Saturday General Session Managing Anxiety Disorder in Primary Care Chris Ticknor, MD Private Practice, Psychiatry Adjunct Professor of Psychiatry UT Health Science Center at San Antonio San Antonio, Texas Educational Objectives By the end of this activity, the participant should be better able to: 1. Implement screening strategies to identify patients who may be suffering from an anxiety disorder. 2. Distinguish between the characteristics of anxiety disorder and other mood disorders. 3. Utilize individualized treatment strategies in treating patients suffering from anxiety, including pharmacologic and nonpharmacologic options. Speaker Disclosure Dr. Ticknor has disclosed that he has received grant support from Lilly and Pfizer. 15
Speaker Disclosure Managing Anxiety Disorders in Primary Care Dr. Ticknor has disclosed that he has received grant support from Lilly and Pfizer. Christopher Ticknor, MD Adjunct Professor of Psychiatry UT Health San Antonio And Private Practice of Psychiatry June 2018 Learning Objectives OVERVIEW By the end of this activity, the participant should be better able to: Implement screening strategies to identify patients who may be suffering from an anxiety disorder. Distinguish between the characteristics of anxiety disorder and other mood disorders. Utilize individualized treatment strategies in treating patients suffering from anxiety, including pharmacologic and nonpharmacologic options. Anxiety Disorders are common in Primary Care They are often Under-diagnosed and Under-treated GAD in particular is a chronic medical condition Anxiety Disorders are associated with significant functional impairment Treatments are often effective Utilize combined pharmacotherapy and counseling psychotherapy Cognitive Behavioral Therapy (CBT) has the strongest outcome benefits for treating anxiety disorders Improvement can be measured using the Sheehan Disability scale (SDS) DSM-IV Diagnostic Criteria for GAD Recognition and Treatment of Generalized Anxiety Disorder Excessive worry or anxiety about a number of events or activities for a minimum of 6 months Difficulty controlling worry At least 3 of the following symptoms: Restlessness Irritability Fatigue Muscle tension Difficulty concentrating Sleep disturbance Focus of anxiety cannot be confined to another Axis I disorder Symptoms cause significant distress or impairment in social, occupational, or other areas of functioning Not due to physiological effects of a substance or general medical condition, and does not occur exclusively during a mood, psychotic, or pervasive development disorder APA, DSM-IV-TR. Washington, DC. American Psychiatric Association; 2000:476 Lifetime prevalence rate of GAD is approximately 4% to 5% 1,2 Approximately twice as high in females as compared to males 1,2 As high as 10% lifetime prevalence rates for females ages 45 and older 2 Most common anxiety disorder seen in primary care 3 and the elderly 4 In one study, approximately 35% of patients presenting with GAD in primary care were correctly diagnosed 5 Some studies show the rates of under-treatment up to 64% 1,6 1. Grant BF, et al. Psychological Medicine. 2005;36:1747-1759. 4. Beekman AT. Et al. Int J Geriatr Psychiatry. 1998;13(10):717-726. 2. Wittchen HU, et al. Arch Gen Psych. 1994;51:355-364. 5. Wittchen HU, et al. J Clin Psychiatry. 2002;63(suppl 8):23-34. 3. Wittchen HU, et al. J. Clin Psychiatry. 2001;62(suppl1):15-19. 6. Olssen I, et al. Care Companion J Clin Psychiatry. 2006;8(6):340-347. 1
Clinical Course and Functional Burden of GAD Generalized Anxiety Disorder Reports of age of onset are highly variable 1 GAD is generally chronic in course 2 Symptoms tens to wax and wane over time Duration of GAD episodes average 11.1 months 1 GAD is associated with significant functional impairment 3,4 1. Grant BF, et al. Psychological Medicine. 2005;36:1747-1759. 3. Kessler RC, et al. Am J Psychiatry. 1999;156:1915-1923. 2. Yonkers KA, et al. Depression Anxiety. 2003;17:173-179. 4. Wittchen HU, et al. In. Clin Psychopharmacol. 2000;15:319-328. The most common anxiety disorder Symptoms present almost every hour of almost every day Four major symptom groups Motor tension Autonomic hyperactivity Apprehensive expectation Vigilance and scanning Treatment of GAD Panic Disorder With or Without Agoraphobia SSRI s often work best SNRI s a close second Buspirone effective for some Consider tricyclics carefully Beta blockers Benzodiazepines with carful monitoring Atypical antipsychotics in severe, treatment refractory cases 1-3% incidence of tardive dyskinesia (AIMS Test) No Paroxetine in Women during child bearing years Inquire about side effects, inc. sexual dysfunction A discrete period of intense fear or discomfort in the absence of real danger that develops abruptly, reached a crescendo within 10 minutes, and is accompanied by 4 (or more) of the following. Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sensation of shortness of breath or smothering Feelings of choking Chest pain or discomfort Panic Disorder (Continued) Treatment of Panic Disorder Feeling dizzy, unsteady, light-headed, or faint Derealization (feelings of unreality) or depersonalization feeling detached from oneself Fear of losing control or going crazy Fear of dying Paresthesias (numbness or tingling sensations) Chills or hot flashes Nausea or abdominal distress Pharmacologic SSRI s (most promising), Alprazolam, Other benzos, MAOI s, Counseling Therapy CBT, Desensitization therapy, Exposure-based CBT (especially useful for PTSD), EMDR, Relaxation training, biofeedback Stress Management Anything that helps Diet & Exercise Avoid or reduce caffeine Pets (no peacocks on airplanes please) 2
Social Anxiety Disorder Specific Phobias Social Anxiety Disorder / Phobias Fear exists in all cultures Fear appears to exist across most species The purpose of fear is to protect an organism from immediate threat and to mobilize the body for quick action to avoid danger and potential harm. Anxiety, on the other hand, is a future-oriented mood state in which the individual anticipates the possibility of threat and experiences a sense of uncontrollability focused on the upcoming negative event. Fear and anxiety are not always adaptive. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others The person recognizes that the fear is excessive or unreasonable The feared experiences are avoided or are endured with intense anxiety or distress, and often interfere with the person s normal routine or employment/school Specific Phobias Treatment of Social Anxiety Disorder and Phobias Lifetime Prevalence with Specific Fear Heights 6% Flying 4% Closed spaces 4% Being alone 3% Storms 3% Animals 6% Blood 4.5% Water 3% ANY 11.3% Cognitive Behavioral Therapy (CBT) Desensitization reprogramming SSRI s Venlafaxine or SNRI s Benzodiazepines MAOI s Gabapentin Beta blockers Obsessive Compulsive Disorder Treatment of OCD An often debilitating disorder The presence of two distinct phenomena The most common obsession is contamination of some type The types of obsessions and compulsions are remarkably consistent across cultures Specific forms / categories Contamination / germs Need for symmetry Somatic obsessions, GI, facial or body features, picking Sexual and aggressive obsessions Pathological doubt Pharmacotherapy, for striking serotonin deficiency syndromes SSRI s The high velocity rifle against anxiety SNRI s of benefit for some people Tricyclics (desipramine) The Abrams tank MAOI s The nuclear weapons against anxiety, panic and OCD. Behavioral therapy can help Desensitization, slowly and carefully in small steps 3
Treatment for OCD Which SSRI to Choose? Importance of Treatment Sertraline 50-200 mg / day Fluvoxamine 100-300 mg / day Citalopram 40 mg / day Escitalopram 20-60 mg / day Fluoxetine 40-100 mg / day Paroxetine 30-6- mg / day (Not in women) No woman during her child bearing years should be prescribed Paroxetine or Divalproex without appropriate, detailed, written informed consent. Document and document some more. Giving the package insert to the patient (and documenting you did so) is your friend. Untreated anxiety or depressive disorders lead to brain inflammation and some degree of brain atrophy in most patients. Interleukin 6 markers in mood disorders research. The Danish study looked at every person in Denmark hospitalized for depression or bipolar disorder over 30 years and looked at how many of those patients developed dementia, compared with matched controls. Each episode of depression (or hypomania) increased risk for dementia by 6% - 13% per episode. Treating major depression, all anxiety disorders, and bipolar disorder reduces the likelihood someone may develop Alzheimer's or other dementias later in life. Thank you! Q & A Chris Ticknor, MD 4
Medication Index Managing Anxiety Disorder in Primary Care The following medications were discussed in this presentation. The table below lists the generic and trade name(s) of these medications. Generic Name Alprazolam Buspirone Citalopram Desipramine Divalproex Escitalopram Fluoxetine Fluvoxamine Gabapentin Paroxetine Sertraline Venlafaxine Trade Name Xanax None Celexa Norpramine Depakote Lexapro Prozac, Sarafem, Selfemra Luvox Horizant, Neurontin Brisdelle, Paxil, Pexeva Zoloft Effexor XR
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