol 51, Suppl 2, July

37 Anxiety Management (continued) Psychological treatment First line: Cognitive-Behavior Therapy (CBT) Inadequate response? other talk therapy Pharmacologic treatment First line: SSRI or non-benzo Inadequate response? other first line Refer Psychological + Pharmacologic Can J Psychiatry, Principles of Diagnosis and Management of Anxiety Disorders. Vol 51, Suppl 2, July

38 Anxiety Management (continued) Benzodiazepines Half-life and dosing considerations 38

39 Anxiety Management (continued) Antidepressant Therapy primarily SSRIs 39

40 Anxiety Management (continued) Patient Education Can J Psychiatry, Principles of Diagnosis and Management of Anxiety Disorders. Vol 51, Suppl 2, July

41 Patient Presentations 41