Generalized Anxiety Disorder (GAD):
Presentation: - ANSWER-- Excessive worry, feelings of apprehension, panic or dread regarding general life
... [Show More] events
accompanied by physiologic arousal
- Symptoms persist for at least 6 months, occurring most days
- Person reports little control of symptoms
- Impairs social, occupational, & interpersonal areas
Presentation:
- Excessive worry, irritability,
- Insomnia, Panic
Physical symptoms:
- Palpitations
- Muscle tension
- Restlessness
- Fatigue
- Sweating
- Difficulty concentrating
- Nausea
- Diarrhea
- Urinary Frequency
- Chest pain
Generalized Anxiety Disorder (GAD):
Diagnosis and Treatment - - ANSWER-Diagnosis:
- R/O physical cause (hyperthyroidism, stimulant abuse, caffeine, drug/alcohol withdrawal/abuse, cardiac arrhythmias)
- At least 3 of the following:
- Restlessness
- Hypervigilance
- Easy fatigability
- Irritability
- Sleep disturbance
- Muscle tension
- Difficulty concentrating
Treatment:
- Mild Cases tx in primary care
- More significant cases refer to psychiatry
- Medications:
- Benzodiazepines → Short term (2-4
weeks)
- SSRI → 1st line
- SNRI
- Buspirone (Buspar): 7.5 mg po BID
(up to total 30 daily)
- TCAs
- Clonidine
- Therapy:
- Cognitive-behavioral
- Psychotherapy
Alternative Tx:
- Herbs
- St. John's Wort, Kava, Phenibut,
- Educate about the risks
- Meditation; include aromatherapy
- Rose, orange oil, sage, lavender, rosemary
-Yoga, massage
http://www.yogajournal.com/article/practicesection/free-from-worry/
- Exercise DAILY
- Diet
- Whole food, high in greens
- Eliminate ETOH, caffeine
- Reduce/eliminate sugar
- Try trial of no gluten
Panic Disorder: - ANSWER-- Characterized by recurrent, unexpected panic attacks
- Panic Attack= period of extreme anxiety usually peaking within 10 minutes and rarely lasts more than 1 hour
- May have a trigger
- Physical symptoms of impending doom
Presentation:
- Can present at any age, although most commonly starts in 20's
- Affects female: males 3:1
- Intense fear with physical symptoms
- Often think they are having a heart attack
- Panic = SEVERE ANXIETY!!!
Symptoms:
- Intense fear plus 4 or more of the following:
- Palpitations, tachycardia
- Sweating
- Trembling/shaking
- SOB
- Sensation of choking
- Nausea/abdominal distress
- Dizziness/faintness
- Depersonalization
- Fear of losing control
- Fear of dying
- Paresthesia
- Chills/hot flushes
Treatment:
- Medications:
- Benzodiazepines
- Short term and helpful acutely → Use
ONLY for 4 weeks
- SSRIs
- Paroxetine (Paxil) 20mg daily works well
Or sertraline (Zoloft) 50 po daily
- Treat 9-12 months
- Psychotherapy
- Stress reduction techniques
Alternative Tx:
- Herbs
- St. John's Wort, Kava root,
- Adrenal Support Herbs- Ashwagandha,
- Eleuthero, Rhodiola, -adaptogens
- Vitamins to support nervous system
- B-complex, Vitamin C, Magnesium,
Calcium,
- Calm
- Diet
- Eliminate ETOH, caffeine, sugar, reduce
simple carbs
- Exercise
- Aerobic daily, yoga
- Relaxation techniques
- Meditation, Tai chi, breathing exercises
Obsessive Compulsive Disorder (OCD) - ANSWER-- Irrational idea or impulse intrudes into awareness
- Obsessions
- Constantly recurring thoughts
- Compulsions
- Repetitive actions
- Anxiety
- Alleviated by ritualistic performance of the
repetitive actions
- Affects 2-3% of the population
Presentation
- Usually need to be asked about the symptoms;
will not mention unless asked
- Patients are:
- Predictable
- Orderly
- Conscientious
- Intelligent
- 2/3 of the patients develop major depression
- Occurs with high stress
- Young, divorced, separated, unemployed
- Under extreme stress can be become
delusional
Treatment
- Medications
- SSRIs
- Prozac dosed high 60-80 mg daily
- Other SSRIs work as well
- Buspar 15-60 mg daily
- Behavioral
- Stress reduction, relaxation techniques
- Cognitive behavioral therapy
- Support groups
- Refer to psychology
Post Traumatic Stress Disorder (PTSD) - ANSWER-- Complex neuropsychological syndrome that results in dysfunction of the prefrontal
cortex and the amygdala and neurotransmitters (dysfunction
affecting fear and memory)
- May have a genetic component
- Begins with exposure to a severely traumatic event outside the norm of human experience
& then is characterized by "reexperiencing" the traumatic event
- Combat, rape, assault, 9/11
Presentation
- Hyperarousal which includes:
- Startle reactions
- Intrusive thoughts
- Illusions
- Over-generalizing associations
- Sleep problems
- Nightmares & dreams about the event
- Impulsivity
- Difficulties concentrating
- Hyperalertness
- Symptoms usually start after long latent Period
Treatment:
- Medications
- Benzodiazepines (ONLY short term)
- SSRI → Zoloft & Prozac
- Betablockers → Lessens peripheral
symptoms of anxiety
- Tegretol
- Impulsivity & anger management
- Behavioral
- Exercise, stress reduction techniques
- Psychotherapy
- Refer to psychology
List 4 Mood Disorders: - ANSWER-- Grief/Bereavement
- Depression
- Bipolar Disorder
- Acute Suicide Risk
List 4 Anxiety & Stress Disorders: - ANSWER-- Generalized Anxiety Disorder
- Panic Attacks/Panic Disorder
- Obsessive-Compulsive Disorder
- PTSD
Grief/Bereavement: - ANSWER-- The human response to the loss of a loved one
- Both emotional & physiological response Impairs immune response
- Mourning - The normal, healthy process of resolving the grief
- Bereavement: The state of mourning
- In 2003, 3 million Americans died, leaving behind 22 million bereaved family members
Presentation:
- Absent or delayed grief
- Excessive and/or prolonged emotions
- Complicated grief:
- Suicidal ideations
- Psychosis
- It is a process that simply takes time
Presentation:
- Prolonged and marked functional impairment
- Marked psychomotor retardation or limitation
- Morbid preoccupation with thoughts or worthlessness
- Feelings that one would be better off dead and should have died with the deceased
- Guilt
Treatment:
- Counseling
- Teach the stages of grief
- Encourage expression of feelings
- Medications
- Benzodiazepines (Short term ONLY)
- Consider SSRI if prolonged grief
- Refer to support groups
- Refer to psychiatry if needed
Depression: - ANSWER-Types of Major Depression
- Major Depression with atypical features
- Major Depression with seasonal onset
- Major Depression with postpartum onset
- A complex mood disorder lasting at least 2 weeks, with a sad mood and/or a loss of interest in pleasurable activities, daily
- Often presents during times of stress
- Associated with abnormalities of neurotransmission, neurophysiology, and neuro-endocrine function
- Serotonin & norepinephrine
- May have a genetic component
- Results from circadian rhythm dysregulation
- Melatonin & seasonal changes
Risk Factors:
- Prior episodes of depression
- Family history
- Alcohol or substance abuse
- Postpartum period
- Significant psychosocial stressors
- Divorce, finances, job loss,
trauma/abuse
- There are several types of depression; we will focus on 2
- MD & BD
Diagnosis:
- R/O any underlying suspected medical causes
- LABS: CBC, BMP, TSH, B12, folate, VDRL, - CT Brain EKG (prior to TCA tx)
- R/O anxiety, pain disorders
- Beck Depression Scale
- Determine suicide risk
Treatment:
- Mild presentation can be managed in primary care; frequent visits
- Medications SSRI, SNRI, TCAs, atypical antidepressants
- Tx for 12 months
- Tapering ECT Phototherapy
- More severe cases should be referred to
psych
- Admit if suicidal; refer ER
Alternative Treatment:
- Reduce/eliminate ETOH
- Encourage exercise
- Encourage healthy diet
- Omega 3s
- Support groups
- Acupuncture, yoga, massage
- Aromatherapy
- Positive Imagery
Name 3 Types of Major Depression: - ANSWER-- Major Depression with atypical features
- Major Depression with seasonal onset
- Major Depression with postpartum onset
Bipolar Disorder: - ANSWER-- Recurrent mood disorder featuring one or more episodes of mania, hypomania, or a mixed episodes of mania & depression
- Occurs along a spectrum
- BD1 One episode of mania w/ or w/o
depression
- BD2 Recurrent depression and hypomania - Cyclothymic
- Depressed mood but not major depression plus hypomania
- 25-50% will attempt suicide; 15% will be successful Affects 7-10% of the population
- Genetic
- Neuroautonomic changes are seen on MRI
- Not sure if developmental or degenerative
- Environment plays a part
- Trauma, stress
Presentation:
- First episode often as adolescent, usually before age 30
- Mania Last 3-6 months if not treated
- Hypomania
- Depression Lasts 6-12 months if not treated
- Cyclic
Diagnosis:
- By history & presentation
- If possible interview family r/o MD or other
Mood disorders
- R/O physical causes (endocrine, infection)
- Often co-morbid substance abuse
See slide 24 (diagnosis of mania)
Treatment of Bipolar Disorder
- Mood stabilizer
- Lithium, Valproic acid, tegretol
- Monitor lithium level closely
- Benzodiazepines if manic
- Antipsychotics
- Antidepressants
- Bupropion or SSRI (Can trigger mania)
- ECT
- Refer to Psychiatry
Adjunctive Treatment:
- Teach stress reduction
- AVOID caffeine, ETOH, stimulants, illegal drugs
- Maintain very regular sleep & work cycles
- Exercise daily
- Yoga & meditation
Acute Suicide Risk - ANSWER-- Self-inflicted death
- 30,000 Americans commit suicide yearly; 11th leading cause of death; 4th leading cause of death for adolescents
- 50% of suicides males 25-65
Risk Factors:
- Single, widowed, white or native
- American male, living alone, adolescent or over 65, unemployed, certain occupations, illness (cancer), mood disorders, substance abuse
Causes:
- Reduced serotonin
- Impulsive/aggressive behaviors
- ETOH often involved
- Genetic
- Usually an environmental trigger
Presentation:
- Severe anxiety
- Severe ruminations
- Disorganized thinking
- Severe, persistent insomnia
- Depression with delusions
- Substance abuse
- Any psychiatric disorders
- Hopelessness
- Self mutilation
- Suicide threats or attempts
Diagnosis:
- Assess risk
- Do they have a plan?
- Do you wish you could just go to sleep and not wake up?
- Do they have access to things necessary to complete their plan?
- Guns, drugs
- The more specific & lethal the plan, the higher the risk
*see slide 27 for suicide scale
Management:
- Diagnose & treat any underlying psych disorders
- Only prescribe 1 week of pills at a time
- Imminent danger; call 911; refer to ER; refer to psych
- Support group
- Document very well
Psychotic Disorders: - ANSWER-Many types:
- Schizophrenia, Mania with psychosis, Schizoaffective disorder
- Basically disturbances of thought which results in a departure from reality; delusions/hallucinations
- It is NOT delirium (which usually has a physical source)
- We will focus on schizophrenia
- Affects 1% of population
- More men than women
- Men have worse prognosis
- Genetic & environmental factors
Schizophrenic brains have larger ventricles and less grey matter. Scientists believe from mutations of several genes.
Presentation & Diagnosis:
DSM Criteria:
- 2 or more positive & negative symptoms present for at least 1 month impacting relationships, work or selfcare
- Continuous symptoms for 6 months with at least 1 month of characteristic symptoms
- Substance abuse & other mood disorders have been excluded
Pathophysiology
- Positive Symptoms
- From excess dopamine
- Negative Symptoms
- From prefrontal cortex abnormalities
Treatment:
- Medications
- Antipsychotics
- Support groups
- Psychotherapy
- Family Support
List 3 types of Psychotic Disorders: - ANSWER-- Schizophrenia
- Mania with psychosis
- Schizoaffective disorder
Substance Abuse: - ANSWER-- Addiction is repeated, chronic behaviors despite negative consequences
- Can be taking any substance (legal or
illegal) or repeating negative behaviors
(gambling, shopping, eating,
hypersexuality)
- Use Sporadically taking a substance with no adverse consequences
- Abuse:
Use of a substance that results in negative
outcomes
- Dependence:
Can be physical, psychological or both
Crazy, Scary American Statistics:
In 2012:
- 18% of adult Americans smoked cigarettes - 51% drank alcohol regularly
- 5% adults smoked marijuana in past year
- 3% adults used pain pills daily
Costs Annually:
-Tobacco $96 Billion
- Alcohol $30 Billion
- Illicit Drugs $11Billion
- Total Cost to society
- $500 Billion
Addiction: - ANSWER-- Chronic illness characterized by craving, inability to control use, compulsive use, and use despite negative consequences
Pathophysiology:
- Use dysregulates neurotransmitters (GABA & dopamine) and affects the mesolimbic pathway:
- Limbic system affects emotions
- Dopaminergic pathways affecting pleasure, reward, motivation & incentive salience
- Area also controls memory, learning, executive decision making and behavioral control
- Abuse eventually results in changes to the brain and leads to dependence
Diagnosis: see slide 34 [Show Less]