Diagnosis and Treatment of Anxiety Disorders

Transcription

1 Diagnosis and Treatment of Anxiety Disorders N.P. Costigan, M.D. Dept. Of Psychiatry Alberta Health Services Clinical Professor Faculties of Family Medicine and Psychiatry U of A 1

2 Overlap Between Depression and Anxiety Disorders Depression and anxiety disorders represent discrete clinical syndromes that have overlapping symptoms. Depressive and anxiety disorders frequently co-occur Because of the overlap in symptoms and comorbidity, it is helpful to think about depression and anxiety on a spectrum Probable shared neurobiological alterations The shared spectrum has implications for common treatment approaches 2 2

3 Major Depressive Episode Diagnostic criteria Five or more of the following criteria must be present for at least two weeks and represent a change from usual functioning Depressed mood most of the day every day Markedly diminished interest in most things Insomnia or hypersomnia nearly every night Significant weight loss or weight gain Psychomotor retardation or agitation Fatigue or loss of energy every day Feelings of worthlessness or excessive guilt Diminished concentration or indecisiveness Recurrent thoughts of death 3 3

4 Major Depression and Anxiety Disorders: Symptom Overlap Major depressive disorder Irritability Worrying, guilt Agitation/restlessness Nervousness, tension Impaired concentration Anhedonia Insomnia Fatigue Anxiety disorders 4 4

5 DSM IV Anxiety Disorders Generalized Anxiety Disorder Panic Disorder with Agoraphobia Panic Disorder without Agoraphobia Social Anxiety Disorder Obsessive Compulsive Disorder Post Traumatic Stress Disorder Specific phobia Acute Stress Disorder 5 5

6 Generalized Anxiety Disorder 6 6

7 Diagnosis Excessive anxiety and worry for 6 months or more AND 3 or more of the following 6 symptoms: restlessness or feeling keyed up or on edge being easily fatigued difficulty concentrating or mind going blank irritability muscle tension sleep disturbance (difficulty falling asleep or staying asleep, or restless, unsatisfying sleep) 7 7

8 Prevalence and Onset 5% of the general population Mean age of onset: adolescence GAD symptoms often detected in childhood Only one-half of patients seek treatment of those seeking treatment, up to 50% are not diagnosed 8 8

9 Summary GAD is a common, chronic, disabling condition Affects 5% of the general population 80% have comorbid mood disorder Antidepressants are first line therapy. Benzodiazepines are second line therapy Novel Anticonvulsants, Novel Antipsychotics are third line therapy 9 9

10 Panic Disorder 10

11 4 or more of the following: Diagnostic Criteria Recurrent panic attacks Dyspnea or the sensation of being smothered Depersonalization or derealization Fear of going crazy or of losing self-control Fear of dying Palpitations or tachycardia Sweating Trembling or shaking Feeling of choking Chest pain or discomfort Nausea or abdominal upset Dizziness, feeling of unsteadiness or faintness Numbness or tingling sensation Flushes or chills Cognitive symptoms Physical symptoms 11 11

12 Diagnosis (cont d) Anticipatory anxiety: one or more of the following for at least 1 month: Persistent concern about having another panic attack Worrying about the consequences of an attack (e.g., having a heart attack) Significant change in behaviour due to recurrent panic attacks 12 12

13 Agoraphobia A. Marked fear or anxiety about two or more of the following five situations: Using public transportation Being in open places Being in enclosed places Standing in line or being in a crowd Being outside of the home alone B. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic or other incapacitating or embarrassing symptoms. C. The situations almost always provoke anxiety. D. The situations are actively avoided. E. The anxiety is out of proportion. F. The fear, anxiety or avoidance is persistent. G. The fear, anxiety or avoidance causes significant distress

14 Social Anxiety Disorder 14

15 Social Anxiety Disorder (Social Phobia) Marked or persistent fear of social or performance situations Individuals fear scrutiny, negative evaluation, humiliation or embarrassment Exposure to (or anticipation of) social/performance situation provokes anxiety Avoidance of social/performance situations Significant distress or impairment in social and occupational functioning 15 15

16 Social Situations Going to a party socializing Lunch with peers making small talk Dating Asking a teacher for help Speaking to a boss at work Asking a salesclerk for help Asking for directions 16 16

17 Performance Situations Public speaking formal; large groups informal; small groups Writing in front of others Eating in front of others Playing an instrument Playing sports Entering a room Using a public toilet 17 17

18 Obsessive-Compulsive Disorder 18

19 Diagnosis Obsessions and/or compulsions recurrent, persistent ideas, thoughts, impulses or images repetitive, purposeful and intentional behaviours that are performed in response to an obsession Time-consuming (>1 hour/day) Marked distress Interference with social and occupational functioning 19 19

20 Obsessive and Compulsive Symptoms on Admission (n=560) Obsessions contamination (45%) pathological doubt (42%) somatic (36%) symmetry (31%) aggressive (28%) sexual (26%) multiple (60%) Compulsions checking (63%) washing (50%) counting (36%) need to ask/confess (31%) symmetry/precision (28%) hoarding (18%) multiple (48%) 20 Rasmussen SA, et al. Psychopharm Bull

21 Post-Traumatic Stress Disorder 21

22 Diagnosis Experience of a traumatic event with sensation of horror, helplessness or fear Re-experience of the traumatic event Avoidance/numbing symptomatology Increased arousal symptoms Impaired functioning Symptoms >1 month duration 22 22

23 Acute Stress Disorder Experience of a traumatic event with sensation of horror, helplessness or fear Re-experience of the traumatic event Avoidance/numbing symptomatology Increased arousal symptoms Impaired functioning Symptoms>1 month duration Duration = 2 days 4 weeks 23 23

24 Trauma and the Probability of PTSD 55% of the population (USA) will experience a major traumatic event Approximately 7 10% will develop PTSD Development of PTSD may be influenced by: pre-traumatic factors trauma-related factors post trauma factors 24 24

25 DSM 5 What s Gone? Acute Stress Disorder moved to Trauma and Stressor and Related Disorders. Post Traumatic Stress Disorder moved to Trauma and Stressor and Related Disorders. Obsessive Compulsive Disorder moved to Obsessive Compulsive and Related Disorders

26 DSM 5 Anxiety Disorders Separation Anxiety Disorder Selective Mutism Specific Phobia Social Anxiety Disorder Panic Disorder Agoraphobia Generalized Anxiety Disorder 26 26

27 Separation Anxiety Disorder Anxiety concerning separation from those to whom the individual is attached. Requires 3 of: 1. Recurrent excessive distress when anticipating or experiencing separation from home or major attachment figures. 2. Persistent excessive worry about losing major attachment figures. 3. Persistent excessive worry about experiencing an untoward event eg.: getting lost, being kidnapped, or getting ill that would result in separation from a major attachment figure. 4. Persistent reluctance or refusal to go out, away from home, to school, to work, etc. 5. Persistent excessive fear of/or reluctance about being alone. 6. Persistent reluctance or refusal to sleep away from home. 7. Repeated nightmares involving the theme of separation. 8. Repeated complaints of physical symptoms when separation is anticipated

28 Selective Mutism Consistent failure to speak in specific social situations in which there is an expectation for speaking eg. at school despite speaking in other situations

29 Specific Phobia Marked fear or anxiety about a specific object or situation eg. flying, heights, animals, receiving an injection, seeing blood

30 Treatment of Anxiety Disorders 1. Psychotherapy 2. Psychopharmacology (medication) 30 30

31 SSRI S Prozac (Fluoxetine) Luvox (Fluoxamine) Zoloft (Sertraline) Paxil (Paroxetine) Celexa ( (Citalopram) Cipralex (Escitalopram) 31 31

32 Selective Serotonin Reuptake Inhibitors- SSRIs Selectively inhibit the reuptake of serotonin serotonin Also have some action on inhibiting the reuptake of noaradrenaline and dopamine Relatively safe in overdose Relatively safe in pregnancy Relatively safe in breastfeeding Side effects Well tolerated Nausea, diarrhea Headache Agitation Insomnia or drowsiness Serotonin syndrome- rare Sexual side effects are common 32 32

33 Other Antidepressants DRUG NDRI- buproprion (Wellbutrin) SNRI (Effexor, Cymbalta, Pristiq) NaSSA mirtazepine (Remeron) RIMA-moclobemide (Manerix) Tricyclics (Elavil, Tofranil, Anafranil) MAOI (Nardil, Parnate) 33 33

34 TOLERABILITY All antidepressants have side effects To the degree that we understand differential effects of antidepressants on neurotransmitters and receptors, we can understand differences in tolerability profiles Given comparable efficacy, tolerability profile is often the critical determinant in selecting an antidepressant medication for a given patient

35 Other Treatments NOVEL ANTI-PSYCHOTICS Seroquel, Risperidone, Zyprexa NOVEL ANTI-CONVULSANTS Carbamazepine, Gabapentin, Lyrica OLDER ANTI-DEPRESSANTS Elavil, Aventil, Trazodone 35 35

36 Cont d BENZODIAZIPINES Lorazepam, Clonazepam, Bromazepam, Alprazolam, Valium, Librium OTHER ANTI-ANXIETY DRUGS Buspar HYPNOTICS Imovane, Restoril, Benzodiapines, 36 36

37 The End 37 37