ANXIETY

Physiological + psychological state:

| cognitive

| somatic
ANXIETY DISORDERS | emotional

| behavioral

Æ Unpleasant feeling:
• uneasy/apprehension/worry/intense fear

Katherine A Tacker, MD Æ Typically out of proportion to the probable risks of

Department of Psychiatry
the situation at hand
OHSU

PHYSICIAN-PATIENT ENCOUNTER MENTAL STATUS EXAM

| Let’s work our way through a visit with a patient
complaining of anxiety symptoms… | Appearance

| Behavior
| Imagine the clinical setting you envision yourself practicing
in one day: | Speech
y ER | Mood
y Medicine or Surgical Ward
y ICU | Affect
Procedure Room
| Thought Process
y
y Outpatient Primary Care or Subspecialty Clinic
y Psychotherapy Office | Thought Content
| Cognition
| Because anxiety finds its way into virtually all fields of
medicine… | Insight/Judgment

| Appearance: | Appearance:

ranges from fastidious to | Behavior:

disheveled possible psychomotor agitation,
tremor/fidgety/hyper-vigilant vs. “frozen”
| Behavior: with fear, intense vs. avoidant eye
| Speech: contact, limited cooperation vs. solicitous
| Mood:
| Speech:
| Affect:
| Mood:
| Thought Process:
| Affect:
| Thought Content:
| Thought Process:
| Cognition: | Thought Content:
| Insight/Judgment: | Cognition:
| Insight/Judgment:

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| Appearance: | Appearance:
| Behavior: | Behavior:
| Speech:
| Speech:
often pressured but interruptible (vs manic | Mood/Affect:
speech which is often unable to be likely congruent with mood, anxious,
interrupted or redirected). Alternatively, a scared, labile, irritable or maybe even
severely anxious person may not speak at all! angry (the feelings that come with “fight
or flight,” since catecholamines are
| Mood: getting ramped up)
| Affect:
| Thought Process: | Thought Process:
| Thought Content: | Thought Content:
| Cognition: | Cognition:
| Insight/Judgment: | Insight/Judgment:

| Appearance: | Appearance:
| Behavior: | Behavior:
| Speech:
| Speech:
| Mood/Affect:
| Mood/Affect:

| Thought Process: | Thought Process:

perseverative, ruminative, circumstantial

(vs. tangential, where they never return to | Thought Content:
the original question asked. Tangential notable for ruminations, obsessions,
more commonly seen in psychosis, mania, worries, concerns regarding danger
delirium, and dementia). If
circumstantial, they can still recall the (doesn’t include psychotic symptoms, and
original question if suicidal ideation present, look for co-
morbid depression)
| Thought Content:
| Cognition: | Cognition:
| Insight/Judgment: | Insight/Judgment:

| Appearance: | Appearance:
| Behavior: | Behavior:
| Speech:
| Speech:
| Mood/Affect:
| Mood/Affect:
| Thought Process:
| Thought Process: | Thought Content:
| Thought Content: | Cognition:

| Cognition: |Insight/Judgment:
generally intact apart from anxiety is often fear out of
concentration and attention proportion to the realistic level of
threat, so insight not necessarily
| Insight/Judgment: that great. Therefore, judgment may
also be impaired

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HPI PRIMARY ANXIETY DISORDERS
* Impairs function!
The patient may describe:
| Specific Phobia
y Primary Anxiety Disorder
| Social Phobia/Anxiety
y Alternative/Additional Psych Disorders | Post Traumatic Stress Disorder

| including substance abuse/dependence | Separation Anxiety

| Panic Disorder +/- Agoraphobia

y Symptoms that point toward medical illness
| Generalized Anxiety Disorder

y Symptoms of Rx adverse effects or interactions | Obsessive Compulsive Disorder

| Agoraphobia
y Significant social stressors

| Specific Phobia:
DSM IV-TR: SPECIFIC PHOBIA
- Fear of specific object or situation
disproportionate to realistic risk | Excessive or unreasonable persistent fear in the
(excluding performance or agoraphobia) presence of (or anticipation of) a specific object or
situation

| Social Phobia
| Examples:
| Post Traumatic Stress Disorder
y Flying, heights, animals, injections, seeing blood, etc.
| Separation Anxiety Disorder

| Panic Disorder +/- Agoraphobia | Exposure almost always invariably induces

| Generalized Anxiety Disorder immediate anxiety response
| Obsessive Compulsive Disorder

| Agoraphobia | Avoided or endured with marked distress or

anxiety

| Specific Phobia DSM IV-TR: SOCIAL PHOBIA

| Social Phobia: | Marked and persistent fear of social or

performance situations (often fear of scrutiny)
- Fear of embarrassment or
humiliation/extreme discomfort
| Fear of doing something embarrassing or
performing in public humiliating

| Post Traumatic Stress Disorder | Exposure almost always predictably induces

| Separation Anxiety Disorder anxiety
| Panic Disorder +/- Agoraphobia

| Generalized Anxiety Disorder | Patient recognizes the fear is excessive or

unreasonable
| Obsessive Compulsive Disorder

| Agoraphobia
| Avoided or endured with marked distress or
anxiety

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| Specific Phobia
DSM IV-TR: PTSD
| Social Phobia

| A: Exposure to Event
| Post Traumatic Stress Disorder:
- Preceded by a severe traumatic | B: Re-experiencing
event that involves threat of injury
or death | C: Avoidance

| Separation Anxiety Disorder | D: Arousal

| Panic Disorder +/- Agoraphobia
| Generalized Anxiety Disorder | E: Duration > 1 month
| Obsessive Compulsive Disorder

| Agoraphobia

DSM IV-TR: PTSD DSM IV-TR: PTSD

| C: (3/7) efforts to avoid associated
| A: experienced, witnessed, or confronted
thoughts/conversation/feelings, avoid
with an event(s) involving actual or activities/places/people that arouse
perceived threat of death or serious injury recollections, unable to recall important
to self or others Æ intense fear, aspects of the trauma, diminished interest
helplessness, or horror or participation, detached or
estrangement, restricted affect, sense of
foreshortened future
| B: (1/5) intrusive thoughts and
recollections, recurrent nightmares,
| D: (2/5) difficulty falling or staying asleep,
flashbacks, psychological reactivity to
irritability/anger outbursts, poor
triggers, physiologic reactivity to triggers
concentration, hypervigilance,
exaggerated startle

| Specific Phobia DSM IV-TR: SEPARATION ANXIETY

| Social Phobia | Developmentally inappropriate/excessive anxiety
| Post Traumatic Stress Disorder
| Separation from home or attached caregivers

| Separation Anxiety Disorder: | (3/6) recurrent excessive distress away from

home or major attachment figure, persistent and
- Childhood condition that impairs excessive worry about harm befalling attachment
ability to attend school/daycare figures, worry about events causing separation
(ie, kidnapping), reluctant to be alone or without
attachment figure, repeated nightmares,
| Panic Disorder +/- Agoraphobia
repeated somatic complaints with separation
| Generalized Anxiety Disorder
| Obsessive Compulsive Disorder | > 4 weeks
| Agoraphobia
| Onset before 18 years old

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| Specific Phobia
| Social Phobia
DSM IV-TR: PANIC DISORDER
| Post Traumatic Stress Disorder | 4/13
| Separation Anxiety Disorder y Palpitations/pounding/rapid heart
y Sweating
| Panic Disorder +/- Agoraphobia: y Trembling/shaking
y SOB
- Sudden attack of severe anxiety
y Choking sensation
symptoms, can last 5 minutes to a
y Chest pain/discomfort
few hours, may come in clusters
y Nausea/abdominal distress
over span of days, increased anxiety
y Dizzy, unsteady, lightheaded
b/w episodes
y Derealization/depersonalization
y Fear of losing control/going crazy
| Generalized Anxiety Disorder
y Fear of dying
| Obsessive Compulsive Disorder
y Paresthesias
| Agoraphobia
y Chills/hot flushes

| Specific Phobia
| Social Phobia DSM IV-TR: GAD
| Post Traumatic Stress Disorder
| Separation Anxiety Disorder | Excessive anxiety and worry about a
| Panic Disorder +/- Agoraphobia variety of activities or events

| Generalized Anxiety Disorder: | Most of the time > 6 months

y Pervasive anxiety without precipitants,
impairs function
| (3/6) restlessness or “on edge,” easily
y If < 6 months, may be “adjustment d/o fatigued, poor concentration/mind going
with anxious mood” blank, irritability, muscle tension, sleep
disturbance
| Obsessive Compulsive Disorder
| Agoraphobia

| Specific Phobia
DSM IV-TR: OCD
| Social Phobia
| Post Traumatic Stress Disorder
| Obsessions
| Separation Anxiety Disorder

| Panic Disorder +/- Agoraphobia

y Recurrent and persistent intrusive or
| Generalized Anxiety Disorder
inappropriate
thoughts/impulses/images
| Obsessive Compulsive Disorder: y Not simply excessive worries about real-
* (different than Obsessive Compulsive Personality d/o) life problems
obsessions (thoughts)/compulsions y Attempts to ignore or neutralize the
(behaviors) impair function - them
irrational, egodystonic y Recognizes thy are a product of own
mind
| Agoraphobia

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DSM IV-TR: OCD DSM IV-TR: OCD

Or*

| Recognizes obsessions and/or compulsions

| Compulsions
are excessive or unreasonable!
y Repetitive behaviors or mental acts
driven to perform in response to an
| Distressing, time consuming, or
obsession or rigid rules
significantly interfere with normal routine
y Aimed at preventing or reducing
or function
distress
y Not realistically connected to the target
of prevention

Specific Phobia
|
DSM IV-TR: AGORAPHOBIA
| Social Phobia
| Post Traumatic Stress Disorder
| Separation Anxiety Disorder | Anxiety about being in a situation/place
| Panic Disorder +/- Agoraphobia difficult or embarrassing to escape or in
| Generalized Anxiety Disorder which help may not be available.
| Obsessive Compulsive Disorder
| Often being outside the home, in some
| Agoraphobia: form of transport, on a bridge, in a crowd,
y Fear of being in places where escape etc.
may be difficult or embarrassing
y Highly co-morbid with panic | Situations are avoided or endured with
disorder and often the more marked distress or anxiety
disabling of the two

OTHER PSYCHIATRIC DISORDERS

OTHER PSYCHIATRIC DISORDERS

| Mimic Anxiety Disorder: | Common Co-Morbidities:

y Mania y concurrent additional anxiety disorders

y Psychosis
y depression
y Substance Intoxication/Withdrawal
y substance abuse/dependence
y ADHD
y Delirium/Dementia y personality disorders

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 SUBSTANCE MEDICAL ETIOLOGY OF SYMPTOMS
INTOXICATION/WITHDRAWAL
|Metabolic/Endocrine
Intoxication: Withdrawal: |Immune
|Infection
• Cocaine • Benzodiazepines
• PCP • Barbiturates |Hypotension/Low Cardiac Output
• Ephedrine • Alcohol |Hypoxia
• Caffeine • Opiates |Neurologic
• Meth/amphetamine • Baclofen |Dietary
• Nicotine • Nicotine

Metabolic HoTN Hy - Immune Infection Neuro Dietary

Endocrine Low CO poxia
•Hyper- •MI/Angina •CHF •SLE •HIV •Temporal •Caffeine RX
thyroidism lobe
•CHF •PNA •Infxs seizures •MSG
•Hypopara- enceph
thyroidism •Arrhythmia •PE •Vertigo •Hyper-
•Meningitis calcemia
•Cushing’s •Valvular
Disease
•Asthma
•Neurosyph
•Mass lesion
•Deficiency
| Adverse Effects
•Insulinoma/h (Mitral valve •COPD •Multiple -- D
ypoglycemia prolapse) •Lyme Sclerosis -- B
•OSA -- Folic Acid
•Pheochromoc •Tamponade •Delirium •Post- -- E ? | Overdose
ytoma •PTX concussive
•Chronic syndrome
•Carcinoid Anemia •Pulmonar

| Drug-Drug Interactions
y edema •Dementia
•Porphyria •Acute Blood
Loss •Toxic:
•Abnormal -- GI lead,
electrolytes -- Gyn mercury,
-- Intra-abd manganese,
•Encphalop -- Retro- organophos
periot
•Menopause •Delirium
tremens

Sympathom/ Cardiac/Bl Endocri Non - Psychiatric Dopa - Anti -

Respiratory ood ne/ steroidal minergic cholinergic
Pressure Hormon
e

•Decongestant •Any med •Levo- •Indomethacin •Antidepressant •L- •Benztropine FAMILY HISTORY
that can thyroxine (activating) dopa/carbidopa (Cogentin)
•Albuterol drive heart (Sinemet)
rate •Insulin •Antipsychotics •Diphenhydramine
•Oral beta (akathisia) •Metoclopramide (Benadryl)

|A family history of many of the

agonists •Any med •Oral (Reglan)
that can drop diabetes •Stimulants: •Scopolamine
•Bronchodilators/ BP Rx •Neuroleptics
Theophylline

•Epinephrine
•Cortico-
steroids
•Amphetamine

•Methylphenidate
•Sedating
antihistamines psychiatric, substance, or medical
•Ephedrine •Aminophyline
•Meperidine
(Demeral) conditions we have mentioned so far
•Pseudoephedrin
e
•Oxybutynin
(Ditropam)
can increase risk to the patient – so
•Anafranil •TCA’s be sure to ask!
•Trihexylphenidyl

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PHYSICAL EXAM PHYSICAL EXAM

| Vitals:
|Vitals:
| Skin:
| HEENT:
BP, Pulse, and RR elevated (but
| Abdomen:
temperature should be wnl)
| Neuro:
| Skin:

| HEENT:
* A careful chest exam may reveal signs of | Abdomen:
potential cardiopulmonary etiologies of
| Neuro:
anxiety symptoms!

PHYSICAL EXAM PHYSICAL EXAM

| Vitals: | Vitals:

| Skin:

|Skin:
piloerection, clammy, diaphoretic |HEENT:
pupillary dilitation, xerostomia
| HEENT:

| Abdomen: | Abdomen:
| Neuro: | Neuro:

PHYSICAL EXAM PHYSICAL EXAM

| Vitals:
| Skin:
| HEENT:
| Vitals:
| Abdomen: | Skin:
- decreased bowel sounds (direct catecholamine | HEENT:
effect)
- xerostomia Æ try to remedy dry mouth Æ | Abdomen:
increased swallowed air and saliva Æ increased
gastric acid production Æ body responds with
increased bicarb Æ increased bowel sounds ! |Neuro:

* so can have either decreased or increased GI pupillary dilatation (from epinephrine),

activity! Chronic anxiety may lead to diarrhea diffuse hyper-reflexia/but down-going
alternating with constipation
toes
| Neuro:

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DIFFERENTIAL DX
LABS
| Initial differential generated from:

y HPI Basic Labs to Consider ?

y Past History

y Physical Exam/MSE

y . . . what next . . . ?

LABS

LABS If indicated per hx, exam, other test results…

| Basic Labs to Consider: | Guaiac/Endoscopy

| Rx levels
y Chem panel | LFTs
y CBC | ECHO
y Thyroid studies | Vitamin levels (B12, folate, Vitamin D,
y UA etc)
y UDS/Etoh level

LABS
STUDIES
If indicated per hx, exam, other test results…
If indicated per history, exam, initial test results…
| Cushings
y (dexamethosone suppresion, urine/salivary/serum
cortisol) | EKG (especially if > 40 years old with chest
| Insulinoma pain or other cardiac symptoms)
y (serum insulin during hypoglycemic episode) | O2 saturation/ABG
Carcinoid
| CXR
|

y (urine 5-HIAA, plasma serotonin, epi provocation)

| Chest/Abdominal CT/US
| Porphyria
y (urine, fecal, and plasma testing possible) | PFTs
| Pheochromocytoma
y (urine/plasma catecholamine/metanephrine levels)

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FORMULATION
DSM IV- TR
| BIOLOGICAL
y (family hx/genetic, medical, Rx) … AXIS I:
| PSYCHOLOGICAL
y (psychiatric hx, current psychiatric symptoms/presentation, | Specific Phobia
psychological defenses) … | Social Phobia/Anxiety
| Post Traumatic Stress Disorder (PTSD)
| SOCIAL
y (cultural identitysocial stressors, environmental context of | Separation Anxiety
presentation) …
| Panic Disorder +/- Agoraphobia

| Patient’s DIAGNOSIS is most likely… | Generalized Anxiety Disorder (GAD)

| Obsessive Compulsive Disorder (OCD)
| INITIAL interventions … | Agoraphobia (without Panic Disorder)

| LONG-TERM treatment considerations …

* Remember to consider common co-morbid Axis I
| PROGNOSIS… diagnoses, like depression and substance abuse

DSM IV - TR
DSM IV - TR
AXIS II:
AXIS III:
| Avoidant Personality Disorder
| anxiety related to a medical condition
| Dependent Personality Disorder
AXIS IV:
| Obsessive Compulsive Personality Disorder | severe social stressors --
y different than Axis I “OCD”
relationships/supports, finances,
| Schizotypal Personality Disorder
employment, housing,
y suspicious, paranoid ideation, social anxiety tragedy/loss/trauma

| Paranoid Personality Disorder AXIS V:

y paranoia, suspicious | 0-100 (varies based on level of
functioning )

TREATMENT PLAN
TREATMENT PLAN | Psychotherapy

| Correct contributing . . . y Cognitive Behavioral Therapy (CBT),

although other modalities can also be
y underlying medical conditions utilized
y Rx issues
y Techniques:
Exposure/Desensitization
| Detox/Rehab
|

| Thought stopping/Substitution
y anxiety often leads to self-medicating with
| Identifying misconceptions
substances, but substance abuse or W/D can
| Sleep hygiene
also cause anxiety
| Exercise

| Avoiding triggers …
Chicken or the Egg ?
* (be cautious that avoidance doesn’t lead to
impairing daily functioning)

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 RX RX, CONT.
y SSRI: fluoxetine (Prozac), citalopram (Celexa), • Gabergic
escitalopram (Lexapro), fluvoxamine (Luvox),
| Benzodiazepine
sertraline (Zoloft), paroxetine (Paxil)
| longer-acting, eg. clonazapam (Klonipin) = less risk
for abuse, smoother ride
• SNRI: duloxetine (Cymbalta), venlafaxine (Effexor) | screen for substance abuse hx

• Beta blocker
• OTHER:
| Often propranolol (Inderal)
• Mirtazapine (Remeron)

• Buspirone (Buspar) • Alpha agent

• Buproprion (Wellbutrin) | prazosin, clonidine (most commonly seen for
nightmare tx)
• Trazodone (Desyrel)

• Nefazodone ( Serzone)
• Anticholinergic
| diphenhydramine (Benadryl), hydroxyzine (Vistaril)

• TCA (nortriptyline, amitriptyline, imipramine)

• MAOI (phenelzine, tranylcypromine) • Antipsychotic
| typical or atypical agent

PHARMACOTHERAPY
| Start Low & Go Slow!:
y “activating” Rx can initially induce anxiety symptoms
y paroxetine (Paxil), fluoxetine (Prozac), buproprion
(Wellbutrin)…

| Taper any medication

Æ sudden W/D can produce anxiety symptoms!

| CAUTION:
y don’t give the patient a benzo just to treat your own
acute anxiety reaction to being in the room with an
anxious patient !

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