charles hart enzer, m.d. 5599 kugler mill road cincinnati, oh 45236-2035 513-281-0074 email:...
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Charles Hart Enzer, M.D.
5599 Kugler Mill RoadCincinnati, OH 45236-2035
513-281-0074Email: [email protected]:
homepages.uc.edu/~enzerch
Child - Adolescent - Adult - Family – Psychiatry
Anxiety--
Rational Evaluation Leads to Rational Management
Objectives:
•Appreciate that Anxiety may not be a disorder •Rapid Assessment for Anxiety Disorders •Learn the Hierarchy of the Differential Diagnosis of Anxiety Disorders
"Prescribing Is So Easy, Understanding People So Hard."
Kafka, Franz. (1917) A Country Doctor. The Penal Colony, Stories and Short Pieces
“Patient Has Anxiety”What is Your Next Step?
• Click to Add Text
What Is the Treatment for Anxiety?
•What Does Hunger Tell Me?–Eat Food
•What Does Thirst Tell me?–Drink?
•What Does Tiredness Tell Me–Get Some Rest
•What Does Anxiety Tell MeGalvanize to Action
•Symptoms are Not Enough for Diagnosis–Impairment Is Required
Normal Fear vs Normal Anxiety
Normal Fear• Physiologic and
Emotional Response to Recognized Sources of Danger
• Basic Survival Mechanism– Pain– Threat of Danger
• One of Innate Emotions • Promotes Fight or
Escape/Avoidance• Ready To Cope with
Present Danger(s)
Normal Anxiety• Apprehension, tension, or
uneasiness from anticipation of danger
• Normal reaction to stress – Galvanize to Action
• Ready To Cope With Upcoming Negative Event(s)
- Pathologic Anxiety -
• When Anxiety Interferes with Effectiveness
• And/or when Anxiety Interferes with Achievement
• And/or when Anxiety Interferes with Satisfactions
• And/or when Anxiety Interferes with Emotional Comfort
• Mood Condition That Occurs Without An Identifiable Triggering Stimulus
Anxiety + Impairment
- Pathologic Anxiety -
• Anxiety Disorders Double the Death Rate
• The Suicide Rate of Some Anxiety Disorders is the Same as the Suicide Rate for the Depressive Disorders
Decision Tree for Anxiety
Learning to Think LikeA Psychiatrist
Apprehensive Anticipation•Future Danger and/or Misfortune
•Accompanied by•Feeling of Dysphoria and/or•Somatic Tension
•Focus of Anticipated Danger May be•Internal or•External
Anxiety:
Symptoms of Anxiety, Fear, Avoidance or Increased Arousal
Due to the Direct Physiological Effect of a General Medical Condition
YesAnxiety Disorder due to a General Medical Condition
293.89
Due to the Direct Physiological Effect of a
Substance (Drug, Alcohol, Caffeine, Medication)
Substance Induced Anxiety
Disorder291.8, 292.89
No
Yes
No
Recurrent, Unexpected
Panic Attacks Plus 1 Month of Worry, Concern about Attacks or
Change in Behavior
Anxiety about Being in Places
from which Escape Might be Difficult or Embarrassing in the Event of Having a Panic
Attack
Panic DisorderWith
Agoraphobia300.21Yes
Yes
Panic DisorderWithout
Agoraphobia300.01NoNo
Agoraphobia [Anxiety about Being in Places from Which Escape is Difficulty and/or
Embarrassing
Anxiety about Separation for Attachment Figure – Onset
in Childhood
Fear of Humiliation or Embarrassment in
Social or Performance Situations
Social Phobia300.23
Separation Anxiety Disorder309.21
Agoraphobia without History of
Panic Disorder300.22
No
No
No
Yes
Yes
Yes
No
Fear Cued by Object or Situation
Obsessions or Compulsions
6-Month Period of Excessive Anxiety
or Worry Plus Associated Symptoms
Generalized Anxiety Disorder
300.02
Obsessive Compulsive
Disorder300.3
Specific Phobia300.29
No
No
No
Yes
Yes
Yes
No
Occurs Exclusively
During a Mood or
Psychotic Disorder
No
Yes
See Mood or Psychotic Disorders
Acute Stress Disorder
308.3
Anxiety in Response to a
Severe Traumatic Event
Posttraumatic Stress Disorder
309.81
Reexperiencing of Event, Increased
Arousal with Avoidance of
Stimulus Associated with Traumatic Event
Duration of More than One Month
No
No
Yes
No
No Yes
Yes
Anxiety that Does not Meet Criteria for One of
the Above Anxiety Disorders and Develops
in Response to a Stressor
Clinically Significant Symptoms that Do
not Meet Criteria for a Specific Anxiety
Disorder
Anxiety Disorder not Otherwise
Specified300.00
Adjustment Disorder with
Anxiety309.24
No
Yes
Yes
No
No Anxiety Disorder (Symptoms of Fear, Anxiety or Avoidance that Are not Clinically Significant)
No
Think Like a Psychiatrist
• Since the era Rudolf Ludwig Karl Virchow (13 October 1821 – 5 September 1902), mere symptom treatment represents a scientifically untenable position in all areas of medicine, psychiatry included
• Looking alike, primary and secondary psychiatric symptoms are etiologically diverse
• They demand serious differential diagnostic effort
• Secondary psychiatric symptoms caused by undetected medical illness will not respond to psychotherapy
• Secondary psychiatric symptoms may be aggravated by psychotropic medications
Think Like a Psychiatrist
• A survey of 4500 psychiatric patients in different times and geographical locations, showed 30 - 50% of patients suffered from previously undiagnosed significant medical abnormalities.
• About 30% of the physical illnesses produced symptoms showing direct relation to the psychopathology of the patient
– Predisposing to the Mental Disorders
– Precipitating the Mental Disorders
– Perpetuating the Mental Disorders
Anxiety from Medical Disorders
Cardiovascular Disorders• Acute Anemias• Arrhythmias• Congestive Heart Failure• Pulmonary Embolism
Endocrine Disorders• Hyperadrenocorticism• Hyperthyroidism• Hypoglycemia• Pheochromocytoma
Metabolic Disorders
• Porphyria
• Vitamin B12 Deficiency
Neurologic Disorders
• Encephalitis
• Neoplasms
• Vestibular Dysfunction
Pain
Respiratory Disorders
• Chronic Obstructive Pulmonary Disease
• Hyperventilation
• Pneumonias
Substance-Induced Anxiety Disorder
• Sedative, or Hypnotic, or Anxiolytic
Adverse Reaction to Medications
• ePocrates Hand Held = #301
• ePocrates Online Alternative Drugs = #86
• ePocrates Online Drugs = #266
• www.pdr.net = #603
Drugs of Abuse During Intoxication or Withdrawal•Alcohol•Amphetamine•Amphetamine-like•Caffeine•Cannabis•Cocaine•Hallucinogen•Phencylcline•Phencylcline-like
Managing Anxiety
1. Suspend Moral Judgment
2. Examine Comprehensively
3. Inform about the Findings
4. Make Recommendations
5. Provide Specific Treatments when Indicated
Doctoring: Sequence is Crucial
Managing Anxiety DisordersRational Evaluation
1. Consider Anxiety Secondary to Medical Condition
2. Consider Anxiety Secondary to Substance(s)
3. Decision Making Tree to Sort out the 50+ Disorders
4. 5 – 45 Seconds Evaluation for Suicide
5. Use Medications On Label Only for Specific Disorder
6. When Will it be Reasonable to Expect a Response
7. For Treatment Failure, Psychiatric Consultation
Managing Anxiety DisordersRational Treatment
The Hippocratic Oath • We Do Not Promise to Cure
• We Do Not Promise to Treat
• We Promise Not to Harm
Managing Anxiety DisordersRational Treatment
1. Review the Advantages of Medical Psychotherapy
2. Review the Advantages of Medication
3. Use Medication On Label Only for Specific Disorder
4. Review the Counter-Indications
5. Review the Cautions
6. Review the Adverse Effects
7. Review the Approved Duration of Treatment
•Managing Anxiety DisordersRational Treatment
•The Shorter the Half-life•The Greater the Addictiveness
•The Faster the Onset•The Greater the Addictiveness
•Sedatives•Hypnotics•Anxiolytics
Managing Anxiety DisordersChoosing a Psychiatric Consultant
• The Psychiatrist is Curious
• The Psychiatrist is Thorough
• The Psychiatrist Enjoys Working with Patients Who Have Failed Treatment
Now, Go Forth:
1.Learn2.Practice3.Learn4.Practice5.. . . ..
And Do No Harm