ANXIETY DISORDERS IN DSM5

Transcription

1 ANXIETY DISORDERS IN DSM5 Dr Robin Lawrence 117a & 96 Harley St

2 PLAN FOR THIS EVENING Diagnostic Systems ICD10 & DSM5 compared A Philosophical Perspective Historic Perspective The Cook Book approach SUGGESTIONS FOR WHAT THE GP SHOULD DO

3 ICD 10 Neurotic, Stress-related and Somatoform Disorders

4 NEUROTIC, STRESS-RELATED & SOMATOFORM Phobic Anxiety Disorders Other Anxiety Disorders Obsessive-compulsive disorder Post Traumatic Stress Disorder Dissociative Disorders Somatoform Disorders Other Neurotic Disorders

5 OTHER ANXIETY DISORDERS Panic Disorder Generalised Anxiety Disorder Mixed Anxiety & Depression

6 DSM 5 Anxiety Disorders

7 ANXIETY DISORDERS Separation Anxiety Selective Mutism Specific Phobia Social Anxiety Disorder Panic Disorder Agoraphobia Generalised Anxiety Disorder Medication Anxiety Disorders Anxiety due to Medical Condition Other Specific Anxiety Disorder Unspecific Anxiety Disorder

8 A BIT OF PHILOSOPHY AND HISTORY From DSM III to DSM5 Sought to make Diagnostic Categories. Platonic Idealism

9 Generally, even complex diagnoses are considered against an imaginary ideal/perfect case for a diagnosis to be made. From DSMIII to DSM-5 the Chinese Menu approach to diagnosis remains.

10 GENERALISED ANXIETY DISORDER DSM 5 A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance). B. The individual finds it difficult to control the worry. C. Three or more of the following six symptoms A. i)restlessness or feeling keyed up or on edge. B. ii) Being easily fatigued. C. iii)difficulty concentrating or mind going blank. D. vi)irritability. E. v)muscle tension F. vi)sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep) D. Clinically significant distress or impairment in social, occupational, other important function E. Not caused by drugs, medication, or a medical condition (eg Hyperthyroidism) F. Not better explained by any other mental illness (eg Panic disorder or PTSD)

11 ANXIETY DISORDER ICD 10 A condition marked by excessive worry and feelings of fear, dread, and uneasiness that last six months or longer. Includes being restless, being tired or irritable, muscle tension, not being able to concentrate or sleep well, shortness of breath, fast heartbeat, sweating, and dizziness. An anxiety disorder characterized by excessive and difficult-tocontrol worry about a number of life situations. The worry is accompanied by restlessness, fatigue, inability to concentrate, irritability, muscle tension, and/or sleep disturbance and lasts for at least 6 months.

12 ANXIETY DISORDER ICD 10 An anxiety disorder [is] characterized by free-floating, persistent, and excessive worry for at least six months. Apprehension of danger and dread accompanied by restlessness, tension, tachycardia, and dyspnea unattached to a clearly identifiable stimulus. Apprehension or fear of impending actual or imagined danger, vulnerability, or uncertainty. Fear and anxiety are part of life. Types include panic disorder obsessive-compulsive disorder post-traumatic stress disorder phobias generalized anxiety disorder

13 IN DSM5 Panic disorder is included Phobias are included Post Traumatic Stress disorder is excluded Obsessive-Compulsive Disorder is excluded

14 THE BEST LONGITUDINAL STUDIES The typical history of a forty five year-old alcoholic male Starts with separation anxiety (5-13) Proceeds with Social Anxiety Disorder - and preloading before social events (13-22) Proceeds to Generalised Anxiety Disorder (22-32) Continues to Major Depressive Disorder (32-42) Develops into Addictive Compulsive Disorder (42 and above) Most commonly Alcoholism

15 IN DSM5 Has a developmental approach: 1. Separation Anxiety 2. Selective Mutism 3. Specific Phobia 4. Social Anxiety Disorder 5. Panic Disorder 6. Agoraphobia 7. Generalised Anxiety Disorder

16 HISTORY DSM 2 (in 1952) and DSM III (1968) copied ICD 6 Modified to the Chinese Menu approach (prescriptive diagnostic categories):

17 NOW ICD 10 was to be replaced with ICD11 in 2015 To harmonise ICD with the latest DSM Not yet published

18 SUGGESTIONS FOR THE GP Use ICD 10 and DSM 5 together: How long has this been going on for? (six months or more) Does it cause you any trouble? Yes or no to the following 6 symptoms i)restlessness or feeling keyed up or on edge ii) Being easily fatigued. iii)difficulty concentrating or mind going blank vi)irritability v)muscle tension vi)sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)

19 MAKE THE DIAGNOSIS Is this any specific kind of Anxiety? Panic disorder? Phobias? Post Traumatic Stress Disorder? Obsessive-Compulsive Disorder? Generalized Anxiety disorder? CHANGE TO ICD10

20 SPECIFIC QUESTIONS DO YOU HAVE PANIC ATTACKS? DOES ANYTHING SPECIFIC BRING IT ON? (PHOBIAS) DO YOU HAVE NIGHTMARES/TRY CONSTANTLY TO REMOVE THE THOUGHT FROM YOUR MIND? (PTSD) ARE YOU A CHECKER DO YOU RUMINATE? WHAT, IF ANYTHING MAKES THIS BETTER (OCD) IS THIS FEELING WITH YOU MOST OF THE TIME? (GAD)

21 AND THEN? Refer

22 ANXIETY IS MUCH HARDER TO TREAT THAN DEPRESSION Because although SSRIs are good for both Anxiety sufferers more often have side-effects. Generally thay can make the patient feel worse before they get better. There are subtle differences between drugs in the same categories Mirtazepine and Seroxat have a special role in PTSD Seroxat has a special role in OCD

23 OTHER DRUGS? MAY WANT TO USE PREGABALIN MAY WANT TO USE BENZODIAZEPINES PERHAPS ONLY DURING THE BAD SYMPTOMS OF SSRI INDUCTION MAY WANT TO USE BETA BLOCKERS MAY USE MOOD STABILISERS

24 OTHER TREATMENTS? EMDR Cognitive Behavioural Therapy Schema Therapy Integrative Therepy Transference or Psychodynamic Therapy

25 SO TONIGHT YOU SHOULD HAVE LEARNED Diagnostic Systems ICD10 & DSM5 compared A Philosophical Perspective Historic Perspective The Cook Book approach SUGGESTIONS FOR WHAT THE GP SHOULD DO

26 Thank You ANXIETY DISORDERS IN DSM5 Dr Robin Lawrence 117a & 96 Harley St Thank You Very Much