Kristin FahselIris Gonzalo-Sowle

SUNYITNUR668

Sense of danger, apprehension, worry, and dread in response to a trigger that is not a truly threatening experience (Fournier, 2013).

Anxiety is a normal reaction to stressful and uncertain situations. It’s your body telling you to stay alert and protect yourself (Anxiety and Depression Association of America, 2010-2014).

Generalized Anxiety Disorder (GAD) is characterized by excessive anxiety and worry lasting more than six months. GAD is diagnosed when anxiety and worry are associated with at least three of the following symptoms: Restlessness or feeling keyed-up or on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance Suicide ideation or completed suicide

(Loomis, Griswold, Pastore, & Dunphy, 2011; Yates, 2012)

Anxiety disorders are common psychiatric disorders. The Diagnostic and Statistical Manual of Mental Disorders (4th edition), Text Revision (DSM-IV-R) classifies anxiety disorders into the following categories:

Anxiety due to a general medical disorder Substance-induced anxiety disorder Generalized anxiety disorder Panic disorder Acute stress disorder Posttraumatic stress disorder (PTSD) Adjustment disorder with anxious features Obsessive-compulsive disorder (OCD) Social phobia (aka Social anxiety disorder) Specific phobia (aka Simple phobia). Examples include animal

type, environmental type, and injection/injury type.

(Yates, 2012)

The body does not distinguish between a physical or psychological threat.

The normal physiologic response to stress is commonly known as “fight or flight.” This response is regulated through cortisol, mediated by the hypothalamus-pituitary-adrenal (HPA) axis. This system operates on a negative feedback loop.

In the CNS, the major neurotransmitters associated with anxiety are norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA).

Other neurotransmitters such as corticotropin-releasing factor may be involved.

Abnormalities in the transmission of these neurotransmitters including poor regulation and increased metabolic activity of different areas of the brain have been associated with anxiety disorders.

(Fournier, 2013)

(http://img.medscape.com/fullsize/migrated/579/825/ga579825.fig1.gif)

(http://what-causes-anxiety.com)

Female to male ratio is 3:2 Prevalence is 5-6% in the general population. Most anxiety disorders begin in childhood,

adolescence, and early adulthood. No difference in prevalence of anxiety disorders

among white, African-American, or Hispanic populations in the Untied States.

Social phobia is the most common anxiety disorder; it has an early onset (by age11, median age is 16 years) and is considered a risk factor for depression and substance abuse.

Specific anxiety disorders (panic disorder and OCD) appear to vary between cultures and countries.

Those with GAD have a 60% of having a comorbid psychiatric diagnosis, usually depression.

(Loomis et al., 2011; Yates, 2012)

Being female Childhood trauma Stress due to an illness Stress buildup Personality Family members with an anxiety

disorder Drug or alcohol use

(Mayo Foundation for Medical Education and Research, 2013)

(http://anxietyadventures.files.wordpress.com/2013/07/anxiety.png?w=64)

http://www.gregdorter.com/toronto-therapist-blog/images/anxiety-cycle.png

Acute Respiratory Distress Syndrome (ARDS) Anorexia Nervosa Asthma Atrial Fibrillation Body Dysmorphic Disorder Cardiogenic Shock Delirium Depression Diabetes, Type I Encephalopathy Fibromyalgia Goiter Irritable Bowel Syndrome Sleep disorders (insomnia, sleep apnea) Thyroiditis Unstable Angina

(Yates, 2012)

Anxiety disorders are the most common mental illness in the US (40 million people).

North America has the highest rate of anxiety. A total of 28% of Americans will suffer

anxiety in their lifetime. Young people are growing up increasingly

anxious-20% of children report “worrying a lot.”

People with anxiety disorders are 6x more likely to be hospitalized.

Anxiety disorders cost the US $42 billion a year in treatments.

(http://OnlinePsychologyDegree.net)

Physical examination Patient history Mental status exam CBC, BMP, TSH, EKG (usually normal) US, CT, MRI (to rule out medical

conditions) Psychological questionnaires:

http://www.phqscreeners.com/pdfs/02_PHQ-9/English.pdf

https://pdbp.ninds.nih.gov/assets/crfs/Hamilton%20Anxiety%20Rating%20Scale%20(HAM-A).pdf

Patient education Cognitive therapy Behavioral therapy

Relaxation techniques Respiratory training

Specialists Psychiatrist Psychologist/Psychotherapy

Lifestyle management/Health promotion Diet Physical activity Sleep Smoking cessation Avoiding alcohol

(Mayo Foundation for Medical Education and Research, 2013)

SSRIs SNRIs Tricyclic Antidepressants Azapirone Benzodiazepines Herbal supplements Other medications

(Mayo Foundation for Medical Education and Research, 2013)

Chronic disease Relapse is more likely with the

discontinuation of medications, especially in the first year of treatment or during periods of increased stress

Severe impairments in all functional areas

Increase in unhealthy habits Suicidal ideation and increased risk for

suicide attempt(Fournier, 2013; Flynn, 2014)

Response to treatment is evaluated after 4-6 weeks

Many patients will experience improvement after 8-12 weeks

Continued treatment over 8 months or longer is associated with a reduction in the risk of relapse

(Davidson et al., 2008)

Patient education includes general information about anxiety, symptom recognition, effective interpretation of physical symptoms, decrease in use of stimulants (nicotine and caffeine), and relaxation training.

Websites Anxiety and Depression Association of America

(www.adaa.org) National Alliance on Mental Illness (www.nami.org) National Institute of Mental Health

(www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml)

Psychiatrist Psychologist Psychotherapist Social worker Cardiology Neurology Endocrinology Massage therapist Chiropractor

Definition:• Multiple unexpected panic attacks

Panic attack – brief period of sympathetic nervous system hyperarousal accompanied by psychological terror

Peak is typically about 10 minutes but can last up to an hour Symptoms include: palpitations, accelerated and pounding

heart rate, sweating, trembling/shaking, shortness of breath, choking sensation, chest pain/discomfort, nausea, feeling dizzy/unsteady/lightheaded/faint, depersonalization, fear of loosing control, fear of dying, paresthesias, chills, or hot flashes

• Not associated with another psychiatric condition• Not associated with alcohol or drug use• Not associated with medical conditions• Associated change in behavior (constant worry about

another panic attack)

(Katon & Ciechanowski, 2013; Domino, Baldor, Golding, Grimes, & Taylor, 2013)

Noradrenergic neurotransmission from the locus coeruleus causes increased sympathetic stimulation

Current research is being performed on abnormal responses to anxiety producing stimuli in the hippocampus, amygdala, and prefrontal cortex

Peripheral and central nervous system dysregulation MRI have demonstrated pathologic involvement of

the temporal lobes, associated cerebral vasoconstriction

Cause unknown System malfunction in dealing with anxiety stimuli Defects in managing strong emotions like fear and

anger

(Dunphy, Winland-Brown, Porter, & Thomas, 2011; Domino et al., 2013)

Incidence• Seen in all age groups, but can be seen in

ages 15-19 and a second peak in ages 35-50• In school aged children, it can be confused

with conduct disorder or ways to avoid school• Females (5%) more affected than males (2%)

Prevalence• About 8% of patients seen in primary care

clinics have panic disorder• Of all patients who present to the ER with

chest pain, 25% is caused by panic disorder

(Katon & Ciechanowski, 2013; Domino et al., 2013)

Any life stressors can precipitate an attack

History of sexual or physical abuse Anxious and overprotective parents Substance abuse General temperament Bipolar disorder Major depression Obsessive compulsive disorder Phobia Family history (increases risk by 18-41%) Still doing research on neurobiology

(Katon & Ciechanowski, 2013; Domino et al., 2013)

Psychiatric Diagnosis:• PTSD• Social phobias• Depression• Bipolar disorder• Substance abuse• OCD• Separation anxiety

disorder

Other Medical Diagnosis:• Hypertension• Mitral valve prolapse• Reflux esophagitis• Interstitial cystitis• Irritable bowel

syndrome• Fibromyalgia• Nicotine

dependence

(Domino et al., 2013)

No physical findings between attacks During attacks:

• Tachycardia (25%), chest pain (22%)• Headaches (20%), dizziness (18%),

hyperventilation, sweating• Epigastric pain (15%)

Perform:• Palpate thyroid – hyperthyroidism can cause

anxiety• Respiratory exam – rule out asthma or limited air

flow• Cardiac exam – evaluate for murmurs or

arrhythmia(Katon & Ciechanowski, 2013; Domino et al., 2013)

Medication side effect (narcotics, beta blockers, steroids, albuterol, fluoroquinolones, interferon, etc)

Substance abuse and withdrawal Hyperthyroidism COPD Tachyarrhythmias Hypoglycemia Pulmonary embolism MI Celiac disease TIA Cushing syndrome Other psychiatric illnesses

(Katon & Ciechanowski, 2013; Domino et al., 2013)

• A person with a panic disorder finds it difficult to carry out normal activities, like going to the grocery store or driving. Over one third of patients become housebound.

• It can interfere with school or work• Patients with repeated attacks may avoid

locations where they frequently occur, for example an elevator or hospitals

(National Institute of Mental Health, n.d.)

No specific testing to indicate condition. Testing is done to rule out other causes.

Laboratory tests• CBC, Glucose, TSH, Electrolytes

Diagnostics• EKG, Pulse Oximetry, Holter monitoring,

ECHO(Katon & Ciechanowski, 2013; Domino et al., 2013)

Cognitive behavioral therapy is key and first line treatment!!• Works best with individuals who are highly motivated and

value problem solving• Provided education, relaxation and breathing techniques• Relapse prevention• Occasionally repeated exposure during counseling• Higher response rates (46% vs 27%) and longer

remissions (20% vs 12%) when used in combination with medications

• Most require 10 – 20 weekly treatments that can last 60 – 120 minutes

• Typically given homework assignments Aerobic exercise reduces symptoms better than

a placebo

(Craske, 2013; Domino et al., 2013; Dunphy et al., 2011)

There is no evidence for superior efficacy in panic disorder among the SSRIs

The onset of therapeutic effect of SSRIs is somewhere between 2 and 4 weeks, but clinical response can take up to 8 to 12 weeks for some patients

First line FDA approved:• Sertraline (Zoloft), Paroxetine (Paxil), Fluoxetine (Prozac),

Alprazolam (Xanax), and Clonazepam (Klonopin)• Avoid Benzodiazepines in patients with history of substance

abuse• All antidepressants except Bupropion (Wellbutrin) can treat

panic attacks, but fluoxetine can initial cause more nervousness

Second line:• Tricyclic antidepressants, specifically Imipramine (start at low

dose and slowly taper)

(Roy-Byrne, 2013; Domino et al., 2013)

Medication dependence (benzodiazepines)

Misdiagnosis of other medical or psychiatric illnesses

(Domino et al., 2013)

If medication is started, patients should be maintained on this until symptoms are under control for at least 6 months to 1 year

Follow up in office every 1 to 2 weeks when starting medications, then every 2 to 4 weeks until therapeutic dose

Appointments can be spaced out farther the more stable the patient is

If no improvement after 8 weeks, can refer to psychiatrist

(Katon & Ciechanowski, 2013; Domino et al., 2013; Dunphy et al., 2011)

Need referral to psychiatrist if accompanied by other psychiatric disorder • Bipolar disorder• Borderline personality disorder• Schizophrenia• Suicidal ideation• Substance abuse

(Domino et al., 2013)

One patient’s quote about panic disorders:

“My friend saw how afraid I was and told me to call my doctor for help. My doctor told me I was physically healthy but that I have panic disorder. My doctor gave me medicine that helps me feel less afraid. I've also been working with a counselor learning ways to cope with my fear. I had to work hard, but after a few months of medicine and therapy, I'm starting to feel like myself again.”

It’s important for patients to know that it is possible to have a normal life again.

Panic disorder is one of the most treatable anxiety disorders.

(National Institute of Mental Health, n.d.)

1. A 24 year old woman has a new onset of panic disorder. You expect to find the following except:

a. Symptoms worse about 10 minutes into the attackb. Chest painc. Shortness of breathd. A rash

2. Which of the following abnormal laboratory work would diagnosis panic disorder?

a. Hct 40b. CR 2.0c. K 5.5d. ESR 30e. No blood work to diagnose

3. What is one of the key treatments for Panic Disorder?a. Medicationsb. Cognitive behavioral therapyc. Aerobic exercise

4. What is considered a first-line medication treatment for generalized anxiety disorders?

a. alprazolamb. citalopramc. duloxetined. amitriptyline 

5. The most common anxiety disorder isa. Obsessive-compulsive disorder (OCD)b. Post-traumatic stress disorder (PTSD)c. Social anxiety disorderd. Panic disorder

 6. Generalized anxiety disorder (GAD) is diagnosed when associated which of the following three symptoms:

a. Restlessness, fatigue, and irritabilityb. Weight loss, anorexia, and persistent nauseac. Difficulty concentrating, muscle tension, and lack of

interestd. Sleep disturbance, depression, and suicidal ideation

7. Bobbie Jo is a 35 year old female is diagnosed with a Panic Disorder. She admits to drinking a six pack a night. After establishing her with a counselor, what would be the appropriate medication choice?

a. Xanax (Alprazolam)b. Ativan (Lorazepam)c. Wellbutrin (Bupropion) d. Zoloft (Sertraline)

8. You prescribe Prozac for a patient with newly diagnosed Panic Disorder, who is otherwise healthy. When will you bring her back in for a follow up in the office?

a. 2 weeksb. 1 monthc. 2 monthsd. 6 months

9. The APN decides to do a workup for a patient with anxiety. What would be expected with the results?

a. CBC shows an elevated WBCb. BMP shows hyperkalemia or hypokalemiac. TSH is elevatedd. The labs are within normal limits

10. Which is considered the best treatment for anxiety disorders?a. Medications onlyb. Medications with cognitive and behavioral therapyc. Stress managementd. Cognitive and behavioral therapy only

1. Answer D. Rash is not a typical symptoms of a panic attack/panic disorder

2. Answer E. Diagnostic testing is done to rule out other conditions, not to

diagnose panic disorder.

3. Answer B. Medication is helpful, but cognitive behavioral therapy is a key component of treatment.

4. Answer: C. Duloxetine (Cymbalta) is a SNRI, which are considered first-line treatment for generalized anxiety disorders.

5. Answer: C. Social anxiety disorder (aka social phobia) is considered the most common anxiety disorder.

6. Answer: A. Restlessness, fatigue, and irritability are all listed as symptoms. GAD is diagnosed when anxiety and worry are

associated with these symptoms.

7. Answer D. Should avoid the use of Benzodiazepines in patients with substance abuse. Wellbutrin is not effective in treatment of panic disorder.

8. Answer A. She should be seen in 1-2 weeks to assess panic attacks or medication side effects.

9. Answer: D. Unless there is an underlying medical condition, the workup for a patient with anxiety is usually within normal limits.

10. Answer: B. Medication can be effective. But scientific research shows that cognitive-behavioral therapy, or CBT, may be just as or more effective than medication (or a combination of CBT and medication) for most people, especially in the long run.

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infographics/130222AnxietyFINAL.jpg

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