Anxiety- incidence & outcomes
* Lifetime prevalence - 29%
* Primary care visits - about 19.5% had at least one anxiety disorder - 41% untreated
* Dx is often missed
- 85.8% for PD; 71% for GAD;
97.8% for social anxiety d/o
* Associated with
- Increased divorce rates,
higher unemployme
Generalized anxiety disorder
* (GAD) - excessive fear, worry,
anxiety more days than not for
at least 6 months.
* Difficult to control worry
* Accompanied by at least 3
somatic complaints
- Restlessness - keyed up -
on edge
- Irritability
- Sleep disturbance
- Muscle tension
- Diffic
Anxiety stats
F > M (2:1)
5-9 % lifetime risk of GAD in general population
30% of pts onset before age 11; 50% before age 18 yrs.
Increased risk in families, with situational stress, and medical disease
May co-exist with depression (~48%) & other MH dx
Physical sx are
Anxiety management (DD/DX)
DD
Substance abuse
Hyperthyroidism
Parkinson's or other neuro dz
Psychiatric problems
Cardio-pulmonary disease
Dx tests
CBC, BMP, TSH
ECG
Anxiety management (TX)
Non-pharm
Relaxation therapy
Biofeedback
CBT
Psychotherapy
These tx may be more effective than pharm tx
Anxiety meds
* Chronic therapy
* SSRI's & SNRI's
**** First line
Good with comorbid depression
BDZ - rare/occas/ST use in acute distress
**** 2nd line
* Potential for misuse &
dependence
* Tolerance typically
develops
* Twice the relapse rate after
discontinuance of
b
Other meds for Anxiety
* TCA
- 2nd line
- Concerns about cardiotoxicity
& OD
* Off label
- Pregabalin - approved in
Europe
- 2nd generation
antipsychotics - eg
Quetiapine
- Hydroxyzine
- Beta blocker
Algorithm for stepped pharmacotherapy for GAD
Anxiety pearls
* Avoid caffeine, ETOH, & other OTC meds
* Only 1 in 4 pts with anxiety disorder is correctly dx & tx - increased HC utilization/cost/lost work-place productivity
* 25% of pts with anxiety have a medical problem as the root of the symptoms
* Patients are
Bipolar
* Episodic, frequently recurrent (90%) & progressive disorder
* 1 episode of at least 1 wk of continuously elevated, expansive, irritable mood associated with 3 or 4 of the following:
- Decreased need for sleep
- Grandiosity, inflated self-esteem
- Pressu
Bipolar I
(aka/pka - manic depression)
- 1.2% (2.3 million) of US population
- Familial illness
- Episode of both low (depressed) & high (manic) mood, usually alternating with periods of normal mood
Bipolar II
- Periods of depression that alternate with period of hypomania (not full mania)
- Familial illness
- More of a problem in women
- 3.8% of US population
Bipolar stats
- Onset in 20s; BD I (18); BD II (22)
- Heritability risk is 0.85
- 6th of 10 leading causes of disability in age 15-44
- The most expensive MH dx - cost 2x depression costs
- Late onset - suspect secondary mania
- Work up
** Routine labs
** Mood disorder
Common comorbidities associated with Bipolar
Anxiety d/o
Substance use d/o
ADHD
Eating d/o
Intermittent explosive d/o
Personality d/o
General medical illness w worse prognosis
Bipolar Depression comorbid depression conditions
** Higher rate of the following in BD
- Migraine
- Obesity
- DM
- Other endocrinopathies
- CV dz
- Epilepsy
- Anxiety disorders, eating disorders, - personality disorders
Effects of bipolar
* High suicide rates
- 25% of BD 1 will attempt; 15% succeed
* Substance use & abuse
Family disruption, divorce, unwanted pregnancies
* STDs
* Violence - perpetrators and victims
* Poor employment history
Bipolar symptoms
* 4 domains of symptoms
--- Manic mood & behavior **Euphoria, recklessness, social
intrusiveness, grandiosity,
impulsivity, excessive libido
--- Dysphoric or negative mood & behavior
** Depression, anxiety, irritability, hostility, violence, suicide
--- C
4 steps to diagnose Bipolar
Phenomenology
Family history
Longitudinal course
-- Abrupt onset, cycling
Treatment response
Diagnosis initially missed in most pts
Accurate dx usually take 5-10 yrs.
diagnostic clues for Bipolar
* 5 S's
Sleep
Sex/socializing
Spending
Speeding
Special projects
Mood Disorder questionnaire (MDQ)
Actual dx requires evidence of manic phase
Differential for BD -
secondary mania
- Thyroid disease - hyper or hypo
- Vitamin deficiency - B12, folate, thiamine, niacin
- Multiple sclerosis, Huntingtons, stroke, etc
- HIV or any lesion(s) involving subcortical or cortical areas, neurosyphilis
- Suspect these above in older pts
- Illici
Bipolar work-up
CBC, BMP, lipid profile, LFT, TSH, pregnancy tests (F), prolactin level, UA and UDS
EKG - check QTc interval baseline
First line Bipolar treatment
* CBT
- Family-centered psychotherapy
* Pharm agents
- First line - mood stabilizers
** Lithium 1500-1800 mg/day
** Valpoate (Depakote) 1000-1500 mg/day
** Both are better w antipsychotic
- Second line mood stabilizers
** Carbamazepine (Tegretol) 600-800
Adjunctive agents for Bipolar
Adjunctive agents in acute therapy
Aripiprazole (Abilify) 5-30 mg/day
Olanzapine (Zyprexa) 10-20 mg/day - 1st line for psychotic depression & mania
Risperidone (Risperdol)2-4 mg/day- 1st line for psychotic depression & mania
Ziprasidone (Geodon) 40-60 mg/
Bipolar pearls 1
Traditional antidepressants can trigger manic episodes
Combination therapy is standard for BD
Medication adherence is a problem
Suicide risk is high - lifetime risk is 29% (15-20% higher than norm)
Bipolar pearls 2
*In post-partum depression, R/O bipolar first
* Think bipolar if.....
- 3 failed antidepressant trials
- Antidepressant resistant GAD or panic
- Tempestuous interpersonal, legal, occupation histories
- 3 or more marriages
* Mood stabilizers 1st; antidepre
Bipolar pearls 3
- Untreated recurrent depressive illness decreases life expectancy by 7 years
- Titrate new drugs to SE tolerability not by blood levels
- Maximize one regimen (if signs of improvement) before switching to another
- Augmentation saves time over substituti
Stategic prescribing in BD comorbidities
Personality disorders - general
* General requirements
- Significant impairment in functioning as it relates to personality
- Impairments are relatively stable across time and consistent across situations
- Impairments not better understood as normative for individual's developmental st
Personality disorder clusters
A - Paranoid, schizoid, and schizotypal
B - Antisocial, borderline, histrionic, narcissistic
C - Avoidant, dependent, obsessive-compulsive
Lots of overlap in clusters
B is most problematic in day-to-day practice; borderline usually the worst
Borderline personality disorder
* Pervasive pattern of instability in interpersonal relationships, identity, impulsivity, and affect
( APA, 2013, DSM-5)
- Interpersonal hypersensitivity & unstable relationships - HALLMARK
- Affective disregulation
- Impulsivity - suicidal behaviors, sus
Borderline personality characteristics
** Five or more of the following:
- Frantic efforts to avoid real or imagined abandonment
- Unstable or intense IPRs alternating between extremes of idealization & devaluation
- Identity disturbance; unstable self-image
- Impulsivity in at least 2 areas t
Borderline personality disorder Etiology
* Life experience
- Hx of childhood neglect/abuse, sexual abuse
* Genetics
- Abnormalities in amygdala; altered prefrontal metabolism; altered neuropeptides
** Prevalence
- 6% primary care pts
- 18% chronic pain pts
- 26% of depressed primary care pts
* F
Borderline personality management
* Psychotherapy - first-line
* Low-dose antipsychotics - for impulse control, decrease anger, affective instability & psychosis
- Olanzapine (Zyprexa)
- Aripiprazole (Abilify)
* Mood stabilizers - valproate, topiramate, lamotrigine
* SSRI - limited eviden
BPD - Primary care actions
* Requires firm limit setting & structure
- Develop & maintain a therapeutic alliance
- Frequent, brief, scheduled visits for needy, demanding, somaticizing BPD pts
- Team care to avoid burnout - collaborate; communicate - open, clear, unambiguous, nonjud
Obsessive-Compulsive Disorder: (OCD)
* Persistent, recurrent, intrusive impulses & thoughts - create distress
* Up to 25% of adults w OCD symptoms
- Cleaning, checking, ordering,
counting, etc
- Repetitive behaviors aimed at
reducing distress from
obsessions
* Onset - bimodal peaks
- Age 11
OCD- pearls
- Previously considered anxiety d/o
- Now has its own DSM-5 classification
- Average time to dx - 11 years
OCD Management
- Earlier treatment - better prognosis
- Resistant to treatment
- CBT/psychotherapy - most effective - first line treatment
- Medication
* SSRI
** High doses usually needed - inc potential of Side effects
* Antipsychotics, ECT, or Surgery
Panic disorder Etiology
Familial/genetics
Temperament
Childhood adversity
Life stress
Neurobiology
Panic Disorder Differential
- Somatic symptom disorder
- Illness anxiety d/o
- Substance abuse
- Medical concerns
* Angina
* Arrhythmias
* COPD
* Temporal lobe epilepsy
* Asthma
* Hyperthyroid
* Pheochromocytoma
Panic disorders Characterized by
Palpitations, pounding heart, inc HR
Sweating trembling, shaking
SOB, smothering sensation
Choking sensation
CP or discomfort
Nausea, abd distress
Dizziness, unsteady, lightheaded, or faint
Feeling of unreality, detachment
Fear of losing control or going
DSM5 classification for panic D/O
At least 4 symptoms
Abrupt onset
Peak w/in 10 minutes
May last minutes-hours
Panic disorder management
- SSRIs
* Start low - go slow
* Treat at least a year
- SNRI - if SSRI not effective
- BZDs
* ST therapy only
* Immediate release
- Alprazolam (Niravam)
* Long-acting
- CBT/Psychotherapy
* Combine w meds
Social anxiety disorder
- Performance anxiety
- Public speaking
- Manifestations
* Trembling, sweating, blushing,
stuttering
* Avoidance vs suffering through
- Support
* Beta blocker (inderall)
* SSRI/SNRI
Somatic symptom disorder
Distressing; result in significant disruption of functioning
Excessive & disproportionate thoughts, feelings, behaviors regarding the symptoms
Symptomatic for 6 months or more (doesn't have to constant)
May or may not have a medically diagnosed condition
Illness anxiety disorder
Persistent preoccupation w having a serious illness (> 6 mo)
Very high levels of health anxiety
Complete absence of sx, or only very mild sx
Excessive health-related behaviors or maladaptive avoidance
Eg. constantly checking for sx; avoiding office visits
Risk factors - chronic somatic symptoms
* Predisposing, Precipitating & Perpetuating factors
- Childhood neglect or sexual abuse
- Chaotic lifestyle & chronic stressors
- ETOH or substance use
- Poor work history
- Tumultuous relationships; change in social support
- Poor coping
- Negative heal
Assessment for Somatic disorders
* CC - physical complaint
* S4 model (any positive = increase likelihood of psych diagnosis - eg. depression/anxiety)
- Symptom count - positive = > 5
- Stress - recent/last week? (yes/no)
- Self-rated health - 5 point scale - -excellent, very good, good,
Common presentations Somatic disorders
- Pain sx
- GI sx
- Cardiopulmonary sx
- Neurologic sx
- Reproductive organ sx
- Preoccupation with sx
- High # of symptoms > 4 in M; > 6 in F
- Vague, inconsistent history; normal PE
Management of somatization
- Empathy - good listening
- Legitimize the pt complaints
- Evaluate and treat diagnosable medical dz
- Minimize diagnostics, invasive tx, & symptomatic tx and specialty referrals
- Reassure that red-flags have been ruled out
- Treat coexisting anxiety or
Management of somatization - 2
- Explore recent life events & pt's coping
- Convey empathy with pt suffering & distress
- Continuity of care - one PCP - ck doc shopping
- Avoid confronting re. psych origin of sx
- Regular, scheduled, time-limited FU
at 2-4 wk intervals that are not sx-
Substance abuse
* Recurring pattern of substance use despite adverse effects in work, family, social, legal, and personal health
* Includes issues of physical and psychologic dependence
* 15% of primary care patients exhibit "at-risk" behaviors r/t substance use
* Polysu
Substance abuse: Need for treatment
SAMHSA report
22.7 million age 12 and over needed treatment for illicit drug or ETOH problem
20.2 million in this group did NOT receive treatment
37.3% didn't have healthcare and could not afford cost
24.5% not ready to stop using
Substance abuse concerns
Anxiety, depression, insomnia, cognitive & memory dysfunction, and behavior problems often present
ETOH & cocaine highly assoc. with violent behavior & accidents (> 50% of murders & their victims intoxicated at time of crime)
ETOH withdrawal - seizures &
CAGE-
C- Cut down
A- Annoyed
G- Guilt
E- eye opener
substance abuse Assessment guidelines
* Start w social acceptable substances - nicotine, caffeine
* ETOH next
* OTC pills - caffeine, pseudorphedrine (Sudafed), cough-DM
* Prescription meds - opioids, sleeping pills, ADHD stimulant meds
* Marijuana
* End w illegal drugs - meth, hallucinogens,
Substance abuse : Assessment guidelines - 2
Quantity
Frequency
Length of pattern of use; time of last use
Route - oral snorting, SQ, IV
Prior detox or other tx program - length of abstinence
Physical exam for substance abuse patients
- Abd - hepatomegaly
- Lymphadenopathy, thrush
- Infective endocarditis
- CAP, TB
- STDs
- Nasal septum erosion
- Skin abscesses
- Intoxication/withdrawal
* Bizarre behavior
* Agitation/sedation
* Pupil dilation/constrict
* Tachycardia
* Conjunctival inje
Substance abuse lab workup
- Drug panel - UDS, blood, breath, hair, saliva, sweat
- Hepatitis panel
- HIV
- STD screening
- Depends on CC/presentation
Substance abuse treatment goals
Non-pharm interventions most effective in breaking cycle
Goal of tx - abstinence
Pharmacologic strategies
Substitutions - Methadone, Buprenorphine, Nicotine patches/gum
Blocking therapies - eg. Naloxone, Naltrexone
Triggered effect therapy - Disulfiram (A
Therapy considerations for substance abuse
* Pharm agents
-- BDZ (long-acting) safe & effective for acute ETOH withdrawal - used to prevent seizures
-- Avoid beta blockers & clonidine in ETOH withdrawal - may mask severity markers in withdrawal
-- Clonidine good for opiate/narcotic withdrawal
-- A