Anxiety Module 2 PDF

**Anxiety** Buttaro: Part 23 **DESCRIPTION** Psychic and physical experience of dread, foreboding, apprehension, or panic in response to emotional or physiologic stimuli; may be acute or chronic. Many anxiety disorders develop in childhood and tend to persist if untreated. Common types of anxiet...

**Anxiety** Buttaro: Part 23 **DESCRIPTION** Psychic and physical experience of dread, foreboding, apprehension, or panic in response to emotional or physiologic stimuli; may be acute or chronic. Many anxiety disorders develop in childhood and tend to persist if untreated. Common types of anxiety disorders included in *DSM-5 *are: - **Separation anxiety disorder:** Is developmentally excessive, inappropriate anxiety and distress regarding separating from attachment figures. - **Selective mutism:** Is consistently failing to speak in situations in which the person is expected to speak, even though the person will speak in other situations, thereby interfering with the person's education and occupation. - **Specific phobia:** Is extreme fear and distress about a specific object or situation, such as snakes or heights. phobic stimulus (animal, natural environment, blood-injection injury, situational, or other). - **Social anxiety disorder (social phobia):** Is extreme fear and distress about social situations in which the individual is exposed to possible scrutiny by other people, causing the person to avoid social situations altogether. - **Panic disorder/ panic attack:** Is characterized by recurring and unanticipated panic attacks. - **Agoraphobia:** Intense fear of being in places or situations where space might be difficult - **posttraumatic stress disorder (PTSD):** Occurs when a person is exposed to a trauma that causes intense psychological distress when they are exposed to either internal or external cues. - **Generalized anxiety disorder (GAD):** GAD is excessive anxiety that occurs more days than not about a wide variety of events or activities. - **Substance/medication-induced anxiety disorder:** As a result of Medications - **Anxiety disorder due to another medical condition:** Other unspecified anxiety disorder, and unspecified anxiety disorder. - If a person's stress level becomes persistent, excessive, overwhelming, and disabling, then an anxiety disorder should be considered. - The core symptoms of panic disorder, generalized anxiety disorder (GAD), and agoraphobia first present in later adolescence. **ETIOLOGY** - [Behavioral theory:] anxiety is the conditioned response to specific environmental stimuli - Genetic component (first-degree relative increases likelihood eightfold) - Environmental factors - Biologic theories - Norepinephrine, serotonin, and gamma-aminobutyric acid (GABA) are poorly regulated - The autonomic nervous system inappropriately responds to stimuli - Functional cerebral pathology causes anxiety disorder symptoms - Hypothalamic pituitary adrenal (HPA) axis highly implicated **INCIDENCE** - 7.7% lifetime prevalence in U.S. population - Incidence higher in women - Most prevalent in 20- to 45-year-olds - Average age of onset 11 years - Separation anxiety is the most common reason given for school refusal (mean age 9 years) --------------------------------------------------------------------------- **Anxiety is the most common psychiatric disorder in the United States.** ---------------------------------------------------------------------------   **RISK FACTORS** - **Organic causes:** - Organic syndromes: endocrinopathies, cardiorespiratory disorders, anemia - Use of or withdrawal from medications and substances - Alcohol - Antihypertensives - Caffeine, including analgesics containing caffeine - Cocaine, marijuana, hallucinogens, synthetics - Corticosteroids - Lidocaine - Oral contraceptives - Nonsteroidal anti-inflammatories - Withdrawal from selective serotonin reuptake inhibitors (SSRIs) - Family history - **Psychosocial stressors:** - Marital discord - Medical illness - Job and/or school-related stress - Financial problems - **Psychiatric disorders:** - Major depressive disorder (MDD) - Posttraumatic stress disorder (PTSD) - Personality disorders - Schizophrenia and other psychotic disorders **ASSESSMENT FINDINGS** - **Children:** - Excessive anxiety about separation after age 3-4 years - Note: DSM-5 states that separation anxiety may be present in adulthood - Unrealistic worry about harm to self or family - Persistent worry about past behavior, competence, or future events. - Children and adolescents tend to experience performance-focused worry and anxiety. - **Adults:** - Characterized by excessive anxiety and worry about a number of events or activities: - Complaints of apprehension, restlessness, edginess, distractibility (difficulty concentrating), irritability, muscle tension - Insomnia, easily fatigued, - [Somatic complaints:] - Fatigue, headaches and irritable bowel syndrome are frequently associated. - Paresthesia, near syncope, derealization, dizziness, diaphoresis - Palpitations, tachycardia, chest pain/tightness, hypertension - Dyspnea, hyperventilation, trembling, twitching, - Nausea, vomiting, diarrhea, SOB. - Excessive rumination - Full remission rates are very low. - It is also important to inquire about psychosocial stressors and a remote history of traumas or abuse because these experiences increase risk for anxiety disorders. **DIFFERENTIAL DIAGNOSES** - Obsessive compulsive disorder - Oppositional defiant disorder - Personality disorders - Depression - Bipolar disorder - Attention deficit disorder - Cognitive disorder such as delirium - Substance intoxication or withdrawal - Posttraumatic stress disorder - Any medical condition that involves stimulation of the sympathetic nervous system - Arrhythmias, MI, valvular disease - Endocrinopathies: hyperthyroidism, Cushing syndrome, hypoglycemia, electrolyte imbalances, menopause - Medication/substance reactions and/or withdrawals: other substances, such as caffeine, cocaine, cannabis, steroids, nicotine, ephedrine and pseudoephedrine, amphetamines, anticholinergics, theophylline, digoxin, Synthroid, and antihypertensives, should be assessed through toxicology studies. - Anemia - Asthma, COPD, pulmonary embolism, pneumothorax **DIAGNOSTIC STUDIES** - Many of the physical symptoms of anxiety (chest pain, shortness of breath, dizziness, and gastrointestinal symptoms) could signal a serious medical illness. - Medical causes must be explored and excluded before a diagnosis of an anxiety disorder is made - Side effects from medications and the physiologic effects of intoxication or withdrawal from substances should be considered when the symptoms of anxiety disorders are reviewed. - the symptoms must meet the criteria in the DSM-5, being at a moderate to severe level and affecting hygiene, relationships, employment, or education. - The importance of ruling out exposure to the anxiety-producing effects of caffeine is often missed, but caffeine may play a critical role in anxiety - TSH - CBC, urinalysis - [Urine drug screen:] Urine toxicology is helpful to determine substance use that may contribute to the symptoms described by the patient. - Focus on medical conditions for which patient is already being treated - Direct attention toward arrhythmias, hyperthyroidism, drugs - Evaluate prominent constellation of symptoms - **Psychologic testing** - **Patient-Reported Outcome Measurement Information System (PROMIS) for emotional distress-anxiety:** available for adults, adolescents and children. - **Hamilton Anxiety Scale:** - **Zung Anxiety Self-Assessment:** - Screening tool: the GAD 7-item instrument (GAD-7) - PTSD is the Primary Care PTSD Screen (PC-PTSD). - For OCD are the Obsessive-Compulsive Inventory, Short Version (OCI-SV) or the Florida Obsessive Compulsive Inventory. - Social Phobia Inventory (SPIN) Mini-SPIN Screening Tool - The Patient Health Questionnaire with Somatic, Anxiety, and Depressive Symptom Scales (PHQ-SADS) combines the Patient Health Questionniare-9 (PHQ-9), the GAD-7, and the Patient Health Questionnaire-15 (PHQ-15) to assess for depression; anxiety, including panic attacks; and somatization. **NONPHARMACOLOGIC MANAGEMENT** - **Psychotherapy (first line treatment together with med)** - Cognitive-behavioral treatment (CBT) has been shown to have the strongest effect sizes in patients with anxiety, - Education about diagnosis, treatment plan, and prognosis - Support and empathic listening - First-line treatment for children and adolescents - Relaxation techniques - Cognitive behavioral therapy - Reconditioning: exposure to feared stimuli in controlled setting to develop tolerance and eventually eradicate the anxiety response - **General measures** - Regular exercise and healthy diet - Adequate sleep and limit caffeine intake - Serial office visits ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Advise patients to avoid alcohol consumption because this increases the risk of drug interactions and is associated with high rates of abuse and rebound anxiety.** ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- **PHARMACOLOGIC MANAGEMENT:** - **[Antidepressants are considered first-line treatment for anxiety disorders (SSRI)]** - Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have been demonstrated to be effective in managing symptoms of GAD, panic disorder, PTSD, social anxiety disorder, and OCD. - (Missed doses may cause withdrawal symptoms) or of drug--drug interactions. - Patients should be educated about the time frame to the onset of an anxiolytic effect, which may be up to 6 weeks while the medication is being titrated. - It may then take up to 12 weeks to experience the full benefit of the medication. - Educate of risk of discontinuation syndromes when missing doses or stopping the medication abruptly. - educate patients on the signs and symptoms of serotonin syndrome (e.g., mental status changes, autonomic instability, and neuromuscular changes) (Life threatening side effect). - Long-term side effects such as weight gain and sexual dysfunction may prove intolerable for some people. - Starting low and going slow" can help to minimize side effects, increase tolerability, and thus improve adherence, - [Benzodiazepines] should be of limited duration, with intent of allowing patient to benefit from behavioral treatments. (Long term uses not recommended). - Have efficacy in the acute management of symptoms related to panic attacks, social anxiety, and GAD. - Benzodiazepine dependence can develop in as little as 3 to 4 weeks. - Prescriptions be limited to short-term usage (2 to 4 weeks). - Increased risk of falls, confusion, and memory problems, especially when used in older adults. Can cause rebound insomnia. - The most common use of benzodiazepines is in combination with SSRIs or SNRIs for short-term management of acute symptoms. - Benzodiazepines may alter the person's ability to drive or to meet usual expectations and must not be stopped abruptly. - Risk of respiratory distress, physiologic dependence, and, eventually, tolerance. - Drugs should play an adjunctive role, except in panic disorder - Drugs reduce---not eradicate---symptoms - Long-term use of selective serotonin reuptake inhibitors (SSRIs) or other serotonergic agents may be required --------------------------------------------------------------------------------------------------------------------------------------------------------- **SSRIs may not achieve therapeutic response for 2-4 weeks. Full anti-anxiety response may take 12 weeks or more. Consider starting with lower doses.** ---------------------------------------------------------------------------------------------------------------------------------------------------------   ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Use of benzodiazepines until an SSRI or selective norepinephrine reuptake inhibitor (SNRI) becomes effective is a common short-term strategy; expectations of use and duration should be discussed with the patient at the time treatment is initiated.** -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------   - **Specific phobia** - Benzodiazepines: short-term use only, up to 1-3 months with planned taper - Works well but concerns about addiction with long-term use - **Generalized anxiety disorder** - First-line treatment - SSRIs - SNRIs - Buspirone - **Adult**: 7.5 mg PO BID-TID; usual range 20-30 mg/day - **Children \1 mg | | | of at least | | | daily | | | 3-4 days; | | | | | | Usual: 3-6 | | | | | | mg/day; | | | | | | Max: 10 | | | | | | mg/day | | | | | | | | | | | | Older or | | | | | | debilitated | | | | | | : | | | | | | 0.25 mg PO | | | | | | BID-TID | | | | +-------------+-------------+-------------+-------------+-------------+ | **Clonazepa | Initial: | Not | \- Monitor | \- Less | | m/Klonopin* | 0.25-0.5 mg | available | for mild | addictive | | * | PO BID-TID; | | impairment | due to long | | | Max: 4 mg | | to | half-life | | | PO daily in | | hypnosis, | | | | divided | | sedation, | \- Boxed | | | doses | | tolerance, | Warning: | | | | | and abuse | Higher | | | Older or | | potential | incidence | | | debilitated | | | of | | | : | | | respiratory | | | Start at | | | failure and | | | lowest dose | | | death when | | | and slowly | | | combined | | | titrate up | | | with | | | | | | opiates | +-------------+-------------+-------------+-------------+-------------+ | **Diazepam/ | Initial: | Not | \- Monitor | \- Less | | Valium** | 2-10 mg PO | available | for mild | addictive | | | BID-QID | | impairment | due to long | | | depending | | to | half-life | | | on severity | | hypnosis, | | | | of symptoms | | sedation, | | | | | | tolerance, | | | | Older or | | and abuse | | | | debilitated | | potential | | | | : | | | | | | 2-2.5 mg PO | | | | | | 1 or 2 | | | | | | times | | | | | | initially; | | | | | | increase | | | | | | gradually | | | | | | as | | | | | | tolerated | | | | +-------------+-------------+-------------+-------------+-------------+ **Anxiety pharmacologic Management** +-----------+-----------+-----------+-----------+-----------+-----------+ | **Generic | **Availab | **Dosage: | **Dosage: | **Side | **Comment | | /Brand** | ility** | Adult** | Pediatric | Effects/M | s** | | | | | ** | onitoring | | | | | | | ** | | +===========+===========+===========+===========+===========+===========+ | **Lorazep | Tabs: 0.5 | Initial: | Not | Monitor | Preferred | | am/Ativan | mg, 1 mg, | 2-3 | available | for mild | BNZ for | | ** | 2 mg | mg/day PO | | impairmen | patients | | | scored | BID-TID | | t | with | | | | | | to | compromis | | | | Older or | | hypnosis; | ed | | | | debilitat | | sedation, | hepatic | | | | ed: | | tolerance | functioni | | | | 1-2 | | , | ng | | | | mg/day PO | | abuse | due to | | | | in | | potential | avoiding | | | | divided | | | the first | | | | doses | | | pass | | | | | | | | | | | | | | Common | | | | | | | BNZ | | | | | | | utilized | | | | | | | to assist | | | | | | | with | | | | | | | detox | | | | | | | from | | | | | | | alcohol; | | | | | | | short-ter | | | | | | | m | | | | | | | use in | | | | | | | monitored | | | | | | | environme | | | | | | | nt | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Fluoxet | Tabs: 10 | 20 mg PO | 8-17 | Monitor | Avoid in | | ine/Proza | mg, 20 | once | years: | for | patients | | c** | mg, 40 mg | daily. | | weight | with | | | | May | Initial: | loss; GI | uncontrol | | | Solution: | increase | 10-20 mg | disturban | led | | | 20 mg/5 | dose | PO daily. | ces | narrow-an | | | mL | after | If | | gle | | | | several | started | No dosage | glaucoma | | | | weeks if | on 10 | adjustmen | | | | | insuffici | mg/day, | t | May alter | | | | ent | increase | recommend | glycemic | | | | clinical | after 1 | ed | control | | | | response | week to | for renal | (hypoglyc | | | | | 20 mg/day | dysfuncti | emia | | | | Doses | | on | during | | | | \>20 mg | Lower | or older | use, | | | | may be | weight | patients. | hyperglyc | | | | administe | children: | However, | emia | | | | red | start at | older | after | | | | in single | 10 mg/day | adults | discontin | | | | dose or | PO; may | may have | uing) | | | | BID | increase | greater | | | | | | after | sensitivi | Discontin | | | | Max: 80 | several | ty | uation | | | | mg daily | weeks to | | should | | | | | 20 mg/day | | take | | | | | | | place | | | | | | | gradually | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Escital | Tabs: 5 | 10 mg PO | \>12 | No dosage | Avoid in | | opram/Lex | mg, 10 | once | years: | adjustmen | patients | | apro** | mg, 20 mg | daily May | dosing is | t | with | | | | increase | same as | recommend | uncontrol | | | Liquid: 5 | in 1-2 | adult | ed | led | | | mg/5 mL | weeks | dosing | for renal | narrow-an | | | | | except | dysfuncti | gle | | | | Max | increase | on | glaucoma | | | | Adults: | should be | or older | | | | | 20 mg PO | delayed 3 | adults. | Prolongs | | | | daily | weeks | However, | QT | | | | | | older | interval | | | | Max Older | Not | adults | | | | | Adults: | approved | may have | Discontin | | | | 10 mg PO | for | greater | uation | | | | daily | patients | sensitivi | should | | | | | \20 mg | Lower | or older | use, | | | | may be | weight | patients. | hyperglyc | | | | administe | children: | However, | emia | | | | red | start at | older | after | | | | in single | 10 mg/day | adults | discontin | | | | dose or | PO; may | may have | uing) | | | | BID | increase | greater | | | | | | after | sensitivi | Discontin | | | | Max: 80 | several | ty | uation | | | | mg daily | weeks to | | should | | | | | 20 mg/day | | take | | | | | | | place | | | | | | | gradually | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Escital | Tabs: 5 | 10 mg PO | \>12 | No dosage | Avoid in | | opram/Lex | mg, 10 | once | years: | adjustmen | patients | | apro** | mg, 20 mg | daily May | dosing is | t | with | | | | increase | same as | recommend | uncontrol | | | Liquid: 5 | in 1-2 | adult | ed | led | | | mg/5 mL | weeks | dosing | for renal | narrow-an | | | | | except | dysfuncti | gle | | | | Max | increase | on | glaucoma | | | | Adults: | should be | or older | | | | | 20 mg PO | delayed 3 | adults. | Prolongs | | | | daily | weeks | However, | QT | | | | | | older | interval | | | | Max Older | Not | adults | | | | | Adults: | approved | may have | Discontin | | | | 10 mg PO | for | greater | uation | | | | daily | patients | sensitivi | should | | | | | \60 mg | | | | | | | confer | | | | | | | greater | | | | | | | benefit | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Venlafa | Tabs: 25 | 37.5-375 | Not | Monitor | Should be | | xine/Effe | mg, 37.5 | mg PO | available | BP before | tapered | | xor, | mg, 50 | daily in | | beginning | over a | | Effexor | mg, 75 | divided | | SNRIs and | minimum | | XR** | mg, 100 | doses | | regularly | of 2 | | | mg | with | | during | weeks | | | | food; | | treatment | | | | Extended- | should | | ; | Advise | | | release | taper | | could | patients | | | tabs: | over a | | increase | not to | | | 37.5 mg, | minimum | | BP | abruptly | | | 75 mg, | of 2 | | | d/c | | | 150 mg, | weeks | | | medicatio | | | 225 mg | | | | n | | | | Extended | | | | | | | release: | | | | | | | 75-225 mg | | | | | | | PO daily | | | | | | | with | | | | | | | food; | | | | | | | taper | | | | | | | dose by | | | | | | | no more | | | | | | | than 75 | | | | | | | mg/week | | | | | | | PO to | | | | | | | discharge | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Buspiro | Tabs: 5 | 7.5 mg PO | 6-17 | Monitor | Not | | ne/Buspar | mg, 7.5 | BID-TID; | years: | for | recommend | | ** | mg, 10 | usual | 7.5-30 mg | signs/sym | ed | | | mg, 15 | range | PO BID | ptoms | for | | | mg, 30 mg | 20-30 | | of | severe | | | | mg/day | Not | serotonin | renal or | | | | | approved | syndrome, | hepatic | | | | Max: 60 | for use | especiall | impairmen | | | | mg daily | in | y | t | | | | | children | in | | | | | | \ - **Panic disorder** - First-line treatment: SSRIs and SNRIs - Tricyclic antidepressants (TCAs): perform risk assessment; can be lethal in overdose - Benzodiazepines - Beta blockers may also be helpful, particularly with panic associated with specific stimuli ------------------------------------------------------------------------------------------------------- **SSRIs carry a boxed warning for increased suicidality in children, adolescents, and young adults.** -------------------------------------------------------------------------------------------------------   **CONSULTATION/REFERRAL** - Emergent care should also be sought if the person is gravely disabled (unable to provide for basic personal needs such as food, clothing, and shelter). - Emergent care would also be required for severe side effects of medications, such as serotonin syndrome, serotonin withdrawal, neuroleptic malignant syndrome, or lithium toxicity. - Parent/child or family intervention - Evidence of substance abuse - Disabling symptoms - Symptoms that worsen despite treatment: consider referral for psychiatric evaluation **FOLLOW-UP** - Regular follow-up visits are important to reinforce education about nonpharmacologic management and proper use of medications - Avoid prescribing anxiolytics by telephone - Remain alert to signs of medication misuse - Tricyclic antidepressants require periodic serum levels along with baseline and follow-up EKGs **EXPECTED COURSE** - Anxiety in children can be a precursor to agoraphobia or panic disorder in adulthood - Treatment of medical cause usually, but not always, initiates improvement - Short-term anxiety disorders usually respond well to treatment - Obsessive-compulsive disorder requires long-term pharmacologic therapy and psychotherapy ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ **Generalized anxiety disorder is a chronic disease with many exacerbations and relapses. Exacerbations are more common during times of stress, and relapses are more common in the first year after medication is discontinued.** ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ **POSSIBLE COMPLICATIONS** - Work- and school-related difficulties - Self-medication leading to alcohol abuse, benzodiazepine dependence - Social impairment - Cardiac arrhythmias related to TCA use - Falls due to sedating effects of medications, especially in older adults - Suicide **Depression (Major depressive disorder)** [**https://www.ncbi.nlm.nih.gov/books/NBK565877/**](https://www.ncbi.nlm.nih.gov/books/NBK565877/) **DESCRIPTION** A constellation of signs and symptoms that have multifactorial causes, including life circumstances, biological predisposition, and epigenetic influences. Disturbances in cognitive, emotional, behavioral, and somatic regulations are common features of depression. In adults, diagnostic criteria include anhedonia or depression and any four or more of the following: **Episode lasting at least 2 weeks.** - Depressed mood - Loss of interest or pleasure in most or all activities - Insomnia or hypersomnia - Change in appetite or weight - Psychomotor retardation or agitation - Low energy - Poor concentration - Thoughts of worthlessness or guilt - Recurrent thoughts about death/suicide. **Persistent Depression Disorder:** Patients with depressed mood for at least **two years** accompanied by at least two of the following symptoms:  - Decreased or increased appetite - Insomnia or hypersomnia - Low energy - Poor self-esteem - Poor concentration - Hopelessness ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ **Anhedonia is a loss of pleasure or interest in things that previously provided joy or pleasure. To be diagnosed with depressive disorder, depression and/or anhedonia must be present with other specifiers.** ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------   **ETIOLOGY** - Impaired synthesis and/or metabolism of norepinephrine, serotonin, dopamine and/or other neurotransmitters. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Gamma-aminobutyric acid (GABA)/glutamate, N-methyl-D-aspartate (NMDA) and other neurotransmitters affecting the structural integrity of the brain are thought to be possible factors or contributing factors in depression.** --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - Evidence indicates genetic predisposition (30-40%) -  60-70% of cases are related to specific environmental factors including adverse events in childhood and ongoing or recent stress due to interpersonal adversities. Examples include childhood sexual abuse, other lifetime trauma, decreased or absent social support, and marital issues. +-----------------------------------------------------------------------+ | - **Serotonin produces calmness and relaxed state** | | | | - **Norepinephrine and dopamine enhance productivity, ambition, | | concentration and ability to feel pleasure** | | | | - **GABA exerts effects on feelings of calmness** | | | | - **NMDA is an excitatory neurotransmitter.** | +-----------------------------------------------------------------------+ **INCIDENCE** - Major depressive disorder affects 16 million adults annually in the U.S. (6.5 million adults older than 65) - 5-20% of U.S. population experiences at some point - 1.5 to 3 times more common among people with an affected first-degree relative - 2% of U.S. preadolescents and 5% of adolescents age 16-25. - Depression is single most significant risk factor for suicide in older adults: 20% die the day of primary care visit; 40% the week of visit; 70% the month of visit **RISK FACTORS** - Psychosocial stressors - Postpartum period - Physical or chronic illness, especially migraines and back pain - Prior episodes of depression and suicide attempts - Family history of suicide - Alcohol or substance abuse - Children with a history of being bullied or abused - Retirement, aging - Significant loss (death of spouse, loss of job, divorce) - Isolation - Comorbidities **ASSESSMENT FINDINGS** - **Children**: - Anorexia - Sleep disturbance - Apathy and sluggishness - Developmental delay - Anxiety, irritability, cries easily, restlessness - Aggression, hyperactivity - School problems - GI or other somatic complaints - Poor self-esteem - Cognitive dulling - Suicidal thoughts or self-injury - Withdrawal or increased clinging behaviors - **Adolescents:** - Similar to adults - Impulsivity - Fatigue - Hopelessness - Substance abuse - **Adults**: - Depressed mood for 2 weeks or longer and/or anhedonia (at least one MUST be present) - Decreased or increased appetite - Weight loss or gain - Sleep disorder - Psychomotor agitation or retardation - Fatigue, loss of energy - Feelings of worthlessness, inappropriate guilt - Recurrent thoughts of death - Difficulty thinking/concentrating or indecisiveness - Vague somatic concerns rather than identifying or sharing emotions such as sadness or hopelessness - Irritability is likely identified in children; depressed mood and hopelessness are more apparent in adults; and somatic concerns are common older adults' - Loss of interest or pleasure in previously enjoyable events and social withdrawal are almost always present - Decreased appetite and insomnia are often present but may be missed in patient report. - Preoccupations with perceived personal deficits along with an exaggerated sense of guilt or worthlessness are also common - Impaired concentration, difficulty with decision-making, and mild memory impairment are possible - Thoughts of death vary from "the world would be better off without me" to engaging in dangerous behaviors without concern for personal safety and to having specific plans for suicide **DIFFERENTIAL DIAGNOSES** - **Children:** - Bipolar disorder - Attention deficit disorder - Separation anxiety - Chronic physical illness - Conduct disorder - Physical or sexual abuse - PTSD - Substance misuse - Organic causes - **Adults**: - Bipolar disorder - Substance misuse - Physical illness: organic brain diseases, diabetes, liver, or renal failure - Grief reaction; important to distinguish - Other psychiatric disorders - Medication abuse/use - Medication withdrawal - Hypothyroidism, B12 deficiency - Dementia **DIAGNOSTIC STUDIES** - **Structured interviews/questionnaires:** - Children's Depression Inventory - Children's Depression Scale - Depression Self-Rating Scale - Hamilton Depression Scale - DSM-5 cross cutting tools for depression (PROMIS) in children (ages 6-17), adolescents (ages 11-17), and adults - Patient Health Questionnaire 9 (PHQ-9; available in a modified form for adolescents) - Beck's Depression Inventory - Child Behavior Checklist for ages 4-18 years - Pediatric symptom checklist - Zung Self-Rating Depression Scale - Geriatric Depression Scale ---------------------------------------------------------------------------------------------- **Laboratory studies do not diagnose depression but are used to rule out other conditions.** ----------------------------------------------------------------------------------------------   - **Laboratory studies:** - TSH to rule out hypothyroidism - Urine drug screen for substance use disorders - ECG as baseline to rule out arrhythmias or heart block before instituting tricyclic antidepressants - Consider fasting blood sugar, vitamin D, vitamin B12 and folate levels - Some genetic testing is available to help with selection of specific psychotropic medications that are metabolized via the CYP450 system. This is especially important in patients who have not responded adequately to multiple trials of antidepressants **PREVENTION** - Maintain a high index of suspicion in adolescents and adults with family or personal history of depression, suicide attempts (especially within the previous 5 years), chronic illness and/or recent loss - Ask whether patient has any plans for suicide, means for suicide - Routine questioning about use of alcohol and drugs starting during adolescence and extending through the lifespan - Ask school-aged children about alcohol and drug use **NONPHARMACOLOGIC MANAGEMENT** - Identify suicidal risk, plan, lethality, availability and intent - Establish safe environment: ensure patient safety in least restrictive environment - When suicidal urges present, obtain "commitment to treatment" statement with a crisis response plan directed at planned responses to behaviors. - Provide community resources, suicide hotline. - Suicide threats should be interpreted as a communication of desperation; take them seriously. Know your state's involuntary commitment laws and APRN scope of practice - Psychoeducation - Ongoing information about illness, symptoms, prognosis, and therapy - Include interpersonal relationships, work, other health-related needs - Discourage major life changes while in a depressive state - Help set realistic, attainable, concrete goals - Educate about importance of avoiding alcohol - Psychotherapy - Treatment of choice with or without pharmacologic interventions in mild to moderate depression - Pharmacologic treatment works best when accompanied by psychotherapy - Establish and maintain a supportive therapeutic relationship - Remain available during times of crisis - Maintain vigilance for signs of destructive impulses - Strengthen expectations of help and hope for the future - Enlist support of others in patient's social network - Electroconvulsive therapy (ECT) - Indicated for depression in which a rapid antidepressant response is imperative: depression coupled with psychotic features, catatonic stupor, mania, severe suicidality, suicidality in pregnancy, or severe nutritional compromise - Indicated for patients who prefer this method of treatment, or who have responded unsatisfactorily to antidepressant medication in the past - High rate of therapeutic success - Chief side effects are transient postictal confusion and memory impairment that resolve in a few days - Light therapy - Particularly effective for seasonal affective disorder - Exposure to bright white artificial light for 30 minutes or more in morning and/or evening - May be used along with pharmacotherapy - Transcranial magnetic stimulation (TMS) - Used in resistant depression - Side effects are significantly reduced - Treatment is 4-5 times a week for 4-6 weeks - Vagus nerve stimulation (VNS) - Approved for adult patients with long-term or recurrent major depression - Requires surgical implantation of a stimulator that runs from collarbone to vagus nerve ------------------------------------------------------------------------------------------------------------------------------------------------------------- **In moderate to severe depression, psychotherapeutic interventions in conjunction with pharmacologic therapy are superior to either approach used alone.** ------------------------------------------------------------------------------------------------------------------------------------------------------------- **PHARMACOLOGIC MANAGEMENT** - Determine coexisting substance use disorders and general medical conditions - Selective serotonin reuptake inhibitors (SSRIs) - Serotonin norepinephrine reuptake inhibitors (SNRIs) - Novel antidepressants - Tricyclic antidepressants (TCAs) - Monoamine oxidase inhibitors are not used first or second line due to food and drug interactions. These drugs are usually prescribed by psychiatric specialists - Atypical antipsychotics may be used to augment poor response to antidepressants alone. When used, these medications should be monitored for side effects common with all antipsychotics +-----------------------------------------------------------------------+ | - **TCAs and SSRIs/SNRIs are equally efficacious, but SSRIs have a | | better side effect profile and would not be fatal if a month's | | supply were taken at once** | | | | - **All antidepressants carry a boxed warning about suicidal | | thoughts and urges in children, adolescents and young adults \ - Lithium concentration should be initially and periodically checked. - Toxicity is always possible, requiring periodic laboratory testing to monitor thyroid, parathyroid, and renal changes, as well as monitoring for cardiac changes. - One of the dilemmas in the treatment of bipolar disorder is whether milder forms of bipolar II should be treated, such as depression with subthreshold hypomania symptoms. **Nonpharmacologic Management** - Nonpharmacologic treatment for bipolar disorder focuses on psychoeducation, cognitive-behavioral therapy, and family therapy, as well as on substance use and misuse and medication adherence. - Irritability can be the first sign of depression in children, adolescents, and adults. - [Older adults who develop cognitive dysfunction should be screened for depression as well as dementia.] It is possible that an older adult could have both dementia and depression. **Domestic Abuse/Violence** **DESCRIPTION** Deliberate pattern of intimidation, physical assault, emotional abuse, battery, sexual assault, economic abuse, neglect and/or other abusive behavior as part of a systematic pattern of power and control perpetrated by a family member or one intimate partner against another. Domestic violence (DV) occurs in opposite-sex and same-sex relationships. DV behaviors seek to intimidate, manipulate, humiliate, isolate, make financially dependent, frighten, terrorize, coerce, threaten, blame, hurt, injure, or wound another person. Child maltreatment (CM) is behavior toward a child that involves substantial risk of emotional or physical harm. The four types of CM are emotional/psychological abuse, physical abuse, sexual abuse, and neglect. - Intimate partner violence (IPV) is defined as a pattern of coercive and controlling behavior exercised by one partner over the other - Behaviors can range from economic control, social isolation, emotional abuse, and stalking to sexual assault and threats of or actual physical violence and death - IPV occurs in all age, racial, socioeconomic, and sexual orientation groups - IPV is a significant public health care problem with widespread and devastating effects for patients, their children, their families, and their communities. **ETIOLOGY** - Perpetrators generally have low self-esteem and a need for power and control. They presume injustice, and the tension culminates in violence - Violence against women is rooted in gender inequality - In the abuse of older adults, immense responsibilities are often an overwhelming stressor, leading to neglect - Children exposed to CM are at greater risk of being victims or perpetrators of violence compared to those who are not exposed to CM **INCIDENCE** - 1 in 7 children experienced abuse and neglect in 2018 - Children living in poverty experience abuse and neglect at rates 5 time higher than other children - 1 in every 3 women worldwide experiences physical and/or sexual violence by an intimate partner at some point in her life - In the U.S., 1 in 4 women and 1 in 9 men have experienced sexual violence, physical violence, and/or stalking by an intimate partner - 38% of U.S. women who are murdered were killed by an intimate partner - 1 in 6 pregnant women in the U.S. has been abused by a partner - 1 in 24 cases of abuse against older adults is not reported, in part due to fear. ------------------------------------------------------------------------------------------------------------------------------- **Approximately 1 in 6 people 60 years and older experience some form of abuse in community settings each year. (WHO, 2020)** -------------------------------------------------------------------------------------------------------------------------------   **RISK FACTORS** - Being female - Dependence (physical, financial, or emotional) - Low education level - History of witnessing or experiencing violence in the home or being maltreated as a child - Substance abuse by perpetrator or victim - Isolation on part of perpetrator or victim - Poor social support for family - Single-parent families - Unplanned or unwanted pregnancies - Low socioeconomic status - Intellectual disability, mental illness, physical disability - Cognitive impairment in older adults - Children with congenital anomalies **ASSESSMENT FINDINGS** - Feelings of hopelessness/helplessness - Chronic fatigue/apathy - Self-medicating substance use - Comorbid mental illness or intellectual disability - Taboo subjects (family secrets) - Lack of affection - Fear, unwillingness to disclose causes of injuries - Signs of neglect: poor hygiene, nutritional deficits, lack of dental or medical attention - Injuries to abdomen, breasts, genitals, and/or torso (areas hidden by clothing) - Burns to back, buttocks, genitals, soles, or palms - Discrepancy between physical findings/injury and alleged or described cause - Gap between time of injury and presentation for treatment - Multiple injuries in various sites and stages of healing - Unexplained hearing loss - Children with aggressive behavior, enuresis, excessive masturbation, poor school performance, school truancy - History of family violence (child, partner, older adult) - History of multiple pregnancies, spontaneous abortions, preterm labor, or low birthweight infants ------------------------------------------------------------------------------------------------------------------------------------------------------------ **Traumatic events such as domestic violence can produce profound and lasting changes in emotion, behavior, physiological arousal, memory and cognition.** ------------------------------------------------------------------------------------------------------------------------------------------------------------   **PHYSICAL COMPLAINTS --** - Bilateral injuries, especially to the extremities - Injuries at multiple sites - Fingernail scratches, cigarette burns, rope burns - Abrasions, minor lacerations, welts - Subconjunctival hemorrhage suggests a vigorous struggle between victim and assailant - Pattern Injuries -  marks, designs, or patterns stamped or imprinted on or immediately below the epithelium  **PSYCHOSOCIAL INDICATORS --** - Depression or anxiety -- treatment for which will not be effective if IPV is not recognized - PTSD - Insomnia or somnolence - Alterations of perception of abuser or self **DIFFERENTIAL DIAGNOSES** - Accidental injuries - Somatic symptom disorder - Chronic fatigue - Borderline personality disorder/no suicidal self-injury disorder **PREVENTION** - Screen women of childbearing age for intimate partner violence such as DV, and provide or refer women who screen positive to ongoing support services - Screening for domestic violence should be a priority in mental health services - Interview patients alone; this is sometimes difficult to do with children - No recommendations for screening all older adults or vulnerable adults - Provide quality care and education early in life - Enhance positive parenting skills - Prevention of adverse childhood experiences (ACEs) before they happen - Include family/partner violence as part of the differential diagnosis when treating any injury - Promote healthy, respectful relationships in families - Provide anticipatory guidance when working with families - Helplines to provide information/referrals; display information in offices - Provide posters and pamphlets about domestic violence in healthcare settings - Increase public awareness and healthcare provider training in domestic violence - Work for policies and programs that support families and reduce stress and inequities - Strengthen economic supports to families **NONPHARMACOLOGIC MANAGEMENT** - Consultation in private, ensuring confidentiality - Listening without pressuring to respond or disclose - Respond to concerns by providing practical care and support, but do not intrude - Maintain a supportive, nonjudgmental attitude, validating what the patient is saying - Reinforce to patients that abuse is never justified - Confirm alliance with the patient - Use professional language interpreters if needed; do not use someone associated with the patient - Ensure the balance between benefit and harm with any intervention, and prioritize the safety of victim and their children - Offer trauma-informed care - Offer empowerment counseling, including advocacy/support with a safety component - Do not recommend joint counseling; abuser may punish victim for exposure - Share information about social support and community resources, particularly contact information - Suggest options and provide support in decision making - Refrain from attempting to make decisions for competent adults - Assist in development of a safety plan, including availability of clothes, keys, documents, and cash - Assist in increasing safety for patient and children when needed - Caution that computers and phones may be monitored by the perpetrator and not completely cleared - Reporting of abuse, neglect or exploitation is mandatory if the victim is a child or an older adult - Review HIPAA regulations about reporting - Some states mandate reporting of suspected domestic violence: review state mandatory reporting laws - Recommend emergency shelter if a life-threatening situation is evident - Assure patient's safety before releasing from care - Meticulous documentation is crucial in case of future legal action - Include photographs if patient consents - Describe events using patient's own words - Pregnancy considerations - Routine prenatal care should include screening for domestic violence at preconception visit, at least once a trimester, and at postnatal visit - Delayed prenatal care - Direct injuries to the abdomen may result in negative reproductive health outcomes. **PHARMACOLOGIC MANAGEMENT** - Dependent on extent of injuries - Treat underlying psychiatric illness if appropriate **CONSULTATION/REFERRAL** - Call 911 immediately if the situation is a life-threatening emergency - Child Welfare Information Gateway - \(800) 4ACHILD (800-422-4453) -