hcp chapter 8 (9) anxiety

7/27/2019 Hcp Chapter 8 (9) Anxiety

1/85

Anxiety DisordersAnxiety Disorders


2/85

SymptomsSymptoms

Trembling, shakyTrembling, shaky

Rapid heartbeatRapid heartbeat

Lightheaded/dizzyLightheaded/dizzy

Diarrhea, frequent urination or bothDiarrhea, frequent urination or both

De-realization (feelings of unreality)De-realization (feelings of unreality)

Impaired attention and concentrationImpaired attention and concentration


3/85

SOBSOB

Sweating, cold hands & feetSweating, cold hands & feet

Paresthesias (tingling of skin)Paresthesias (tingling of skin)

Sleep onset insomnia (initial insomnia)Sleep onset insomnia (initial insomnia)

Nervousness, edginess, tensionNervousness, edginess, tension


4/85

Anxiety vs PanicAnxiety vs Panic

AnxietyAnxiety PanicPanic

Onset:Onset: Can be gradualCan be gradual Very suddenVery sudden

Duration:Duration: ProlongedProlonged One to 30One to 30minutesminutes

Intensity:Intensity: Mild toMild tomoderatemoderate

SevereSevere

Precipitated byPrecipitated bystressorsstressors

GenerallyGenerally Often notOften not


5/85

10 Anxiety Syndromes10 Anxiety Syndromes

GADGAD

Anxiety associated w/adjustment disorderAnxiety associated w/adjustment disorder

Specific PhobiasSpecific Phobias

Social phobias/social anxiety disorderSocial phobias/social anxiety disorder

Agoraphobia w/out panicAgoraphobia w/out panic


6/85

10 Syndromes, cont.10 Syndromes, cont.

Anxiety due to a medical conditionAnxiety due to a medical condition

Anxiety due to AOD useAnxiety due to AOD use

Anxiety symptoms secondary to another primaryAnxiety symptoms secondary to another primarymental disorder (i.e., depression)mental disorder (i.e., depression)

Neurotic anxiety (more characterological)Neurotic anxiety (more characterological)

Panic DisorderPanic Disorder


7/85

A few factsA few facts

Lifetime prevalence rates for all anxietyLifetime prevalence rates for all anxiety

disorders: 25%disorders: 25%

37 million people per year suffer in USA37 million people per year suffer in USA

Persons w/panic disorders are 18X morePersons w/panic disorders are 18X more

likely to commit suicide than normallikely to commit suicide than normal


8/85

Facts,cont.Facts,cont.

Women to men: 2:1Women to men: 2:1

Only about 30% of persons w/anxietyOnly about 30% of persons w/anxietydisorders receive TX, but TX is effective indisorders receive TX, but TX is effective in

70-90% of those treated! (so these are70-90% of those treated! (so these are

very treatable conditions)!very treatable conditions)!


9/85

TheoriesTheories


10/85

FreudFreud

Neurotic conditions like anxiety: arose fromNeurotic conditions like anxiety: arose fromthe U/C perception of danger:the U/C perception of danger:

Realistic anxiety (danger from environment)Realistic anxiety (danger from environment)

Moral anxiety (danger from super-ego)Moral anxiety (danger from super-ego)

ID anxiety (danger from the ID)ID anxiety (danger from the ID)

U/C perception of danger provoked signalU/C perception of danger provoked signal

anxiety and ignited defensive responsesanxiety and ignited defensive responses


11/85

CBTCBTAnxiety is generated when people over-Anxiety is generated when people over-

evaluate the danger in some situations orevaluate the danger in some situations orunderestimate their coping abilities.underestimate their coping abilities.

The perception of danger triggers theThe perception of danger triggers thefight/flight responsefight/flight response

When a person is anxious, theirWhen a person is anxious, theirperceptions of reality are misrepresentedperceptions of reality are misrepresented(false alarms)(false alarms)


12/85

Biological TheoriesBiological Theories In humans and many animals, there areIn humans and many animals, there are

pathways of nerve networks, brain structures,pathways of nerve networks, brain structures,

and endocrine glands that respond to stress withand endocrine glands that respond to stress withfight/flight responding.fight/flight responding.

Responses trigger complex chemical andResponses trigger complex chemical andhormonal reactionshormonal reactions

NON-essential processes shut down (digestionNON-essential processes shut down (digestion

and reproduction) andand reproduction) and

Energy is channeled into survival mechanismsEnergy is channeled into survival mechanisms


13/85


14/85

Cortisol

Stressful

Event

Amygdala

Hypothalamus

Pituitary

Adrenal

cortex Thyroid

Thyroxin

Cortex

Locus

Coeruleus

Sympathetic

Nervous

System

Adrenal

Medulla

AdrenalineNoradrenaline

Neural Pathways: Fight/Flight Response

From: Preston, et al (2010)


15/85

AMYGDALA

HYPOTHALAMUS

PARABRACHIAL

NUCLEUS LOCUS

COERULEUS

PERIAQUA-

DUCTAL

GRAY AREA

PITUITARY PITUITARY

ADRENAL

CORTEX

THYROID

GLAND

ADRENAL

MEDULLA

NEUROENDOCRINE PATHWAYS

NE*

THROUGH

OUT THE

BODY

RESPIRATION FREEZE AVOID

ESCAPE(NE*)

ALERTNESS

ADRENALINE NE*

S

N

SCRF TRH

ACTH TSH

CORTISOL T3 T4

Norepinephrine: heart rate, BP From Preston, et al 2010


16/85

Explanation:Explanation:

As stressful events are perceived at theAs stressful events are perceived at thelevel of the cortex and processed in alevel of the cortex and processed in a

crude way on the sub-cortical level (thecrude way on the sub-cortical level (the

amygdala) lower brain areas becomeamygdala) lower brain areas become

activated.activated.

FIGURE 2 6 Th li bi t (R i t d ith i i f K l t J W 2007


17/85

FIGURE 2.6c The limbic system. (Reprinted, with permission, from Kalat, J. W., 2007.

Biological Psychology, 9th edition, 2007 Wadsworth.)


18/85

Explanation, cont.Explanation, cont.

The limbic system is PUT ON ALERT soThe limbic system is PUT ON ALERT so

that if actual danger is present, there isthat if actual danger is present, there is

burst of excitation in the part of the brainburst of excitation in the part of the brain

stem called the locus coeruleus. (LC) (alsostem called the locus coeruleus. (LC) (also

called the adrenal gland of the brain. Thecalled the adrenal gland of the brain. The

LC nerve cells are mediated byLC nerve cells are mediated by

norepinephrinenorepinephrine


19/85


20/85


21/85

On the surfaceOn the surface

On the surface of the majority of nerveOn the surface of the majority of nervecells in the brain (including the cells of thecells in the brain (including the cells of theLocus Coeruleus) there are tiny gatewaysLocus Coeruleus) there are tiny gatewayscalled chloride iron channels. (see figurecalled chloride iron channels. (see figure

8-D, p. 107).8-D, p. 107). These carry a slight (--) charge and existThese carry a slight (--) charge and exist

in abundance in the fluid surroundingin abundance in the fluid surrounding

nerve cells.nerve cells. The ion channels can be openedThe ion channels can be opened

(activated) when stimulated by naturally(activated) when stimulated by naturallyoccurring GABA.occurring GABA.


22/85


23/85

Benzodiazapine MoleculesBenzodiazapine Molecules

((the kind found in anti-anxiety medicationsthe kind found in anti-anxiety medications))

Bind to the chloride ion channels, furtherBind to the chloride ion channels, further

enhancing the in-flow of negative ions andenhancing the in-flow of negative ions and

producing a widespread CALMING effect inproducing a widespread CALMING effect in

many areas of the brain.many areas of the brain.


24/85

The speculation is that this explains manyThe speculation is that this explains many

kinds of anxiety disorders!kinds of anxiety disorders!

Since there is a a receptor on the chlorideSince there is a a receptor on the chlorideion channel that responds toion channel that responds tobenzodiazepine medications, there maybenzodiazepine medications, there maybe a benzodiazepine-like chemicalbe a benzodiazepine-like chemical

existing in the CNSexisting in the CNS

To date, however, such a chemical hasTo date, however, such a chemical has

yet to be identified, (althoughyet to be identified, (although somesome strongstrongsuggestion by researchers that it may besuggestion by researchers that it may beadenosine).adenosine).


25/85

If this theory is correct:If this theory is correct:

It could help to explain why some people areIt could help to explain why some people are

more high strung than others and less able tomore high strung than others and less able tostay calm during stressful times.stay calm during stressful times.

Such people may suffer from a deficiency of aSuch people may suffer from a deficiency of a

yet to be identified endogenous neuro-chemical.yet to be identified endogenous neuro-chemical.

Excitability in the LC area (locus coeruleus) isExcitability in the LC area (locus coeruleus) isalso impacted by serotonin, so anything thatalso impacted by serotonin, so anything that

impacts serotonin production, release,impacts serotonin production, release,absorption or re-uptake can have an impact onabsorption or re-uptake can have an impact onlocus coeruleus functioning..locus coeruleus functioning..

L d F


26/85

Learned Fear:Learned Fear:

Seems to be mediated mostly by theSeems to be mediated mostly by the

amygdala.amygdala.

After one is exposed to scary events, theAfter one is exposed to scary events, the

amygdala encodes parts of the experienceamygdala encodes parts of the experienceso that memories can help with futureso that memories can help with future

survival.survival.

Unfortunately, these memories are quiteUnfortunately, these memories are quite

indelible and can be resistant to extinction!indelible and can be resistant to extinction!


27/85

FINALLY,FINALLY,

Once the memory is registered/stored in theOnce the memory is registered/stored in the

amygdala the brain develops a heightenedamygdala the brain develops a heightenedsensitivity to re-activation of these memories andsensitivity to re-activation of these memories andautonomic/automatic responding.autonomic/automatic responding.

Re-exposure to similar cues can triggerRe-exposure to similar cues can triggersignificant or extreme reactions.significant or extreme reactions.

Some speculation that serotonin plays a role inSome speculation that serotonin plays a role in

inhibiting the reactivity of the amygdala for anti-inhibiting the reactivity of the amygdala for anti-depressants that enhance serotonin productiondepressants that enhance serotonin productionor utilization are now FIRST LINES OFor utilization are now FIRST LINES OFDEFENSE IN TREATING MANY TYPES OFDEFENSE IN TREATING MANY TYPES OF

ANXIETYANXIETY


28/85

Other information:Other information:

Many times in the 6-12 months prior to theMany times in the 6-12 months prior to theonset of panic, a person will have aonset of panic, a person will have asignificant loss.significant loss.

This raises speculation that experiencesThis raises speculation that experiencesof loss can re-sensitize theof loss can re-sensitize the

neurotransmitters that once played a roleneurotransmitters that once played a rolein separation anxietyin separation anxiety

See other chapters on OCD and PTSD (chapters 9 & 11)See other chapters on OCD and PTSD (chapters 9 & 11)


29/85

DisordersDisorders


30/85

Generalized Anxiety DisorderGeneralized Anxiety Disorder

Long TermLong Term

May have No Specific life stressorsMay have No Specific life stressors

Chronic worryChronic worry What if..What if..


31/85

Stress Related AnxietyStress Related Anxiety

Person generally functions well, butPerson generally functions well, but

anxiety SX have emerged in response toanxiety SX have emerged in response to

major stressmajor stress


32/85


Repeated episodes of full blown panic.Repeated episodes of full blown panic.

Other phobias may develop (agoraOther phobias may develop (agoraphobia)phobia)


33/85

Social AnxietySocial Anxiety

Experienced only when the person is inExperienced only when the person is in

interpersonal settings, like publicinterpersonal settings, like public

speaking, asking someone for a date,speaking, asking someone for a date,

social gatherings, etc.social gatherings, etc.


34/85

Medical Illnesses and MedicationsMedical Illnesses and Medications

Presenting w/Anxiety SXPresenting w/Anxiety SX

Dont assume the person has a psychiatricDont assume the person has a psychiatric

condition, it might be physical.condition, it might be physical.

E.g., thyroidE.g., thyroid

Some prescribed and some OTC Rx?Some prescribed and some OTC Rx?


35/85

Anxiety as Part of a Primary MentalAnxiety as Part of a Primary Mental

DisorderDisorder

Anxiety can be part of depression,Anxiety can be part of depression,

schizophrenia, OBS, AOD use.schizophrenia, OBS, AOD use.


36/85

Disorders that can cause AnxietyDisorders that can cause Anxiety

Adrenal tumorAdrenal tumor HypoglycemiaHypoglycemia

AlcoholismAlcoholism HyperthyroidismHyperthyroidism

Angina PectorisAngina Pectoris MenieresMenieres diseasedisease(early) (middle ear)(early) (middle ear)

Cardiac ArrhythmiaCardiac Arrhythmia Mitral valve pro-lapseMitral valve pro-lapse

CNS degenerativeCNS degenerativediseasedisease

Parathyroid diseaseParathyroid disease

Cushings diseaseCushings disease Partial-complex seizuresPartial-complex seizuresCoronary insufficiencyCoronary insufficiency Post-concussionPost-concussion

syndromesyndrome

DeliriumDelirium PMSPMS


37/85

Drugs that Can Cause AnxietyDrugs that Can Cause Anxiety

AmphetaminesAmphetamines Appetite suppressantsAppetite suppressants Asthma medicationsAsthma medications

CaffeineCaffeine

CNS depressants (withdrawal)CNS depressants (withdrawal) CocaineCocaine Nasal decongestantsNasal decongestants

SteroidsSteroids StimulantsStimulants Thyroid replacementThyroid replacement


38/85

Anti-Anxiety TreatmentAnti-Anxiety TreatmentWhen to Try Medication?When to Try Medication?


39/85

GADGAD

Problems with Benzodiazepines:Problems with Benzodiazepines:

They can cause depression in some peopleThey can cause depression in some people

People can develop tolerance/dependencePeople can develop tolerance/dependenceproblems w/chronic benzodiazapine useproblems w/chronic benzodiazapine use

SSRIs, venlafaxine (Effexor) and buspironSSRIs, venlafaxine (Effexor) and buspiron

(Buspar) can be effective along with(Buspar) can be effective along withpsychotherapy and patients do not developpsychotherapy and patients do not developtolerance to these medications.tolerance to these medications.


40/85

GAD RXGAD RX

Buspirone is slow acting and requires 2-Buspirone is slow acting and requires 2-weeks of TX before symptoms improve.weeks of TX before symptoms improve.

The problem with this medication isThe problem with this medication ispremature discontinuationpremature discontinuation

Venlafaxine (Effexor) can help GAD butVenlafaxine (Effexor) can help GAD butnot good with panic attacksnot good with panic attacks

Again, 2-6 weeks are needed beforeAgain, 2-6 weeks are needed before

improvement may be noticed.improvement may be noticed.


41/85

Stress Related AnxietyStress Related Anxiety Minor tranquilizers can be helpful in reducingMinor tranquilizers can be helpful in reducing

stress anxiety symptoms (especially insomniastress anxiety symptoms (especially insomniaand restlessness).and restlessness).

Consider if stress is acute and likely to be ofConsider if stress is acute and likely to be of

short durationshort duration

Anti-anxiety meds should only be used for 1-4Anti-anxiety meds should only be used for 1-4weeks.weeks.

If this is one of a SERIES of life stresses, medsIf this is one of a SERIES of life stresses, medsmay be contraindicated.may be contraindicated.


42/85

Stress Related RXStress Related RX

All benzodiazapines are effective in TXAll benzodiazapines are effective in TXstress related anxietystress related anxiety

Side effects and half life are keySide effects and half life are keyconsiderationsconsiderations

Side effect is a common side effect.Side effect is a common side effect.

Best to use low dose of benzo forBest to use low dose of benzo fordaytime anxietydaytime anxiety


43/85

Stress,cont.Stress,cont.

Second side effect is rush (euphoria) thatSecond side effect is rush (euphoria) thatcan lead to abuse. (can help sleep but cancan lead to abuse. (can help sleep but canlead to abuse).lead to abuse).

Half life of the drug is an importantHalf life of the drug is an importantconsiderationconsideration

Meds w/shorter half life may need veryMeds w/shorter half life may need verygradual D/C (over several weeks)gradual D/C (over several weeks)


44/85

DosesDoses

Example lorazepam (Ativan) start with 0.5Example lorazepam (Ativan) start with 0.5

mg b.i.d.or t.i.d. and increase every threemg b.i.d.or t.i.d. and increase every three

days as needed to a final does of 2-6days as needed to a final does of 2-6

mg/day.mg/day.

Goal: symptom relief over 1-4 weeksGoal: symptom relief over 1-4 weeks

If symptoms persist: reassess diagnosisIf symptoms persist: reassess diagnosis


45/85

Long Term Use ofLong Term Use of

Benzodiazepines?Benzodiazepines? In general: not good but this may notIn general: not good but this may not

always be the case!always be the case!

Key: monitor for signs ofKey: monitor for signs ofincreasedincreaseddosingdosingespecially w/o medical adviceespecially w/o medical advice

D/C of benzodiazepines can have seriousD/C of benzodiazepines can have seriousside effects and should ALWAYS be doneside effects and should ALWAYS be donegraduallygradually


46/85

A Word About Stress Induced InsomniaA Word About Stress Induced Insomnia

Initial insomniaInitial insomnia (sleep onset) usually indicates(sleep onset) usually indicates

anxietyanxiety,, butbut

Middle insomnia (waking up in the middle of theMiddle insomnia (waking up in the middle of the

night) ornight) or

Late insomnia (early morning awakening)Late insomnia (early morning awakening)usually indicateusually indicate depression.depression.

Treatment should be initiate only if insomnia isTreatment should be initiate only if insomnia iscaused by recent events and is not a chroniccaused by recent events and is not a chronicproblem.problem.


47/85

A Word About Stress Induced Insomnia,A Word About Stress Induced Insomnia,

cont.cont.

Zolpidem Tartrate (Ambien) is NOT aZolpidem Tartrate (Ambien) is NOT a

benzodiadepine and studies suggest thatbenzodiadepine and studies suggest that

dependence isdependence is less likelyless likelywith this drug so itwith this drug so it

maymaybe a safe(r) alternative for people withbe a safe(r) alternative for people withhistory or risk of AOD abuse/dependencehistory or risk of AOD abuse/dependence

Trazedone (an antidepressant) is also a safeTrazedone (an antidepressant) is also a safe

alternative & is used for people in recovery fromalternative & is used for people in recovery from

SUDsSUDs


48/85

Treatment of PanicTreatment of Panic

DisorderDisorder


49/85


If only one isolated panic attack, notIf only one isolated panic attack, not

sufficient to warrant RX.sufficient to warrant RX.

4 of more attacks within a one month4 of more attacks within a one month

period suggests panic disorderperiod suggests panic disorder


50/85

Phase 1Phase 1

Goal: Eliminate or reduce the frequency andGoal: Eliminate or reduce the frequency and

intensity of panic attacks with anti-panicintensity of panic attacks with anti-panic

medications.medications.

Three main classifications of medications:Three main classifications of medications:

BenzodiazepinesBenzodiazepines

AntidepressantsAntidepressants

MAO inhibitorsMAO inhibitors


51/85

Benzodiazepines:Benzodiazepines:

Advantages:Advantages:Very Effective, works quickly, reduces anticipatory anxiety.Very Effective, works quickly, reduces anticipatory anxiety.

Disadvantages:Disadvantages: Most persons require a larger dose forMost persons require a larger dose for

these drugs to be effective, so sedation is a commonthese drugs to be effective, so sedation is a commonproblem.problem.

Meds are effective only if person takes them regularly.Meds are effective only if person takes them regularly.

Also, with prolonged use, dependence WILL developAlso, with prolonged use, dependence WILL develop

VERY gradual withdrawal is required to avoid withdrawalVERY gradual withdrawal is required to avoid withdrawal

symptoms (including seizures and death)symptoms (including seizures and death)


52/85

Anti-DepressantsAnti-Depressants

TricyclicTricyclic

SSRIsSSRIs

SSNRIs (venlafaxine or Effexor)SSNRIs (venlafaxine or Effexor)

Mirtazapine (Remeron)Mirtazapine (Remeron)

NOTE: bupropion (Wellbutrin) NOT for panicNOTE: bupropion (Wellbutrin) NOT for panic

Anti Depressants contAnti Depressants cont


53/85

Anti-Depressants, cont.Anti-Depressants, cont.

Advantages:Advantages:

Effective in tx of panic. Can tx concurrentEffective in tx of panic. Can tx concurrent

depression. No risk of addiction.depression. No risk of addiction.

Disadvantages:Disadvantages:

Delayed action (2-4 weeks before SX relief).Delayed action (2-4 weeks before SX relief).

Some people initially have an INCREASE inSome people initially have an INCREASE in

panic attacks (can add short term benzo.)panic attacks (can add short term benzo.)

MAO InhibitorsMAO Inhibitors


54/85

MAO InhibitorsMAO InhibitorsAdvantages:Advantages:

Very effective, can TXVery effective, can TX

concurrent depression, can be used for longconcurrent depression, can be used for long

term without risk of tolerance orterm without risk of tolerance or

dependence.dependence.

Disadvantages:Disadvantages:

Delayed action (2-4 weeks). Can treat likeDelayed action (2-4 weeks). Can treat like

typical depression for symptom relief. Dietarytypical depression for symptom relief. Dietary

restrictions,restrictions,


55/85

Phase 2Phase 2

Patients have attacks and develop strongPatients have attacks and develop stronganticipatory anxiety, phobias, andanticipatory anxiety, phobias, and

avoidance.avoidance.

These problems do NOT respond toThese problems do NOT respond to

medications, so a variety of behavioral andmedications, so a variety of behavioral and

CBT interventions are needed. (RelaxationCBT interventions are needed. (Relaxation

therapy, systematic desensitization,therapy, systematic desensitization,

examine cognitive distortions, etc.).examine cognitive distortions, etc.).


56/85

TX Methods:TX Methods:

Reduce or control symptoms of panicReduce or control symptoms of panic

Have the person gradually confront theHave the person gradually confront the

problem situation with 60 minuteproblem situation with 60 minute

exposuresexposures


57/85

Social AnxietySocial Anxiety SSRIs frequently present with initial increasedSSRIs frequently present with initial increased

anxiety as a side effect during the first weeks ofanxiety as a side effect during the first weeks oftreatment.treatment.

Remember, Remember, activation syndromactivation syndrom with SSRIs with SSRIscan be VERY problematic for TX anxiety andcan be VERY problematic for TX anxiety andcan be a major source ofcan be a major source ofpatient initiatedpatient initiateddiscontinuation.discontinuation.

SSRIs begin toSSRIs begin to reducereduce anxiety symptoms byanxiety symptoms byweek 4 of treatmentweek 4 of treatment


58/85

Problems:Problems:

Prescribing benzodiazepines for people with personalPrescribing benzodiazepines for people with personalor family HX of AOD problems generally not a goodor family HX of AOD problems generally not a goodchoice. Important to monitor for requests for higherchoice. Important to monitor for requests for higherdoses.doses.

Alternatives:Alternatives:

1.1. Trazedone for sleepTrazedone for sleep

2.2. Buspirone (Buspar)for generalized anxietyBuspirone (Buspar)for generalized anxiety

3.3. Mirtazapine (Remeron)Mirtazapine (Remeron)4.4. Gabapentin (ANTI-SEIZURE RX)Gabapentin (ANTI-SEIZURE RX)


59/85

Common ErrorsCommon Errors


60/85

SSRIs can cause increased anxiety at first, butSSRIs can cause increased anxiety at first, but

by week 4 begin to significantly reduce SX ofby week 4 begin to significantly reduce SX ofanxietyanxiety

Personal or family HX of AOD problems are atPersonal or family HX of AOD problems are at

thigh risk for dependence (Benzos)thigh risk for dependence (Benzos)

Abrupt cessation of benzodiazepines is veryAbrupt cessation of benzodiazepines is very

dangerous! NEVER cold turkey. Always,dangerous! NEVER cold turkey. Always,medically supervised, gradual taper down.medically supervised, gradual taper down.

Mi di i i ll f il iMi di i i ll f il i


61/85

Misdiagnosis: especially failure recognizeMisdiagnosis: especially failure recognizedepression or emerging psychosis and treatingdepression or emerging psychosis and treatingwith benzodiazepines (that can worsenwith benzodiazepines (that can worsen

symptoms)symptoms)

Over-sedation with benzos for daytime TXOver-sedation with benzos for daytime TX

Benzodiazepines in the elderly can causeBenzodiazepines in the elderly can causecognitive impairment and impaired gait, socognitive impairment and impaired gait, somust be used with caution (and doses adjustedmust be used with caution (and doses adjustedfor age).for age).

Patients w/anxiety disorders should consumePatients w/anxiety disorders should consumeNO caffeine. Partial responses or breakNO caffeine. Partial responses or breakthrough symptoms can be caused bythrough symptoms can be caused byunreported caffeine use!unreported caffeine use!


62/85

RememberRemember

Stress and anxiety can be a part ofStress and anxiety can be a part of

normal, daily living.normal, daily living.

Medication treatment should be initiatedMedication treatment should be initiated

ONLY if symptoms are significant andONLY if symptoms are significant and

severely interfere with normal functioning.severely interfere with normal functioning.


63/85

When to Refer for Medical TreatmentWhen to Refer for Medical Treatment

The following are generally (initially) NOT treatedThe following are generally (initially) NOT treated

with psychotropic medications and a referralwith psychotropic medications and a referral

should be made only if the personsshould be made only if the persons

symptoms are severe or if they dontsymptoms are severe or if they dont

respond to psychotherapy:respond to psychotherapy:

GADGAD

Specific PhobiasSpecific Phobias Social PhobiasSocial Phobias Agoraphobia without panicAgoraphobia without panic

Treat the PrimaryTreat the Primary


64/85

Treat the PrimaryTreat the Primary

Disorder if:Disorder if:

Anxiety is part of a general medicalAnxiety is part of a general medical

conditioncondition

Anxiety is related to substance abuseAnxiety is related to substance abuse

Anxiety is part of another psychiatricAnxiety is part of another psychiatricconditioncondition

T Wi h M di i O l if ST t With M di ti O l if S t


65/85

Treat With Medications Only if Symptoms areTreat With Medications Only if Symptoms are

Severe and Dont Respond to PsychotherapySevere and Dont Respond to Psychotherapy

Initial Insomnia (cant fall asleep)Initial Insomnia (cant fall asleep)

Daytime aggression or restlessnessDaytime aggression or restlessness

Impaired concentrationImpaired concentration

(note: medication should be short term(note: medication should be short termgenerally only 1-4 weeks)generally only 1-4 weeks)

Combination of RX andCombination of RX and


66/85

Combination of RX andCombination of RX and

Psychotherapy for:Psychotherapy for:

Recurring Panic Attacks if:Recurring Panic Attacks if: Person has had 4 or more attacks in pastPerson has had 4 or more attacks in past

monthmonth

Person has developed ANTICIPATORYPerson has developed ANTICIPATORY

anxiety, phobias, or avoidanceanxiety, phobias, or avoidance

Person has developed secondary symptomsPerson has developed secondary symptoms

like clinical depression or alcohol abuse.like clinical depression or alcohol abuse.


67/85

Communicating withCommunicating with

ClientsClients

Psychotherapy is the Treatment ofPsychotherapy is the Treatment of


68/85

Psychotherapy is the Treatment ofPsychotherapy is the Treatment of

Choice for:Choice for:

Anxiety associated with acute stressAnxiety associated with acute stress

Neurotic anxiety (the anxiety is more aNeurotic anxiety (the anxiety is more a

part of the persons character or style)part of the persons character or style)


69/85

GADGAD

If buspirone, venlafaxine, or SSRIs areIf buspirone, venlafaxine, or SSRIs are

prescribed, expect from 2-6 weeks for theprescribed, expect from 2-6 weeks for the

medication to take effect.medication to take effect.

Often, medication is not enough.Often, medication is not enough.

Psychotherapy, stress mgt, relaxationPsychotherapy, stress mgt, relaxation

training, regular exercise and biofeedbacktraining, regular exercise and biofeedbackcan be very helpfulcan be very helpful


70/85

Stress Related AnxietyStress Related Anxiety

Go to the dentist with a toothache! (medsGo to the dentist with a toothache! (meds

can help but they wont fix the underlyingcan help but they wont fix the underlying

cause of the stress)cause of the stress)

Dont abruptly D/C use of tranquilizers.Dont abruptly D/C use of tranquilizers.

Do not drink alcohol of any kind if taking aDo not drink alcohol of any kind if taking a

minor tranquilizerminor tranquilizer

Panic DisordersPanic Disorders


71/85

Evidence that panic is a biochemicalEvidence that panic is a biochemical

dysfunction not a psychological disorder!dysfunction not a psychological disorder!

Meds must be taken each day to beMeds must be taken each day to be

effectiveeffective

Meds treat only the panic attacks. OnceMeds treat only the panic attacks. Once

these are controlled, graded exposure tothese are controlled, graded exposure todeal with anticipatory anxiety anddeal with anticipatory anxiety and

avoidance are needed. Best to do this withavoidance are needed. Best to do this with

a therapist.a therapist.


72/85

Panic,cont.Panic,cont.

MAO inhibitors require dietary andMAO inhibitors require dietary andmedication restrictions.medication restrictions.

If alprazolam (Xanax), lorazepam (Ativan)If alprazolam (Xanax), lorazepam (Ativan)or conazepam (Klonapin) are used,or conazepam (Klonapin) are used,

person must NEVER abruptly discontinueperson must NEVER abruptly discontinue

the medication. Medication reductionthe medication. Medication reductionshould be done gradually, usually 0.25 toshould be done gradually, usually 0.25 to

0.5 mg per day per week0.5 mg per day per week


73/85

Social PhobiasSocial Phobias

If medications are used (MAO, SSRI,If medications are used (MAO, SSRI,

venlafaxine, or beta blockers) this must bevenlafaxine, or beta blockers) this must be

accompanied by EXPOSURE (one mustaccompanied by EXPOSURE (one must

be willing to enter certain social situationsbe willing to enter certain social situationsand try new behaviors.)and try new behaviors.)

Psychotherapy is indicated.Psychotherapy is indicated.


74/85


75/85


76/85

OCDOCD

Lifetime prevalence: 2.5%, but 7% in FirstLifetime prevalence: 2.5%, but 7% in First

Degree Relatives of those with theDegree Relatives of those with the

conditioncondition !!

Ratio of men to women: 1:1Ratio of men to women: 1:1

Age of onset: 1/3 begin in childhood. 2/3Age of onset: 1/3 begin in childhood. 2/3

begin in adolescence or early adulthoodbegin in adolescence or early adulthood


77/85

OCDOCD

Incidence in children is about 1%Incidence in children is about 1%

Course: Some milder forms of OCD canCourse: Some milder forms of OCD can

be transient, but most moderate to severebe transient, but most moderate to severe

cases last for years if untreated. Even withcases last for years if untreated. Even with

treatment, symptoms can persist.treatment, symptoms can persist.


78/85

Etiology?Etiology?

Traditional psychoanalytic theoriesTraditional psychoanalytic theoriessuggested an early internalization ofsuggested an early internalization of

perfectionism, overly strict and rigidperfectionism, overly strict and rigid

parenting, and stifled childhood autonomy.parenting, and stifled childhood autonomy.

While these theories may apply in OCD,While these theories may apply in OCD,

they are NOT necessary for OCD to occur.they are NOT necessary for OCD to occur.

Biological theories probably more likely.Biological theories probably more likely.

Biology contBiology cont


79/85

Biology, cont.Biology, cont.

May be damage to the basal ganglia in theMay be damage to the basal ganglia in the

sub-cortical brain structuressub-cortical brain structures

Neuro-imaging studies are convincing.Neuro-imaging studies are convincing.

Significant increases in metabolic activitySignificant increases in metabolic activity

in the prefrontal cortex and basal gangliain the prefrontal cortex and basal ganglia

People with OCD can respond well toPeople with OCD can respond well to

SSRIsSSRIs


80/85

Two Main Biological Theories:Two Main Biological Theories:

1. The frontal lobes do not work to inhibit1. The frontal lobes do not work to inhibit

the urge to respond so innate urges andthe urge to respond so innate urges and

behavioral routines develop that resemblebehavioral routines develop that resemble

primitive urges like: nest building,primitive urges like: nest building,grooming, and checking territorialgrooming, and checking territorial

boundaries (ordering, straightening,boundaries (ordering, straightening,

cleaning, checking, hand washing,cleaning, checking, hand washing,checking door locks, etc.).checking door locks, etc.).

2 Naturally existing pathways that typically serve2 Naturally existing pathways that typically serve


81/85

2. Naturally existing pathways that typically serve2. Naturally existing pathways that typically serveadaptive purposes, especially those that helpadaptive purposes, especially those that helpwhen one is exposed to danger. These arewhen one is exposed to danger. These are

governed by the frontal cortex which allow forgoverned by the frontal cortex which allow forsustained attention and focus.sustained attention and focus.

In normal people, this sustained attention shutsIn normal people, this sustained attention shutsdown when danger has subsided or when it hasdown when danger has subsided or when it hasbeen ruled out.been ruled out.

But in affected people, the neural loop thatBut in affected people, the neural loop thatprovides feedback that the threat is over doesprovides feedback that the threat is over doesnot work. The person gets caught in a worrynot work. The person gets caught in a worrylooploop

T t t


82/85

Treatment:Treatment:

Standard treatment does not have a goodStandard treatment does not have a good

track record with OCD.track record with OCD.

Behavioral techniques can be helpful.Behavioral techniques can be helpful.

(Systematic de-sensitization &(Systematic de-sensitization &

exposure, CBT)exposure, CBT)

Can be helpful 75-80% of the time.Can be helpful 75-80% of the time.

M di ti T t t


83/85

Medication Treatments:Medication Treatments:

Clormipramine (Anafranil)Clormipramine (Anafranil)

Fluoxetine (Prozac)Fluoxetine (Prozac)

Fluvoxamine (Luvox)Fluvoxamine (Luvox)

Sertraline (Zoloft)Sertraline (Zoloft)

Paroxetine (Paxil)Paroxetine (Paxil)

Citalopram (Celexa)Citalopram (Celexa) Escitalpram (Lexapro)Escitalpram (Lexapro)

VidVid


84/85

VideoVideo

Somatic features that were similar to heart attack.Somatic features that were similar to heart attack. Felt panic, chest pain, cannot breathe and losing consciousnessFelt panic, chest pain, cannot breathe and losing consciousness

Feelings of fear, flushed face, tingling, thoughts of deathFeelings of fear, flushed face, tingling, thoughts of death Multiple episodes in a week, possibly during the day.Multiple episodes in a week, possibly during the day.

No particular antecedent to attacks.No particular antecedent to attacks. Possibility that the stress of work may have impacted attackPossibility that the stress of work may have impacted attackfrequency. While in physical stress, there is no panic, when breaksfrequency. While in physical stress, there is no panic, when breaksor slow-downs happen, the panic intensity, frequency does increaseor slow-downs happen, the panic intensity, frequency does increase

Onset of first attack was at 39 years, initial attacks led toOnset of first attack was at 39 years, initial attacks led togreater propensity for attacks to occur more frequently in thegreater propensity for attacks to occur more frequently in the

first few monthsfirst few months Agrophobia fear of situations that cause him to fear suchAgrophobia fear of situations that cause him to fear such

situations and therefore withdraw.situations and therefore withdraw.

OCD VidOCD Vid


85/85

OCD - VidOCD - Vid

Obsessive thought Obsessive thought recurrent and persistent thoughts that do not subside quickly (may last hours).recurrent and persistent thoughts that do not subside quickly (may last hours). Irrational thoughts (person is aware of it)Irrational thoughts (person is aware of it) Unique thoughts to the individual. Bothersome and troublingUnique thoughts to the individual. Bothersome and troubling Perseverance of thoughts, little things especiallyPerseverance of thoughts, little things especially

Compulsive behavior Compulsive behavior checking things. Ritualistic behaviors that are irrational and reoccurring over and over.checking things. Ritualistic behaviors that are irrational and reoccurring over and over. It is the reaction, the consequence of obsessive thoughtsIt is the reaction, the consequence of obsessive thoughts

Counting behaviors before answeringCounting behaviors before answering

Stress predicts or is associated with greater obsessive thoughtsStress predicts or is associated with greater obsessive thoughts Has feelings of helplessness, depression, and suicideHas feelings of helplessness, depression, and suicide Depressive episodes and OCD have been comorbidDepressive episodes and OCD have been comorbid Inability to control thoughts.Inability to control thoughts.

Learn to manage symptoms (feelings of shame can underlie the thoughtsLearn to manage symptoms (feelings of shame can underlie the thoughtsand behaviors)and behaviors)

hcp chapter 8 (9) anxiety

Documents