Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Anxiety

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Anxiety - Key Features

1. Do not attribute acute symptoms of panic (e.g., shortness of breath, palpitations, hyperventilation) to anxiety without first excluding serious medical pathology (e.g., pulmonary embolism, myocardial infarction ) from the differential diagnosis (especially in patients with established anxiety disorder).

2. When working up a patient with symptoms of anxiety, and before making the diagnosis of an anxiety disorder:
a) Exclude serious medical pathology.
b) Identify:
- other co-morbid psychiatric conditions
- abuse.
- substance abuse.
c) Assess the risk of suicide.

3. In patients with known anxiety disorders, do not assume all new symptoms are attributable to the anxiety disorder.

4. Offer appropriate treatment for anxiety:
- benzodiazepines (eg. deal with fear of them, avoid doses that are too low or too high, consider dependence, other anxiolytics).
- non-pharmacologic treatment.

5. In a patient with symptoms of anxiety, take and interpret an appropriate history to differentiate clearly between agoraphobia, social phobia, generalized anxiety disorder, and panic disorder.

Physical causes: (always rule these out before making diagnosis)

• Cardiovascular: angina, arrythmias, CHF, HTN, hypovolemia, MI, syncope
• Dietary: caffeine, MSG, vitamin-deficiency diseases
• Drug-related: akathisia (2nd antipsychotic Rx), anticholinergic toxicity, digitalis toxicity, hallucinogens, hypotensive agents, stimulants, withdrawal symptoms, bronchodilators
• Immunologic: anaphylaxis, SLE
• Metabolic:Cushing’s disease, hyperkalemia, hyperthermia, hyper/hypothyroidism, hypocalcemia,hypoglycemia, hyponatremia
• Neurologic: encephalopathies, essential tremor, intracranial mass lesions, post-concussive syndrome, seizure disorders, vertigo
• Respiratory: asthma, COPD, pneumonia, pneumothorax, pulm edema, PE
• Secreting tumors: carcinoid, insulinoma, pheochromocytoma

Drugs that can cause anxiety like symptoms:

• Stimulants (amphetamine, caffeine, cocaine, etc)
• Sympathomimetics (ephedrine, epinephrin, pseudoephedrine)
• Anticholinergics (cogentin, benadryl, demerol, TCA’s etc)
• Dopaminergics (sinimet, metoclopramide, neuroleptics, levodopa, etc)
• Miscellaneous (baclofen, cycloserine, hallucinogens, indomethacin)
• Drug withdrawal (barbitruates, benzos, narotics, alcohol, sedatives)

Be aware of risk of suicide in anxiety patients:
Risk Factors: “SAD PERSONS”

• Sex-male
• Age >60
• Depression
• Previous attempts
• Etoh
• Rational thinking loss (nuts-o)
• Suicide in family
• Organized plan
• No spouse/supports
• Serious illness

Patients with 0-2 of the above RF’s can be sent home. Those with 3-4 should be followed closely, and hospitalization should be considered. Those with 5-6 should be strongly considered for hospitalizations.

Risk Factors:
Family Hx of GAD, stressful life events, Hx of childhood emotional/ physical abuse/witnessing trauma

GAD
Excessive worry & anxiety that are difficult to control, cause significant distress and impairment, occurs in most days of at least 6 months period. 3 or more of:

• Restlessness
• Easy fatigability
• Difficulty concentrating
• Irritability
• Muscle tension

Management:

Medications:
1. SSRIs: Paroxetine (20mg), Sertraline(50mg), Citalopram( 20mg),escitalopram(10mg), Fluxetine(20mg),Fluvoxamine(50-100mg)
2. SNRIs: Venlafaxine XR 75-225 mg/day, Duloxetine
3. TCAs: Imipramine
4. BNZ: Alprazolam, lorazepam, oxazepam,chlordiazepoxide, diazepam,Clonazepam, alprazolam
5. Other: Buspirone 10-20 mg tid (same effect of oxazepam w/o risk of dependence), Pregabaline, Mirtazepine (refractory anxiety and insomnia), Quetiapine, Herbals
CBT
Combination of CBT & Meds

SSRI and SNRI are the 1st line meds, all meds take up to 4 weeks to effect, can use BNZ meanwhile until 1st line meds take effect, continue Tx for 12 months
Always look for physical and drug causes before starting on anxiety medications

Panic Attack/Disorder
A discrete period of intense fear or discomfort in which ≥4 of following develops suddenly, reaches to peak in 10 min, lasts usually <1hour

•Palpitation, pounding heart, ↑HR
•Sweating
•Trembling/shaking
•Feeling of choking
•Chest pain or discomfort
•Nausea/ Abdo distress
•Dizziness/lightheadedness/fainting
•Derealization/Depersonalization
•Fears of loosing control/getting crazy
•Fear of dying
•Chills/Hot flashes
•Paresthesia/numbness

Mnemonic: STUDENTS fear of 3Cs
Sweating, trembling, unsteadiness, deralizaition/depersonalization, excess Temp/HR, Nausea, Tingling, syncope, fear of dying, chest pain, chills, choking
Panic disorder: Recurrent panic attacks with ≥1 of: Fear/worry of future attacks, Change in behavior due to fear of attacks, phobic avoidance of situation that can trigger the attack Management:

1. SSRIs:all SSRIs are effective equally
2. SNRIs
3. TCAs: Clomipramine, Imipramine, Nortriptyline
4. BNZ: Clonazepam(0.5-4mg), Alprazolam(0.5-6mg), Lorazepam(0.5-6mg)
5. MOAIs: Phenelezine, Meclobemide
6. CBT: very effective

Continue Tx for 1 year then reassess

Agoraphobia
Anxiety about or avoidance of certain situations where help may not be available or it would be embarrassing or difficult to leave the situation if panic Sx happens. Situations are like waiting in lines, crowds, grocery stores, shopping malls, movies, driving, flying, public transport, doctors/dentist appointments, away from home
Management:

CBT
Antidepressants
BNZ short term

Specific Phobia
Significant anxiety associated with a specific object or situation that typically leads to avoidance behavior
Like:Animals, insects, flying, height, water, closed spaces
Management: Exposure therapy (CBT), Systematic Desentisitization (CBT), Relaxation/breathing therapy, Meds are 2nd line: BNZ(Lorazepam 0.5-2mg 30 minutes before exposure), Cycloserine

Social Anxiety Disorder (SAD) /Social Phobia
Excessive fears of scrutiny, embarrassment and humiliation in social or performance situations, leading to significant distress and/or impairment in functioning
Types: generalized social fears, in most interpersonal and performance situations, and SAD with discrete fears in only to 1- few situation
Management: generalized SAD( all meds for GAD), Specific SAD(Propranolol 20-60mg, 30 min before situation, Lorazepam ), CBT

SSRIs side effects:
Serotonin syndrome (lethal, agitation, delirium,↑HR, HTN,↑T, tremor, GI distress, myoclonus, hyperreflexia: D/C SSRI, BNZ, Cyproheptadine), sexual dysfunction, Wt gain, drowsiness, dry mouth, blurred vision, constipation, nausea

Table 1. Diagnostic Criteria for CG*
Note: Patients must meet all 3 criteria to be diagnosed with CG.

Criteria Description
Criterion A Yearning and heartache for the deceased at least daily or to the extent that it significantly distresses individuals and/or disrupts their functioning.

Do you feel yourself yearning/longing frequently for the person who has gone?
How is this impacting your life?

Criterion B The person must experience 4 of the following 8 symptoms at least several times a day or to a distressing or disruptive degree:

1. Difficulty accepting the death. Are you having trouble accepting the loss of ____?
2. Difficulty trusting others. Has it been hard for you to trust other people since the loss of ___?
3. Difficulty moving on with one’s life. Do you feel that moving on (for example, making new friends) would be difficult?
4. Excessive bitterness or anger about the death. Do you feel angry about the loss of ____?
5. Numbness/detachment from others. Do you feel emotionally numb or detached from others since the loss of ____?
6. Life is empty or meaningless without the deceased. Do you feel that life is empty or meaningless without ____?
7. Lack of hope for the future. Do you feel that the future holds no meaning, hope or possibility for fulfilment without ____?
8. Agitation. Do you feel jumpy or on edge since ____ died?

Criterion C The above symptoms cause marked, persistent dysfunction in multiple domains (e.g., social, occupational).
  • Note: These diagnostic criteria do not appear in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). To date, CG has not been categorized as a mental disorder.

DIAGNOSIS
14. Although people experiencing uncomplicated grief may initially exhibit some of the symptoms of CG, by six months post-loss, their distressing feelings will have diminished in intensity. They begin to accept the loss and to re-establish a balance in their lives.2;3
a. Those patients exhibiting symptoms (Table 1) for more than six consecutive months can be diagnosed with CG.3
b. A diagnosis can be made regardless of when the six-month period of symptoms occurs in relation to the loss. For most people diagnosed with CG, however, there is no delay in symptom onset. More commonly, “their grief has been intense and unrelenting since the death.”4
15. There is some diagnostic overlap between CG and other psychiatric disorders including: 20
• major depressive disorder (MDD): sadness, loss of interest, loss of self esteem, guilt
• post-traumatic stress disorder (PTSD): triggered by a traumatic event or a shock; may be manifested by feelings of helplessness, visualization of intrusive images and avoidance behaviour
16. Research has found, however, that CG is both “distinctive and distinguishable” from MDD and PTSD.21-23 Careful assessment can help to distinguish between these disorders.
• For example, CG-related guilt is usually limited to the death of a loved one; thoughts of death are related to a desire to be reunited. MDD, on the other hand, “is associated with more global feelings of worthlessness and thoughts of death with suicide.”24
• The diagnosis of MDD and PTSD can be made before the typical six-month period required for CG.
17. Co-morbidities are common in CG. In one U.S. study of 206 patients diagnosed with CG, 75% had some psychiatric co-morbidity, the most prevalent being MDD (55%) and PTSD (48%).25 This finding is consistent with other studies using referral populations.17 Standard practice guidelines can guide the diagnosis and treatment of MDD and PTSD

Study Guide

Anxiety

Resources

BC Guideline for Anxiety in Children and youth
Up to date
Toronto notes 2011