Anxiety – CCP guideline 2014

Anxiety

  • Universal human characteristic involving tension, apprehension, or terror
  • Serves as an adaptive mechanism (fight or flight)
  • Becomes pathological when
    1. fear is out of proportion to risk/severity of threat
    2. response continues beyond existence of threat or become generalized to other situations
    3. Impaired social or occupational functions

Overview of the management of anxiety and related disorders

  1. Screen for anxiety and related symptoms
    • The key dx criteria for anxiety disorders is the requirement that the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  2. Conduct ddx (consider severity, impairment, comorbidity)
    • Medical Conditions: hyperthyroidism, cardiopulmonary disorders, traumatic brain injury
    • Another psychiatric condition
    • Medication-induced or drug-related.
  3. Identify specific anxiety or related disorder
  4. psychological and / or pharmacological tx
  5. Perform follow-up

General screening Questions

  • During the past 2 weeks how much have you been bothered by the following problems?
    • feeling nervous, anxious, frightened, worried, or on edge
    • Feeling panic or being frightened
    • Avoiding situations that make you anxious

Common risk factors in patients with anxiety and related disorders

  • Family history of anxiety
  • Personal history of anxiety or mood disorder
  • Childhood stressful life events or trauma
  • Being female
  • Chronic medical illness
  • Behavioral inhibition

1 Do not attribute acute symptoms of panic (e.g., shortness of breath, palpitations, hyperventilation) to anxiety without first excluding serious medical pathology (e.g., pulmonary embolism, myocardial infarction ) from the differential diagnosis (especially in patients with established anxiety disorder).

Differential Diagnosis of Anxiety Disorders

  • C/V: Post-MI, arrhythmia, congestive heart failure, pulmonary embolus, mitral valve prolapse
  • Resp: Asthma, COPD, pneumonia, hyperventilation
  • Endocrine: Hyperthyroidism, pheochromocytoma, hypoglycemia, hyperadrenalism, hyperparathyroidism
  • Metabolic: Vitamin B12 deficiency, porphyria
  • Neurologica: Neoplasm, vestibular dysfunction, encephalitis
  • Substance Induced: Intoxication (caffeine, amphetamines, cocaine, thyroid preparations, OTC for colds/ decongestants), withdrawal (benzodiazepines, alcohol)
  • Other Psychiatric Disorders: Psychotic disorders, mood disorders, personality disorders (OCPD), somatoform disorders

2 When working up a patient with symptoms of anxiety, and before making the diagnosis of an anxiety disorder:
a) Exclude serious medical pathology.
b) Identify:
– other co-morbid psychiatric conditions.
abuse.
substance abuse.
c) Assess the risk of suicide.

Basic lab tests

  • Complete blood count
  • Fasting glucose
  • Fasting lipid profile (TC, vLDL, LDL, HDL, TG)
  • Thyroid-stimulating hormone
  • Electrolytes
  • Liver enzymes

If warranted

  • U/A and Urine toxicology for substance use

Additional screening

  • Neurologica consultation, CXR, ECG, CT

Patients with an anxiety disorder warrant explicit evaluation for suicide risk. The presence of a comorbid mood disorder significantly increases the risk of suicidal behavior.


3 In patients with known anxiety disorders, do not assume all new symptoms are attributable to the anxiety disorder.

4 Offer appropriate treatment for anxiety:
– benzodiazepines (eg. deal with fear of them, avoid doses that are too low or too high, consider dependence, other anxiolytics).

BZD – useful adjunctive therapy early in Tx, particularly for acute anxiety or agitation, to help pt in times of acute crises, or while waiting for onset of adequeat efficacy of antidepressants.

  • Complications: 
    • Dependency, sedation, fatigue, cognitive impairment (may persist after cessation – esp memory impairment) – slurred speech, memory impairment, weakness
    • Associated with withdrawal, rebound, dependence- short/intermediate-acting > long-acting BZD
    • older pt >65yo, ↑ risk for falls & # due to psychomotor impairment.
  •  Usually restricted to short-term use, and generally dosed regularly rather than prn.

– non-pharmacologic treatment.

CBT is an efficacious psychological treatment for panic disorder.

Minimal intervention formats, such as self-help books, treatment via telephone/ videoconferencing, and internet-based CBT (ICBT) have been shown to be more effective than wait-list or relaxation controls, as effective as face-to-face CBT, and may be cost-effective options particularly for agoraphobic patients who are unwilling or unable to attend a clinic.

anxiety Tx


SSRI / SNRI s/e
  • headache, irritability, GI complaints (↑UGIB), insomnia, sexual dysfunction, wt gain, increased anxiety, drowsiness, fatigue, tremor.
  • Most s/e occur early and transiently during the first 2 weeks of Tx, but sexual dysfunction and wt gain, may persist for the duration of Tx.
  • Increase risk of SI in children and adolescents.
  • Abrupt d/c of SSRI/SNRI can lead to a discontinuation syndrome with GI, psychiatric, vasomotor, and other symptoms
Buspirone s/e:
  • dizziness, drowsiness, nausea
Atypical antipsychotics:
  • wt gain, DM, metabolic s/e – alt glucose/lipid levels
  • worse with olanzapine, intermidiate with resperidone & quetiapine, lower with aripiprazole
Anticonvulsants:
  • GI s/e, somnolence, wt gain, tremor, dermatologic & hematologic s/e

5 In a patient with symptoms of anxiety, take and interpret an appropriate history to differentiate clearly between agoraphobia, social phobia, generalized anxiety disorder, and panic disorder.

Screening questions for specific anxiety and related disorders (MACSCREEN)

Panic disorder

  • Do you have sudden episodes/spells/attacks of intense fear or discomfort that are unexpected or out of the blue?

If you answered “YES” then continue

  • Have you had more than one of these attacks?
  • Does the worst part of these attacks usually peak within several minutes?
  • Have you ever had one of these attacks and spent the next month or more living in fear of having another attack or worrying about the consequences of the attack?

SAD (Based on Mini-SPIN)

  • Does fear of embarrassment cause you to avoid doing things or speaking to people?
  • Do you avoid activities in which you are the center of attention?
  • Is being embarrassed or looking stupid among your worst fears?

GAD

  • During the past 4 weeks, have you been bothered by feeling worried, tense, or anxious most of the time?
  • Are you frequently tense, irritable, and having trouble sleeping?

OCD

Obsessions:

Are you bothered by repeated and unwanted thoughts of any of the following types:

  •  Thoughts of hurting someone else
  • Sexual thoughts
  • Excessive concern about contamination/germs/disease
  • Preoccupation with doubts (“what if” questions) or an inability to make decisions
  • Mental rituals (e.g., counting, praying, repeating)
  • Other unwanted intrusive thoughts

If you answered “YES” to any of the above… Do you have trouble resisting these thoughts, images, or impulses when they come into your mind?

Compulsions:

Do you feel driven to perform certain actions or habits over and over again, or in a certain way, or until it feels just right? Such as:

  • Washing, cleaning
  • Checking (e.g., doors, locks, appliances)
  • Ordering/arranging
  • Repeating (e.g., counting, touching, praying)
  • Hoarding/collecting/saving

If you answered “YES” to any of the above… Do you have trouble resisting the urge to do these things?

PTSD

  • Have you experienced or seen a life-threatening or traumatic event such as a rape, accident, someone badly hurt or killed, assault, natural or man-made disaster, war, or torture?

If you answered “YES”

  • Do you re-experience the event?

Disorder Key features

Panic disorder

  • Recurrent unexpected panic attacks, in the absence of triggers
  • Persistent concern about additional panic attacks and/or maladaptive change in behavior related to the attacks

Agoraphobia

  • Marked, unreasonable fear or anxiety about a situation
  • Active avoidance of feared situation due to thoughts that escape might be difficult or help unavailable if panic-like symptoms occur

Specific phobia

  • Marked, unreasonable fear or anxiety about a specific object or situation, which is actively avoided (e.g., flying, heights, animals, receiving an injection, seeing blood)

Social anxiety disorder (SAD)

  • Marked, excessive or unrealistic fear or anxiety about social situations in which there is possible exposure to scrutiny by others
  • Active avoidance of feared situation

Generalized anxiety disorder (GAD)

  • Excessive, difficult to control anxiety and worry (apprehensive expectation) about multiple events or activities (e.g., school/work difficulties)
  • Accompanied by symptoms such as restlessness/feeling on edge or muscle tension

Obsessive–compulsive disorder (OCD)

  • Obsessions: recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and that cause marked anxiety or distress
  • Compulsions: repetitive behaviors (e.g., hand washing) or mental acts (e.g., counting) that the individual feels driven to perform to reduce the anxiety generated by the obsessions

Posttraumatic stress disorder (PTSD)

  • Exposure to actual or threatened death, serious injury, or sexual violation
  • Intrusion symptoms (e.g., distressing memories or dreams, flashbacks, intense distress) and avoidance of stimuli associated with the event
  • Negative alterations in cognitions and mood (e.g., negative beliefs and emotions, detachment), as well as marked
    alterations in arousal and reactivity (e.g., irritable behavior, hypervigilance)

DSM5 – Panic Attacks

  • An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes,
  • and includes ≥4 of the following symptoms: STUDENTS FEAR the 3 C’s
  1. Sweating
  2. Trembling or shaking
  3. Unsteadiness, dizziness, light-headed, or faint
  4. Depersonalization (being detached from onself) , Derealization (feelings of unreality)
  5. Excessive (accelerated) heart rate, palpitations, pounding heart
  6. Nausea or abdominal distress
  7. Tingling sensations, numbness, Paresthesias
  8. Shortness of breath sensation or smothering
  9. Fear of losing control or going crazy
  10. Fear of dying
  11. Choking feelings
  12. Chest pain or discomfort
  13. Chills or heat sensations

DSM5 – Panic Disorder (≥4) – STUDENTS FEAR the 3 C’s

The person has experienced both of the following:

  1. Recurrent unexpected panic attacks
  2. ≥1 of the attacks followed by ≥1 month of 1 or both of the following:
    • Persistent concern or worry about additional panic attacks or their consequences
    • Significant maladaptive change in behavior related to the attacks

DSM-5 diagnosis of agoraphobia

  1. Marked fear or anxiety about ≥2 of the following 5 groups of situations:
    1. Public transportation (e.g., traveling in automobiles, buses, trains, ships, or planes)
    2. Open spaces (e.g., parking lots, market places, or bridges)
    3. Being in shops, theatres, or cinemas
    4. Standing in line or being in a crowd
    5. Being outside of the home alone in other situations
  2. The individual fears or avoids these situations due to thoughts that escape might be difficult or help might not be available in the event of panic-like symptoms
  3. The agoraphobic situations almost always provoke fear or anxiety
  4. The situations are actively avoided, require presence of a companion, or endured with marked fear or anxiety
  5. The fear or anxiety is out of proportion to actual danger posed by agoraphobic situation
  6. The fear, anxiety, or avoidance is persistent, typically lasting ≥6 months
  7. The fear, anxiety, and avoidance cause clinically significant distress or functional impairment

 DSM-5 diagnosis of specific phobia

  1. Marked fear or anxiety about a specific object or situation (e.g., flying,seeing blood)
  2. The phobic object or situation almost always provokes immediate fear or anxiety and is actively avoided or endured with marked fear or anxiety
  3. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation
  4. The fear, anxiety, or avoidance is persistent, typically ≥6 months
  5. There is marked distress or functional impairment
  • Animal: spiders, insects, dogs
  • Natural environment: heights, storms, water
  • Blood-injection-injury: needles, invasive medical procedures
  • Situational: airplanes, elevators, enclosed spaces
  • Other: choking or vomiting in children, loud sounds or costumed characters

DSM-5 diagnosis of SAD (social phobia)

  1. Marked fear or anxiety about social situations in which the person may be exposed to scrutiny by others
  2. Fear that actions or showing anxiety symptoms will cause negative evaluation (e.g., embarrassment, humiliation) or offend others
  3. The social situation:
    • Almost always provokes fear or anxiety
    • Is actively avoided or endured with marked fear or anxiety
  4. The fear, anxiety, or avoidance:
    • Is out of proportion to the actual threat posed by the social situation
    • Is persistent, typically ≥6 months
    • Causes significant distress or functional impairment
  5. If another medical condition is present (e.g., stuttering, obesity), the disturbance is unrelated or out of proportion to it
  6. Specify “performance only” if the fear is restricted to speaking or performing in public

DSM-5 diagnosis of GAD

  1. Excessive anxiety and worry (apprehensive expectation) about a number of events or activities (e.g., school/work performance)
  2. The individual finds it difficult to control the worry
  3. Excessive anxiety and worry are associated with ≥3 of the following symptoms (with at least some occurring more days than not for ≥6 months): PRIME
    • Poor concentration
    • Restlessness or feeling keyed-up or on edge
    • Irritability & Impaired sleep
    • Muscle tension
    • Eeasy fatiguability
  4. The disturbance causes clinically significant distress or functional impairment

 DSM-5 diagnosis of OCD

  1. Presence of either obsessions, compulsions, or both
  2. Obsessions are defined by the following:
    • Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and that cause marked anxiety or distress
    • The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with other thoughts or actions
  3. Compulsions are defined by the following:
    • Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or
      according to rigid rules
    • Compulsions are aimed preventing or reducing anxiety or preventing some dreaded situation or event; however, they are not connected in a realistic way with what they are designed to neutralize
      or are clearly excessive
  4. The obsessions or compulsions are time-consuming (e.g., take >1 h/day) or cause clinically significant distress or functional impairment
  5. Specify patient’s degree of insight as to reality of OCD beliefs:
    • Good or fair insight (i.e., definitely or probably not true)
    • Poor insight (i.e., probably true)
    • Absent insight (i.e., completely convinced beliefs are true)
    • Specify if “tic-related” OCD

DSM-5 diagnosis of PTSD

  1. The person has been exposed to actual or threatened death, serious injury, or sexual violation in ≥1 of the following ways:
    • Directly experienced or witnessed the traumatic event, learned that trauma occurred to close family member or friend (actual or threatened death must have been violent or accidental), experienced repeated exposure to aversive details of trauma
  2. Presence of ≥1 of the following intrusion symptoms associated with the trauma:
    • Recurrent, involuntary, and intrusive distressing memories, distressing dreams, dissociative reactions (e.g., flashbacks), psychological or physiological distress at reminders of traum
  3.  Persistent avoidance of stimuli associated with the trauma, including ≥1 of the following:
    • Avoidance of distressing memories or feelings and external reminders (e.g., people, places) of the trauma
  4. Negative alterations in cognitions and mood associated with the trauma, including ≥2 of the following:
    • Inability to recall important aspect of the trauma, diminished interest or participation in activities, feeling of detachment or estrangement from others, persistent negative beliefs, distorted blame, and negative emotional state
  5. Marked alterations in arousal and reactivity associated with the trauma, including ≥2 of the following:
    • Irritable or aggressive behavior, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, problems with concentration, sleep disturbance
  6. Duration of disturbance >1 month
  7. Symptoms cause clinically significant distress or impaired functioning
  8. Specify whether with dissociative symptoms (depersonalization or derealization) or with delayed expression (full criteria not met until at least 6 months after the event)

DSM-5 diagnoses specific to children

Separation anxiety disorder

Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by ≥3 of the following:

  • Distress when separation occurs, worry about loss or separation, reluctance to leave home, be alone, or go to sleep because of fear of separation, nightmares involving separation, or complaints of physical symptoms (e.g., headaches, upset stomach) when separation occurs
    • Duration of at least 4 weeks
    • Onset before 18 years of age
    • The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning

Selective mutism

  • Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations

Anxiety or related disorder

  • Changes to adult DSM-5 diagnostic criteria specific to children

Specific phobia

  • The fear or anxiety may be expressed by crying, tantrums, freezing, or clinging
  • Other specifiers: loud sounds or costumed characters

SAD (social phobia)

  • The anxiety must occur in peer settings, not just during interactions with adults
  • The fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failure to speak in social situations

OCD, panic disorder

  • No pediatric specific criteria

PTSD

  • Qualifiers in children
  • Intrusion symptoms: repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed; there may be frightening dreams without recognizable content; trauma-specific re-enactment may occur in play
  • Specific subtype for children ≤6 years of age

GAD

  • Less stringent criteria for symptoms than in adults

 Reference:

  • Canadian Clinical practice Guideline for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. July 2014: http://www.biomedcentral.com/content/pdf/1471-244X-14-S1-S1.pdf
  • TN2013
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Posted in 6 Anxiety, 99 Priority Topics, FM 99 priority topics, Psych

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