Anderson Spickard, III, MD, MS

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Anderson Spickard, III, MD, MS Powered By Docstoc

                                                                 Acute medical threat ?
Clinical suspicion                           YES
                                                                 Pulm embolus
of anxiety                                                       Myocardial infarction

          Complaints of excessive anxiousness


   Positive screen by history
   and/or questionnaire                                   Acute psychiatric threat?
                                                            Suicidal ideation
                                                            Homicidal ideation
            Somatic complaints* with
            negative workup
                                                                      Urgent or emergent
                                                                      psychiatric evaluation

                                    Initial workup
                                                                             Page 2-3

                                    Management                            See handout

      * Examples of somatic complaints

         Cardiopulmonary ---- chest pain, hyperventilation, tachycardia, palpitations
         Neurologic -----tremor, dizziness, lightheadedness, headache, paresthesias
         Gastrointestinal----- nausea, vomiting, diarrhea, abd pain, anorexia
         Other ----- hyperhidrosis, erechle dysfunction, polyuria
                       Initial Workup

             *   H&P
             *   Mental status exam
             *   Screen for substance abuse
             *   Lab tests tailored to secondary causes (p.3)

1 Assess severity and categorize

   Delusions/psychotic features present?         YES          Psychiatric referral

   Reaction to recent life stressor?          YES             Adjustment Disorder

   Chronic, persistent excessive worry
   about more than one life circumstance?         YES         Generalized Anxiety
   (> 6 mo)                                                   Disorder

  Sudden onset of physical or cognitive               YES      Panic Disorder
  symptoms in self-limited episodes (>4 mo)?

  Persistent,irrational fear of specific situation?     YES      Social Phobia

  Persistent distressing re-experience of                           PTSD
  traumatic event?                                     YES

  Persistent, repetitive thoughts or purposeful                  Obsessive
  behavior that is involuntary and senseless?          YES       Compulsive

2 Consider secondary causes of anxiety

Other Psychiatric Diseases
Somatization                         Alcohol
                                     Antihypertensive Withdrawal

Chronic Medical Conditions               Endocrine Disorders

COPD                                     Hyperthyroidism
Brain tumor                              Hypothyroidism
Demyelinating disease                    Hypoglycemia
Collagen vascular disease                Premenstrual syndrome
B12 deficiency                           Hypercortisolism
Heavy metal intoxication                 Addison's Disease
Anderson Spickard, III, MD, MS

I.      Learning Objectives

       to be familiar with a classification scheme for anxiety disorders
       to distinguish panic disorder from generalized anxiety disorder
       to know the non-pharmacological and pharmacological treatments of anxiety
       to know when to refer a patient with anxiety for psychiatric evaluation

II.     Clinical Classification

        A. Adjustment Disorder with Anxious Mood
               1.      common in primary care
               2.      response to stress or(s)
               3.      resolves in 6 months

        B. Generalized Anxiety Disorder
1.      chronic anxiety 6 months
2.      no triggers
3.      +/- panic attacks
4.      motor, autonomic, apprehension, viligence
                          a.     motor: - trembling, aches, fatigability, easy startled, eyelid twitch, restlessness
                          b.     autonomic -sweating, palps, dry mouth, lightheaded ness, flushing, tachy, pallor
                          c.     apprehension - worry, fear, rumination
                          d.     vigilance - insomnia, hyerattentiveness,  concentration

        C. Panic Disorder
               1.       panic attacks
                                4 or more panic attacks per month, if less than 4, call it “symptom attacks”
                                4 of 12 symptoms with attack:
                                 a        chest pain                           g.         palpitations
                                 b.       choking                              h.         shortness of breath
                                 c.       dizziness                            I.         sweating
                                 d.       flushing                             j.         trembling
                                 e.       nausea/abdominal distress            k.         numbness or tingling
                                 f.       depersonalization or derealization l.           fear of dying, fear of going
                                                                                          crazy or losing control
                                impending doom or fear of dying is sentinel

                 2.       worry
                                  at least one of attacks followed by one month of one or more of following:
                                   a.        concern about having additional attacks
                                   b.        concern about implications of attack (losing control, MI, going crazy)
                                   c.        significant change in behavior related to the attacks

                 3.       +/- trigger
                          a.        initially there is no anxiety provoking event such as being the center of attention
                          b.        this distinguishes from other situational forms of anxiety
                          c.        however, anticipatory fear of subsequent episodes develops which leads to

                                  subsequent avoidance behavior and phobias

                4.       phobias
                         a.      places where feel trapped like crowds, parties, lines
                         b.      extreme avoidance is called agoraphobia

                5.       associations
                         a.       MVP prolapse is associated with but does not preclude panic disorder, having
                                  MVP does not alter treatment strategies
                         b.       no organic cause: caffeine, hyperTH, controlled substance
                         c.       up to 90% of patients with panic disorder have depression, and 20% abuse

       D. Simple Phobia
              1.      irrational fear to specific stimulus

       E.   Social Phobia
               1.       fear of being center of attention or criticized publicly

       F. Post Traumatic Stress Disorder
               1.      re-experience of traumatic event ( rape, injury, natural disaster, war) in thoughts, dreams,
                       or flashbacks
               2.      many symptoms

       G. Obsessive-Compulsive Disorder
                     obsessions - unwanted, intrusive thoughts of bizarre, senseless nature
                     compulsions - repetitive behaviors in ritualized manner

                         a.       different from psychosis because patients have insight into their thoughts
                         b.       shame is major feature
                         c.       in primary care, manifested by preoccupations with bodily functions (bowel) or
                                  susceptibility to disease

III.   Non-Pharmacologic Approach

       A. Primary care MD
              1.       frequent visits
              2.       empathetic listening: legitimization of symptoms and frustrations
              3.       judicious testing, framing of tests, e.g. “I believe the test I have ordered will be normal,
                       when it returns normal, we will move on to our plan of more discussion about the stress
                       you are under,...”
              4.       identification of triggers: stress, nicotine, alcohol, caffeine, cocaine, anticholinergics
              5.       diaries of symptoms and their relation to current events
              6.       reassurance, provision of hope and promise of physician presence
              7.       7resetting of expectations: focus on restoring function rather than alleviating symptoms
              8.       avoid benzodiazepines if possible with the exception of short treatment courses

      B. When to refer to psychiatry
            1.        severe disease
                      a.       suicidal
                      b.       disabling symptoms
                      c.       symptoms worsen on therapy

              2.       much phobia
                       a.     behavioral and cognitive therapy work well

      C. Psychiatry approaches
             1.       behavioral therapy
                      a.       exposure: imaginal techniques either gradually or flooding
                      b.       coping skills: respiratory control, relaxation therapy

              2.       cognitive therapy
                       a.       restructuring: connecting thinking and feeling (explanations), learn that
                                sensations that trigger panic attacks are not dangerous, e.g. will exercise patient
                                until he gets dyspneic, patient will then concentrate on dyspnea to confirm that
                                every sensation of shortness of breath need to be a panic attack

              3.       cognitive-behavioral
                       a.       education: definitions of panic attack, diaries, self help material, e.g. learn that
                                not all chest pain is due to a heart attack
                       b.       coping skills: relaxation, breathing exercises
                       c.       exposure: hyperventilate or exercise in office to induce panic attack, next use
                                coping skills to mitigate, then go into natural settings to experience panic attack

IV.   Pharmacologic Approach

      A. Caution
             These are general guidelines only. Surprisingly few studies have been performed that have
             suitable control groups, low drop-out rates, and long follow-up periods to validate their findings.
             Application to a general population is difficult because most studies involve patients selected from
             specialized psychiatric clinics, e.g. phobia clinics.

      B. If panic attacks (Panic Disorder or Generalized Anxiety Disorder)

              1.       Tricylcic antidepressant (studied) or SSRI (used, but not studied yet)
                       a.       full antidepression doses required
                       b.       Imipramine best studied, start 5 mg up to 150-200 q day, 6 weeks before
                                beneficial effect

              2.       Benzodiazepines
                       a.      if exacerbation and impairs daily functioning
                       b.      use only for short period
                       c.      Alprazolam (Xanax) .25-.5 mg tid (4-6 mg/day max) or Klonipin (Clonazepam)
                               .5 mg qhs or bid (2 mg/day max)
                       d.      side effects of sedation, slurred speech, fatigue, and can have delirium tremens

                                   with severe withdrawal, so wean slowly .
        C. If chronic
                1.        Buspirone
                          a.      a non-benzodiazepine, non-addicting, has anxiolytic and antidepressant activity
                          b.      5 mg tid, four weeks before beneficial effect
                          c.      side effects of dizziness, drowsiness, nausea, headache

                 2.       psychiatric referral usually necessary

        D. If phobias
                1.        behavioral therapy
                          a.      single dose benzodiazepine prn event

        E. If Obsessive Compulsive Disorder or Post Traumatic Stress Disorder
                1.       psychiatric referral

        F. If performance anxiety
                1.      Propranolol 10 mg prn

        G. When to dc treatment
              1.        panic free 6-12 months, taper benzos, warn pts that relapses are common (33%)

V.      What Do the Studies Show?

Meta-Analysis of Panic Disorder             Clum GA et al. Journ Consult and Clin Psych 1993; 61:317-26.

        29 studies with a control group
        coping > flooding > meds + psych > antidepressants > benzos
        problems: studies dissimilar, high drop out in antidepressants grps, short follow-up

Alprazolam vs Cognitive- Behavior Rx in Panic Disorder
                                          Klosko JS et al.     Journ Consult and Clin Psych 1990; 58:77-84.

        Phobic clinic at SUNY, # of PA’s post, no pre PA measuret though all with PA within one week of
        cogn-behah > Alprazolam > placebo
        problems: short f/u

Relax vs Exposure/Cognitive vs Both in Panic Disorder
                                           Craske MG et al. Behav Therapy 1991; 22:289-304.

        15 weeks of one of three arms
        followed 2 yrs: at 3 mo, 6 mo, 12 mo, 24 mo
        many anxiety and depression measures
        confusing, too many comparisons, some improvement and some decline in all arms
        authors conclude all arms showed improvement but relaxation the least
        problem: not convincing that improvements on scales correlated with important clinical improvements,
        more clear benefit seems necessary to warrent 15 weeks therapy

        weak scientific methods, studies from pysch journals, pts selected from phobic clinics, not primary care

cogn/behav therapy seems to work better for sicker pts than does medication

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