Generalized Anxiety Disorder and Panic Disorder. Ellen Gluzman, MD Assistant Professor of Psychiatry Temple University Philadelphia, PA

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1 Generalized Anxiety Disorder and Panic Disorder Ellen Gluzman, MD Assistant Professor of Psychiatry Temple University Philadelphia, PA

2 Fear vs. Anxiety Fear is an emotional response to a threat Anxiety is a similar emotional experience but without a clear external threat Some anxiety is normal A little bit of anxiety is what gets us to study for the big test, make sure we re prepared for the big snow fall, etc. Anxiety that significantly impairs functioning may be normal during periods of severe stress, and should resolve once the stressor resolves Anxiety disorder exists when anxiety is out of proportion to stressors or fails to resolve once stressors resolve

3 Panic Disorder Recurrent unexpected panic attacks A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: Note: The abrupt surge can occur from a calm state or an anxious state. Palpitations, pounding heart, or accelerated heart rate. Sweating. Trembling or shaking. Sensations of shortness of breath or smothering. Feelings of choking. Chest pain or discomfort. Nausea or abdominal distress. Feeling dizzy, unsteady, light-headed, or faint. Chills or heat sensations. Paresthesias (numbness or tingling sensations). Derealization (feelings of unreality) or depersonalization (being detached from oneself). Fear of losing control or going crazy. Fear of dying. Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. At least one of the attacks has been followed by 1 month or more of persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, going crazy ).

4 Epidemiology of Panic Disorder The lifetime prevalence 3.8% Females are twice as likely as males to experience generalized anxiety disorder Median age of onset is 23 years old

5 Differential Diagnosis for Panic Disorder Important to rule out medical causes Often patients will present particularly worrying that there is an underlying medical cause SUBSTANCES Cocaine Amphetamines Caffeine Withdrawal from alcohol or benzos Multiple other substances important to review patient s medications for possible culprits Other underlying psychiatric disorders

6 Algorithm for the treatment and management of anxiety disorder Identify anxiety symptoms 1. Assess Impact on Function 2. Assess suicide risk Differential diagnosis 1. Take history to ensure it is not substance induced anxiety 2. Anxiety due to Medical condition 3. conduct physical and laboratory test Identify specific causes of disorder 1. Separation, Social, Panic, Phobia 2. Generalized anxiety disorder Treatment 1. Consider patient preference 2. Cognitive behavior therapy 3. Pharmaceutical therapy Specific Phobia Cognitive behavior therapy Benzodiazepines as needed Separation disorder, panic, generalized anxiety 1.Cognitive behavior therapy 2. Antidepressants 3. Atypical antipsychotics

7 Treatment of Panic Disorder: Commonly Used Antidepressants SSRIs First line treatment May initially worsen anxiety through activating properties, so, as the timeless saying goes, start low and go slow Start and half the dose that would normally be starting dose for depression (i.e., fluoxetine 10mg) Can gradually increase to maximum tolerated dose Benefit should begin 2-3 weeks after initiation SNRI (venlafaxine, aka Effexor) Considerations similar to SSRIs Commonly used antidepressants with no clear benefit in panic disorder: Trazodone Bupropion (Wellbutrin)

8 Treatment of Panic Disorder: Less Commonly Used Antidepressants TCAs Cause more side effects than SSRIs, including anticholinergic side effects, orthostasis, danger in overdose Similarly to SSRIs, require slow titration from low dose MAOIs Multiple side effects (risk of serotonin syndrome, hypertensive crisis, etc) May be an option for a patient who failed other treatment options

9 Treatment of Panic Disorder: Benzodiazepines Benzos have been consistently shown to be fast-onset anxiety-relief and may be used most commonly for a brief period of time while waiting for SSRI to become effective Shorter acting benzos (i.e, alprazolam, aka Xanax) may have rebound symptoms between doses, quick onset of withdrawal, and may need to be dosed more frequently Alprazolam very commonly substance of abuse Longer acting benzos (i.e, clonazepam, aka Klonopin) may have less rebound and withdrawal symptoms between doses As patient s SSRI (or other antidepressant) treatment becomes effective, benzos should be slowly tapered off Slow taper can prevent rebound symptoms

10 Benzodiazepine Use Benzodiazepines should be avoided in: Patients with history of substance use, especially benzodiazepine or alcohol use disorder Check the Prescription Drug Monitoring Program to see if the patient is already receiving a benzo prescription from a different physician Patients who are taking opioids Benzodiazepine interaction with opioids can cause respiratory depression, coma, and death Recent FDA black box warning Patients who may be at an increased risk for delirium or falls (i.e., elderly) Consider referral to a psychiatrist if a patient is not able to discontinue benzos after a brief course of treatment

11 Alternatives to Benzodiazepines Using slightly sedating antidepressant (i.e., paroxetine) Hydroxyzine (aka Atarax) Some off-label medications that have been used for anxiety Atypical antipsychotics (i.e., low dose quetiapine, aka Seroquel) Anticonvulsants, (ie., gabapentin, aka Neurontin) These medications have very equivocal evidence in the literature Don t underestimate the power of placebo effect

12 Therapy Most evidence-based therapy for anxiety disorders is CBT Critical evaluation of automatic thoughts that may trigger anxiety Relaxation and breathing training Exposure therapy Effectiveness can be prevented by patient being on a benzodiazepine while undergoing therapy

13 Generalized Anxiety Disorder Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities. The individual finds it difficult to control the worry. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Restlessness or feeling keyed up or on edge. Being easily fatigued. Difficulty concentrating or mind going blank. Irritability. Muscle tension. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

14 GAD Epidemiology The lifetime prevalence 4.3% Females are twice as likely as males to experience generalized anxiety disorder Men more likely to have a comorbid substance use disorder Median age of onset is 30 years old, but has a wide spread over lifetime Seen much more frequently by primary care physicians and other medical practitioners than by psychiatrists Patients often present with somatic symptoms (e.g., headache, back pain and other muscle aches, gastrointestinal distress, insomnia)

15 Differential Diagnosis Underlying medical condition Underlying substance use Another psychiatric disorder, including social anxiety disorder, adjustment disorder, PTSD, etc.

16 Treatment of GAD First line treatment is antidepressants Most commonly SSRIs Buspirone (aka Buspar) TCAs and MAOIs less common Similar considerations in dosing and side effects as in panic disorder Benzos can be used as a short-term adjunct treatment while the antidepressant becomes effective Same concerns for substance use, withdrawal, and adverse effects as discussed previously Off-label use of atypicals and anticonvulsants CBT, as well as other types of therapy

17 When to Refer to a Psychiatrist If anxiety disorder is not responsive to common treatment If there are multiple comorbidities, including depression or bipolar illness, substance-use, comorbid personality disorder

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