The Anxious PatientThe Anxious PatientA Patient-Centered, Evidence-Based A Patient-Centered, Evidence-Based Diagnostic and Treatment ProcessDiagnostic and Treatment Process1,21,2

A Presentation for SOMC Medical EducationA Presentation for SOMC Medical Education

Kendall L. Stewart, MD, MBA, DFAPAKendall L. Stewart, MD, MBA, DFAPAMarch 18, 2011March 18, 2011

1 This is problem-oriented learning with numerous links to supporting resource material.2 Please let me know how I can improve my service to you on your evaluation, in person or on Facebook.

Why should you learn about these disorders?

• They are the most common mental disorders.

• These disorders are frequently missed, ignored or mistreated.

• These disorders cause substantial distress and impairment.1

• Patients with these disorders over-utilize other medical services.2,3

• Many physicians still lump these disorders and minimize them as “nerves.”

• These disorders can usually be effectively treated.1 Significant distress and/or impairment are required to make a psychiatric diagnosis.

2 Anxiety and depression are frequently masked by physical complaints.3 One of my elderly patients never talked about her anxiety, only the “burning in my head.”

What are some of the physical manifestations of anxiety?

• Diarrhea• Dizziness or

light-headedness• Hyperhidrosis• Hyperreflexia• Hypertension• Palpitations• Pupillary

mydriasis

• Restlessness• Syncope• Tachycardia• Tingling in the

extremities• Tremors1,2,3

• Upset stomach (“butterflies”)

• Urinary frequency, hesitancy, urgency

1 Most tremors are worsened by anxiety.2 I admitted a man from the ED who developed a significant conduction disturbance.3 I unexpectedly experienced panic when undergoing MR imaging.

What are some of the mental manifestations of anxiety?

• Apprehension• Vigilance • Scanning• Shame• Confusion• Distortion of perception• Decreased concentration• Poor recall• Impaired association• Selective inattention• False assumption1,2

1 Anxious patients always assume the worst.2 One of my patients noted, “You don’t look so good.”

What is a clinical decision tree for diagnosing the anxiety disorders?

“Normal”Anxiety

Anxiety

AnxietyDisorders

Anxiety 2o toGen Med Cond

Substance-InducedAnxiety

Anxiety Assoc

With AnotherMental

Disorder

Etc. Gen Anxiety Disorder Etc. Etc. Etc.Acute Stress Disorder

PTSD

OCD

Social Phobia

Specific Phobia

Agoraphobia

Panic Disorder

Adjustment Disorders Hypoglycemia

Hypothyroidism

CHF

Pulmonary Embolism

COPD

Caffeine

Alcohol

Stimulants

Anesthetics

Sedatives

Mood Disorder

Cognitive Disorder

Dissociative Disorder

1 These categories form an excellent conceptual algorithm for evaluating psychiatric symptoms in clinical practice.

What is the difference between normal and pathologic anxiety?

• It is often impossible to tell.• Whether the anxiety or fear promotes

adaptation or causes impairment must be considered.

• Whether a given distress is judged normal or pathologic depends on one’s resources, psychological defenses, and coping mechanisms.1,2

• “Is this more than the usual ups and downs of life?” will often point the physician in the right direction.

1 Strong emotion of any sort impairs your ability to think clearly and act rationally.2 One of my patients came out of the restroom to find the atrium door locked. The sign on my door mayhave discouraged potential rescuers. All she needed to do was turn the deadbolt and walk out.

What specific diagnoses are included in this category?

• Panic disorder without agoraphobia

• Panic disorder with agoraphobia

• Agoraphobia without a history with panic disorder

• Specific phobia• Social phobia• Obsessive-

compulsive disorder

• Posttraumatic stress disorder

• Acute stress disorder

• Generalized anxiety disorder

• Anxiety disorder due to a [GMC]

• Anxiety disorder NOS1

1 Always remember to ask about caffeine.

What is the epidemiology of anxiety?

• This in one of the most common groups of psychiatric disorders.

• One in four persons has diagnosable anxiety disorder.

• The 12-month prevalence rate is 17.7%.

• The prevalence of these disorders decreases with higher socioeconomic status.

MenWomen

0%5%

10%15%20%25%

30%

35%

Lifetime Prevalence of Anxiety Disorder

What is the biological basis of anxiety?1,2

1 Kaplan & Sadock, 20082These observations are true for all of the anxiety disorders.

• Autonomic Nervous System– Increased sympathetic tone in anxious patients

• Neurotransmitters– Norepinephrine– Serotonin– γ- aminobutyric acid (GABA)

• Brain-Imaging Studies– Some patients with anxiety disorders have

functional or anatomical changes.• Genetic Studies

– Some genetic component clearly contributes to the development of anxiety disorders.

• Neuroanatomical Considerations– The locus ceruleus and raphe nuclei project to

the limbic system.– The limbic system contains a high

concentration of GABAA receptors.– The frontal cerebral cortex is connected with

the parahippocampal region, the cingulate gyrus, and the hypothalamus.

What about anxiety due to another medical condition?

• Anxiety commonly accompanies many different general medical conditions.

• These underlying conditions cause anxiety via the noradrenergic and perhaps the serotonergic systems.

• Paroxysmal bouts of anxiety should make clinicians suspicious.

• The clinical features can be identical to those of the primary anxiety disorders.

• Primary anxiety disorders generally have their onset before age 35.

• Anxiety symptoms may persist after the primary disorder is treated.

• The underlying disorder should be treated first, but the anxiety may need to be addressed separately.1,2

1 If you decide up front that the patient is a crock, this will set you up for some serious mistakes.2 One of my “crock” patients presented to the ED with the history of a dilated pupil.

What about substance-induced anxiety disorders?

• This is a common consequence of recreational and prescription drug abuse.

• You must think about it and ask about it every time.

• Don’t forget about caffeine.

• The associated clinical features may vary with the substance involved.1,2

• Cognitive impairments in comprehension, calculation and memory usually disappear when the substance is discontinued.

• The differential diagnosis includes– Primary anxiety

disorders– Anxiety due a general

medical condition (for which the patient may be receiving the implicated drug)

– Mood disorders– Personality disorders– Malingering

• Removal of the offending substance is the preferred treatment

1 People who take a lot of speed become overtly paranoid.2 I evaluated a patient at a MHC who was convinced that the FBI was landing UFOs in his backyard.

What about mixed anxiety-depressive disorder?

• These are patients that don’t meet full criteria for either a mood or an anxiety disorder.

• They are particularly common in primary care practices.

• On careful examination, they often are depressed. The accompanying anxiety is misleading.

• For this reason, the syndrome is controversial.

• This combination of symptoms leads to considerable functional impairment.

• Up to 2/3 of depressed persons are also anxious and up to 9/10 of panic patients experience depression.

• If this emerges as a specific diagnosis, it may affect about 1% of the population.

• The serotonergic drugs are helpful for both the anxiety and depression.1,21 These “mixed syndromes” can be very challenging. Unfortunately, few of your patients will have read the book.

2 When in doubt, treat for depression. It is very hard to get patients off benzodiazepines.

Where can you learn more?

• 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, 20081

• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 20072

• 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

1,2Please note that you must master all of the information in a basic neurology textbook and a basic psychiatrytextbook to do well on the comprehensive, standardized final examination.

Where can you find evidence-based information about mental disorders?

• 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.Kendall L. Stewart, M.D.VPMA and Chief Medical OfficerVPMA and Chief Medical OfficerSouthern Ohio Medical CenterSouthern Ohio Medical Center

Chairman & CEOChairman & CEOThe SOMC Medical Care Foundation, Inc.The SOMC Medical Care Foundation, Inc.

1805 27th Street1805 27th StreetWaller BuildingWaller Building

Suite B01Suite B01Portsmouth, Ohio 45662Portsmouth, Ohio 45662

740.356.8153740.356.8153

StewartK@somc.org StewartK@somc.org KendallLStewartMD@yahoo.comKendallLStewartMD@yahoo.com

www.somc.orgwww.somc.orgwww.KendallLStewartMD.comwww.KendallLStewartMD.com

1Speaking and consultation fees benefit the SOMC Endowment Fund.

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