Transcript The Anxiety Disorders Some Practical Questions & Answers

Generalized
Anxiety Disorder
A Patient-Centered, Evidence-Based
Diagnostic and Treatment Process
A Presentation for the Students of Ohio University
Heritage College of Osteopathic Medicine
Kendall L. Stewart, MD, MBA, DFAPA
November 29, 2011
Why is this important?
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Generalized Anxiety Disorder (GAD) is
a very common disorder.
The lifetime prevalence is 5-percent.
Females are affected about twice as
often.
In anxiety disorder clinics about 25percent of patients have presenting or
comorbid GAD.
Most of these patients will readily
admit that they have been nervous
worrywarts as long as they can
remember.
The usual course is chronic and
fluctuating, and these people are worse
during times of stress.
There is a genetic contribution to the
development of this disorder.1,2
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After mastering the information in
this presentation, you will be able
to
– Describe how patients with GAD
often present,
– Detail the diagnostic criteria,
– Describe some of the associated
features,
– List some differential diagnoses,
– Write a preliminary treatment
plan, and
– Identify some of the frequent
treatment challenges.
My mother was one of the worst worriers I’ve ever seen. She once woke me up to tell me about one of
her bad dreams. They experience every side effect and fret about the news.
2 Our older son has inherited this tendency and once expressed his worry about my plane crashing.
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How might a patient with GAD
present?
• This is a 53-year-old-man.
• “I’ve been a worrywart for as
long as I can remember.”1,2
• “Most of what I worried about
never happened, but I always
think about the worst things
that might occur.”
• “I always feel tense and
restless.”
• “It’s like I’m trembling on the
inside.”
• “Because of this, I’m often
irritable.”
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• “I have trouble falling asleep
because I can’t get stuff off my
mind.”
• “Sometimes I get so upset that I
sweat, my mouth gets dry, my
heart races.”
• “These symptoms come on
gradually, not suddenly.”
• “My family doc put me on
diazepam 20 years ago, and I
couldn’t get by without it.”
• “I have never taken more than
the doctor prescribed, but I
can’t do without it.”
• You can listen to these patients
describe their struggles here.
For these folk, there is always something to worry about.
Three old men in the nursing home were worried about their bodily functions.
What associated features might you
see?
• Chronic muscle tension is common.
• These patients may exhibit an exaggerated startle
response.
• Mood disorders very frequently co-occur.
• Other anxiety disorders also frequently co-occur.1,2
• These patients are also at higher risk for developing
substance use disorders.
• The general medical disorders that are often associated
with stress such as headache and irritable bowel
syndrome are frequently present also.
• These patients frequently use somatic complaints to
describe emotional discomfort.
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50 to 90-percent of people with GAD have another mental disorder.
The female-to-male ratio for GAD is 2-to-1.
What other diagnoses might you include in
the differential diagnosis?
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Normal anxiety1
– Waiting for 3 hours for news of your wife’s first C-section
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Other anxiety disorders
– GAD may be the “foundation” disorder.
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Anxiety secondary to a general medical condition
– Pheochromocytoma
– Hyperthyroidism
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Substance-induced anxiety
– Caffeine is the most common culprit.
– Withdrawal from alcohol is also common.
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Anxiety secondary to other psychiatric disorders
– All of them.
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I experienced real anxiety waiting to hear about Jonathan.
What might a typical treatment plan
look like?
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Generalized anxiety
– Provide reassurance.
– Suggest discontinuance of all
caffeine.
– Consider no treatment at all.1,2
– Try all non-medicinal
interventions next.
– Use the anxiety pyramid.
– Consider buspirone 15 mg twice
per day.
– Consider rare benzodiazepine use.
– Reserve chronic benzodiazepine
use for those people who
• Do not respond adequately to any
other intervention
• Respond dramatically to routine
medication use,
• Do not suffer unacceptable side
effects, and
• Do not abuse the medication.
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Other comorbid disorders
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Maladaptive attitudes and behaviors
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Diagnose and treat these conditions
vigorously.
Consider cognitive behavioral
psychotherapy (CBT)
Education and self help
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Provide educational resources.
Recommend a daily exercise regimen.
Recommend a healthy diet.
Suggest healthy distractions.
Recommend meditation.
Recommend online resources with
caution.
Recommend self-help groups with
caution.
people are miserable, but they are not miserable enough to change.
People with troubled marriages often see a psychiatrist as a last resort.
How do you treat Generalized Anxiety
Disorder?1
Routine benzodiazepine
PRN benzodiazepine2
Buspirone and/or an antidepressant
PRN antihistamine
Non-medicinal interventions
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on healthy distractions and sensory override techniques.
The benzodiazepines can cause dense amnesia. A colleague took alprazolam for flight anxiety.
What are some of the treatment
challenges you can expect?
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These people are wired this way.
They do best when they are distracted.
They often confuse worry with love.
They sometimes demand pills, but they are often
willing to avoid them.
• They annoy people around them, including their
physicians.1,2
• They always have physical complaints, and deciding
when to order more tests and when not to is an ongoing
challenge.
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These folk are invested in their worries, and they love to talk about them. Staying awake can be a challenge.
I can get a 30-second nap. Once, my notes flat lined. A mute child challenged a sleepy intern.
Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third
Edition, 2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical
Psychiatry, 2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April
2007
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship,
Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review,
Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home,
Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Where can you find evidence-based
information about mental disorders?
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Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties of your
choice here.
Subscribe to Evidence-Based Mental Health and search a database at the
National Registry of Evidence-Based Programs and Practices maintained by
the Substance Abuse and Mental Health Services Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
[email protected]
[email protected]
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Jeffrey Hill, DO
OUCOM 1987
Darren Adams, DO
OUCOM 2002
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