Generalized Anxiety Disorder & Panic Disorder Jeannette Dagam, D.O. Department of Psychiatry The...
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Transcript of Generalized Anxiety Disorder & Panic Disorder Jeannette Dagam, D.O. Department of Psychiatry The...
Generalized Anxiety Disorder & Panic Disorder
Jeannette Dagam, D.O.
Department of Psychiatry
The Ohio State University
College of Medicine
Objectives At the end of this module, you will know the following:
Identify etiological and diagnostic considerations in patients with anxiety disorders: Panic Disorder. Differential diagnosis Clinical Workup DSM 5 criteria Clinical Features Epidemiology Pathophysiology Course Treatment
Approach to the Patient with a Chief Complaint of Anxiety
History & Physical• Lethality Assessment• Past Psychiatric
History• Family Psychiatric
History• Medical/Surgical
History• Physical
Mental Status Examination
Appearance
Level of consciousness/alertness
Orientation/memory
Psychomotor abnormalities (agitation or retardation)
Suicidal or homicidal ideation
Hallucinations or delusional thought content
Insight
Judgment
Impulse Control
Laboratory and Diagnostic Testing
Standard workup Other testing to consider
Differential Diagnosis of Anxiety / General Medical Conditions
Endocrine
Neurologic
Infections
Cardiopulmonary disease
Cancers
Autoimmune disorders
Differential Diagnosis of Anxiety – Substance-Induced Disorders
Intoxication
Withdrawal
Surreptitious use medications
Side effects of medications
Differential Diagnosis of Anxiety / Other Psychiatric DisordersMajor Depressive Disorder
Schizoaffective Disorder or Schizophrenia
Delusional disorder or Paranoid Personality Disorder
Delirium
Adjustment Disorders with anxious or mixed features
Social Phobia
Obsessive Compulsive Disorder
DSM 5 CriteriaGeneralized Anxiety Disorder A. Excessive anxiety and worry (apprehensive expectation), occurring more days
than not for at least 6 months, about a number of events or activities (such as work or school performance).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months).
Note: Only one item is required in children.
(1) restlessness or feeling keyed up or on edge
(2) being easily fatigued
(3) difficulty concentrating or mind going blank
(4)irritability
(5)muscle tension
(6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
DSM 5 Criteria Generalized Anxiety Disorder D. The focus of the anxiety and worry is not confined to features of an Axis I
Disorder, e.g., the anxiety or worry is not about having a panic attack (as in panic disorder), being in embarrassed in public (as in social phobia), being contaminated (as in obsessive-compulsive disorder), being away from home or close relatives (as in separation anxiety disorder), gaining weight (as in anorexia nervosa), having multiple physical complaints (as in somatization disorder), or having a serious illness (as in hypochondriasis), and the anxiety and worry do not occur exclusively during posttraumatic stress disorder.
E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder.
DSM 5 CriteriaPanic DisorderA. 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. 1) Palpitations, pounding heart, or accelerated heart rate 2) Sweating 3) Trembling or shaking 4) Sensations of shortness of breath or smothering 5) Feelings of choking 6) Chest pain or discomfort 7) Nausea or abdominal discomfort 8) Feeling dizzy, unsteady, light-headed, or faint 9) Chills or heat sensations 10) Paresthesias (numbness or tingling sensations) 11) Derealization (feelings of unreality) or depersonalization (being detached from oneself) 12) Fear of losing control or ‘going crazy’ 13) Fear of dying
DSM 5 CriteriaPanic Disorder
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
1. Persistent concern or worry about additional panic attacks or their consequences (.e.g., losing control, having a heart attack, or ‘going crazy’)
2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations)
C. The disturbance is not attributable to the physiologic effects of a substance (e.g., a drug of abuse, a medications) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders)
D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in OCD; in response to reminders of traumatic events, as in PTSD; or in response to separation from attachment figures, as in separation anxiety disorder ).
DSM 5 CriteriaPanic Attack Note: Symptoms are presented for the purpose of identifying a panic attack; however
panic attack is not a mental disorder and cannot be coded. Panic attacks can occur in the context of any anxiety disorder as well as other mental disorder (e.g., depressive disorders, PTSD, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is identified, it should be noted as a specifier (e.g., “posttraumatic stress disorder with panic attacks”).
For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier.
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.
DSM 5 CriteriaPanic Attack 1) Palpitations, pounding heart, or accelerated heart rate 2) Sweating 3) Trembling or shaking 4) Sensations of shortness of breath or smothering 5) Feelings of choking 6) Chest pain or discomfort 7) Nausea or abdominal discomfort 8) Feeling dizzy, unsteady, light-headed, or faint 9) Chills or heat sensations 10) Paresthesias (numbness or tingling sensations) 11) Derealization (feelings of unreality) or depersonalization (being detached from oneself) 12) Fear of losing control or ‘going crazy’ 13) Fear of dying
Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.
DSM 5 Criteria AgoraphobiaA. Marked fear or anxiety about two (or more) of the following five situations:
A. 1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).
B. 2. Being in open spaces (e.g., parking lots, marketplaces, bridges).
C. 3. Being in enclosed places (e.g., shops, theaters, cinemas).
D. 4. Standing in line or being in a crowd.
E. 5. Being outside of the home alone.
B. The individual fears or avoids these situations because of thoughts escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence).
C. The agoraphobic situations almost always provoke fear or anxiety.
D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
DSM-5 CriteriaAgoraphobia G. The fear, anxiety, or avoidance causes clinically significant distress or
impairment in social, occupational, or other important areas of functioning. H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s
disease) is present, the fear, anxiety, or avoidance is clearly excessive. I. The fear, anxiety, or avoidance is not better explained by the symptoms of
another mental disorder – for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder); and are not related exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder).
Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.
EpidemiologyGeneralized Anxiety Disorder (GAD)
Common in primary care settings
Higher prevalence in women
High comorbidity with other psychiatric disorders including substance abuse disorders
Heritability Generalized Anxiety Disorder
Familial Genetic loading
PathophysiologyGeneralized Anxiety Disorder
Biologically heterogeneous
Knowledge about the disorder
derived indirectly
GABA, serotonin and norepinephrine neurotransmitters interplaying within the limbic system
Epidemiology Panic Disorder
More common in women
Average onset in the 3rd decade of life
Various medical settings demonstrate prevalence rates
Heritability of Panic Disorder
First degree relatives at high risk
Earlier age of onset confers a higher risk
Twin studies
Biopsychosocial CorrelatesPanic Disorder
Decreased exercise tolerance, with increased oxygen consumption and increased production of lactic acid
Increased prevalence of Irritable Bowel Syndrome
Increased prevalence of Peptic Ulcer
Decreased resting pCO2
Increased sensitivity to anxiogenic effects of stimulants (e.g., caffeine)
Increased frequency of history of childhood Separation Anxiety Disorder
Increased frequency of asymptomatic mitral valve prolapse (MVP)
Mitral Valve Prolapse and Panic Disorder
Historically tagged as the culprit
Absence of significant differentiation between patient groups
Does not confer increased risk
Physiologic Challenge Studies Panic Disorder Panic Disorder patients have an increased sensitivity to the anxiogenic effects of
caffeine; however large doses of caffeine can induce panic attacks in anyone Panic Disorder patients have an increased sensitivity to the physiologic effects of
hyperventilation (which decreases pCO2 concentration) and often have Panic Attacks during voluntary over-breathing of room air. Hyperventilation, however, does not produce Panic Attacks in persons who do not have Panic Disorder
Panic Attacks are easily induced in many patients with Panic Disorder, but not in controls who do not have Panic Disorder, in response to: Injection of sodium lactate Breathing air in which CO2 is elevated Injection of isoproterenol, a beta-receptor agonist Injection of yohimbine, an alpha 2 – receptor antagonist Injection of cholecystokinin tetrapeptide Injection of flumazenil, a benzodiazepine receptor antagonist
Neuroanatomic correlatesPanic Disorder
Neurotransmitter/Neuromodulator Abnormalities in Panic Disorder
Norepinephrine in the locus ceruleus
Serotonin in midbrain neurons
GABA in the limbic system
Adenosine or Cholecystokinin at CNS sites not yet identified
CourseGeneralized Anxiety Disorder
The majority of individuals with GAD report that they have felt anxious and nervous all their lives
Over half of those presenting for treatment report onset in childhood or adolescence, onset occurring after age 20 years
is not uncommon
The course is chronic but fluctuating and often worsens during times of stress
Course Panic Disorder
Age of onset
Usual course
Onset of agoraphobia
CoursePanic Disorder
Agoraphobia
Naturalistic studies
Treatment
• SSRIs, SNRIs, TCAs, MAOIsAntidepressants
• Lorazepam, clonazepam, diazepam, etc.Benzodiazepines
• Buspirone• HydroxyzineOther Agents
• Cognitive Behavioral Therapy• Relaxation exercisesPsychotherapy
References
ISP Module for Psychiatry / OSU Dept. of Psychiatry Clinical Manual of Anxiety Disorders, edited by Dan J.
Stein, MD, PhD; American Psychiatric Publishing, Inc. 2004
DSM 5, American Psychiatric Association, 2013
Panic Disorder GAD Quiz
In Summary
Anxiety and panic are common features within many psychiatric conditions, but the focus, scope and intensity of one’s worry is important in determining whether an independent anxiety or panic disorder exists.
Anxiety as a trait has a familial association – panic disorder develops up to 8 times more often in first degree relatives.
Among the anxiety disorders, generalized anxiety disorder is the most biologically heterogeneous condition.
Effective management of anxiety disorders often involves both pharmacologic and psychological interventions.
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