Key Points in the Diagnosis and Management of Anxiety Disorders Transcript PDF

Key Points in the Diagnosis and Management of Anxiety Disorders Tran... https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533770-dt-... Key Points in the Diagnosis and Management of Anxiety Disorders All right. Well, here we are for part 2 of week...

Key Points in the Diagnosis and Management of Anxiety Disorders Tran... https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533770-dt-... Key Points in the Diagnosis and Management of Anxiety Disorders All right. Well, here we are for part 2 of week 2: Key Points in the Diagnosis and Management of Anxiety Disorders. Just like with the mood disorders, I'm going to review some of the !ne points of the physiologic treatment targets. And then some of the key points in di"erentiating and treatment, expecting that you get the bigger picture with all of your activities for this week. But let's get on to our slide set here. OK now, you may begin to detect a pattern. Although it probably won't be the pattern for the entire course. But certainly, between mood disorders and anxiety disorders, some of what I have to say today, you have heard before in the 6026 course. But that's OK, because it helps to hear it again. So we won't revisit synaptic transmission, already did that. But with anxiety disorders, there are many of the same neurotransmitters. It's just that it's di"erent neural pathways that are a"ected. And so the two primary features of anxiety disorders that I want to talk about here are worry and anxiety. And they are two di"erent things. Worry is that cognitive apprehensive expectation. That your brain going over and over a thing. We all know what worry is because we all do it sometimes appropriately. Sometimes we have something really important to do and it may have big consequences. And we're not sure how it's going to go. We're not sure if it's ready. So we worry about it. I mean, that's as it should be. It's a normal emotion. Anxiety as a symptom refers to the physiologic hyper-vigilance. The sympathetic nervous system response. The tachycardia. The tachypnea. The palpitations. That sense of impending doom. And similarly, that is a normal response when you are in a situation that provokes anxiety. Anxiety heightens your awareness a little bit. It makes you more aware of your surroundings, more aware of your actions, and the consequences. And it's a good thing. Like everything else in mental health, when they are disproportionate, inappropriate, et cetera, and have some impact on social or occupational function, then they may 1 of 14 11/2/24, 4:17 PM Key Points in the Diagnosis and Management of Anxiety Disorders Tran... https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533770-dt-... become a symptom or even a disease state. But the reason I'm highlighting worry and the physical symptom of anxiety is because they are the core features of every anxiety disorder. Anxiety gets confusing. We have anxiety as a normal-- we use the word. I mean, the word can be confusing because we use it in many ways. Anxiety is a normal physiologic response like I just described. Anxiety can be a symptom. Like I'm anxious about this or that. And I'm too anxious. It's inappropriate. I shouldn't be this anxious. I'm anxious and I don't know why. Or you can have an anxiety disorder. There are a family of anxiety disorders. And that includes things like general anxiety disorder, and panic disorder, and social anxiety disorder. And all of those disorders are disorders, and they have diagnostic criteria, and they're not the same thing, and they're not always treated the same way. Sometimes in the practice setting, the reason patients don't really respond to anti anxiety treatments is that they don't have an anxiety disorder, or perhaps they don't have the anxiety disorder that you are treating. So again, diagnostic criteria matters. Knowing what really should be there and what's not there really does matter. And so the two cardinal features of any anxiety disorder are worry and the physiologic symptom of anxiety. So worry appears to be a consequence of imbalances of some of those neurotransmitters we've already talked about. Gamma aminobutyric acid, 5-HT, which is serotonin, norepinephrine, and dopamine. And in the world of anxiety disorders, dopamine has varying levels of in#uence or prevalence in certain disorders. And there does appear to be a genetic link to the enzymes of dopamine degradation, which means there is more likely to be a genetic link in people with certain anxiety disorders, not all of them. Well, maybe all of them. But it's very clear in certain anxiety disorders that there appears to be a genetic-- a fairly strong genetic link, and it's because of the enzymes, or at least theorized to be because of the enzymes of dopamine degradation. I do have this habit of speaking in all or nothing terms, which I really shouldn't do, and I try to be aware of it. And so please keep in mind that when I say things like that that it's not always that general or that global of a term. I mean, yes, there does appear to be a genetic link. But like I said last week, there's some sort of genetic predisposition to almost every mental health disorder. But with certain anxiety disorders, there does appear to be a much stronger genetic 2 of 14 11/2/24, 4:17 PM Key Points in the Diagnosis and Management of Anxiety Disorders Tran... https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533770-dt-... component. And it is theorized to be related to genetic expression of the enzymes of dopamine degradation. So increased dopamine in certain neural pathways can exaggerate certain anxiety disorder symptoms. Hope that made sense. All right, so worry is that apprehensive expectation that oh my gosh, oh my gosh. What if. What if. What if. And that's theorized to be more of a problem in prefrontal pathways. The corticosteroid ophthalmic cortical loop that we'll look at in a moment. The anxiety, the physical symptom of anxiety, and the term is used interchangeably with fear. So when you see on your slide here fear/anxiety. Here I am using the word anxiety to represent the physiologic sympathetic nervous system stimulation that occurs. And this is about the amygdala. I mentioned this in the last slide set. The amygdala is fear central. The amygdala processes sensory input, that of which you are aware and mostly that of which you are not aware. The amygdala is very primitive. It can pick up very subtle changes in environment, and then it processes those inputs, those sensory inputs. And then if a physiologic anxiety response is warranted, it is triggered from the amygdala. You get sympathetic activation. And it's really an amygdala brain STEM thing. Your pulse goes up. Your blood pressure goes up. Your pupils dilate. These are all very primitive responses that help you be on top of your game and ready to respond to a stressor. It also increases the emotional piece, the heightened vigilance. The heightened worry. This really comes-- this starts with the amygdala. So the amygdala, that little tiny cluster of cells deep in the brain, right near the hippocampus, which does become signi!cant when we look at PTSD, particularly, as one of the anxiety disorders. This part of the brain is referred to as the "lizard" brain. It is the most primitive part of the brain. It developed very early in-- not even embryonic. Whatever you are before an embryo, zygote, or something. Very, very early in development the amygdala emerges. And like the last bullet point says, it integrates sensory and cognitive information to determine whether or not a fear and a worry response is warranted. Like I said, sometimes it's appropriate. If you were actually paying attention in 6026, I probably gave you the example of when you like !nd yourself for some reason having to walk in an unfamiliar area late at night, and you're all alone. And you're already a little heightened. You're very aware. You're looking around. 3 of 14 11/2/24, 4:17 PM Key Points in the Diagnosis and Management of Anxiety Disorders Tran... https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533770-dt-... But your amygdala is perceiving sensory input of which you are not even aware. Subtle sounds that you may not consciously hear. Subtle subtleties in movement. Maybe like the tiniest little rustle in a bush or something that you don't consciously see but your amygdala processes it. Subtle changes in temperature, in smell, that might imply someone or something is nearby or was recently nearby. Almost all of this happens at an unconscious or subconscious level. Which is why when you think that your quote, "intuition, or your gut," or something like that, is telling you something. It's not really your gut. It's your amygdala because it is on it. And so in the normal healthy person that doesn't have an anxiety disorder, we get anxious when we have good reason to be. And we don't get anxious when we don't have reason. We worry when there's a good reason to. And we don't worry when there's not a good reason to. In anxiety disorders, patients typically have exaggerated responses in both of those areas. They worry for no good reason. And they have anxiety attacks for no good reason. On the #ip side, manic patients, for instance. Those with elevated mood, they don't worry when they should and they don't get anxious when they should. See where we're going with this thing? That little amygdala, it's got a lot of power. These people who are not even manic, not people with disorders. But just some people are thrill seekers. They're always like living on the edge. These are your skydivers. Your bungee jumpers. Like whatever exciting thing people do. Very often, they just have a dampened response from the amygdala. I always used to say my son had no amygdala. He just seemed to have no fear of anything. But I mean, I guess he does have an amygdala. Anyway, that's what it does. So yeah, I already said this. But I'll say it again, because it's important. When stimulated, the response is appropriate. And when it's inappropriate, excessive, or unwarranted, well, that's when you're going to have symptoms of an anxiety disorder. So again, I keep using the word fear synonymously or interchangeably with anxiety as a symptom, as a physiologic response. This is your sympathetic nervous system, fear, or #ight, freeze. There's another fear, #ight, or !ght. Yeah, fear is not there. Fight, #ight, freeze, fear whatever. And one of those F words. That's all from the amygdala. So I think we looked at this picture in the last slide. But now we're going to look at it from a slightly di"erent perspective. Now, we really are focusing on that amygdala. So here's my laser pointer again. And there it is, right there. Deep, deep in the brain. Very close to the hippocampus. Very close to the hypothalamus. 4 of 14 11/2/24, 4:17 PM Key Points in the Diagnosis and Management of Anxiety Disorders Tran... https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533770-dt-... This is anxiety central. And like I said, it receives sensory stimuli. It processes those stimuli. And in the healthy patient, when warranted, it will kick out responses. If you need to be worried, then you will send via prefrontal motor pathways to the appropriate areas. You will get messages to the anterior cingulate cortex that says, hey, we've got a situation. We're walking through a parking lot at 3:00 AM and all of the lights are out. Let's be on alert. Remember this is the area that helps like coordinate responses. It makes you be appropriately alert, a little bit apprehensive without going overboard in the healthy state. So that's the worry piece. Here's that physiologic fear. This is the communication between the amygdala and the brain stem. When this is activated, that's when your pulse goes up, your blood pressure goes up, et cetera, et cetera. So this is the physiologic fear response. And this is that worry piece. It's a slightly di"erent way of looking at it. But it begins in the amygdala and triggers those prefrontal pathways. This is the cortical striatal thalamic cortical loop. So the prefrontal cortex, remember there's a huge relationship here between cognition and emotion. You tend to be more aware of what's going on at this level. So maybe you appreciate that you're in that parking lot. And so you will communicate messages through subcortical structures. Remember the striatum is largely about motor movement. The thalamus is command central for processing all sensory input. And the amygdala is just sub to the thalamus. I know it's not visualized here. But the amygdala is one of those sensory input pieces. The thalamus is sort of like command central. The thalamus takes the input it's getting from the prefrontal pathways in the striatum, and deciding what sort of motor response is warranted. But when this starts to become like a positive feedback exaggerated loop, like all of the sensory input here triggers further prefrontal-- what's the word I want. I guess prefrontal stimulation, then that exaggerates the thalamic response and it just goes back. I'm not saying this very well. But hopefully you get what I'm talking about. Inappropriate activity in these pathways when it becomes very circular, that's where you get this stu". Apprehensive expectation, this is the hallmark feature of an anxiety disorder. This is the worry. Worry for no good reason. Misery, catastrophic thinking, recurrent thought. These are all characterizations of worry. You probably know somebody who's always miserable. It's like a worry. Like oh my gosh. What if. What if. No, I don't want to do this. What about that? What if this 5 of 14 11/2/24, 4:17 PM Key Points in the Diagnosis and Management of Anxiety Disorders Tran... https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533770-dt-... happens? You probably also know somebody-- well, maybe everybody doesn't know all of this. But there are lots of folks out there who like, everything is a catastrophe. There's no little thing going on, right? Everything's a big deal. If you're driving the car and you're on a long road trip, and you're in the middle of say, like, in the middle of a big state like Montana, or something. And there's a little hitch in the transmission. The worrier will, oh my gosh. All of a sudden, the engine is going to seize. The transmission is going to go out. What are you going to do? There's nobody around for miles. Whereas, like you or I might go, that's weird. Transmission, it seemed like it slipped. Maybe at the next reasonable stop, I will stop and check it out. So like this is the di"erence between a normal worry response, and this apprehensive expectation exaggerated phenomenon that you see in anxiety disorders. The real thing I want you to take away from this !rst part of the discussion is that worry is normal, anxiety is normal. When they become abnormal to the point of interfering with social or occupational function, then you've got a symptom. The symptom could be a symptom of something else entirely. Or it could be a symptom of an anxiety disorder. So when you appreciate that the patient has worry or anxiety as a symptom, then you have to consider all of your potential di"erential diagnoses. It could be a substance use phenomenon. It could be hyperthyroidism. It could be excess use of albuterol. Or it could be an anxiety disorder. So then you consider the diagnostic criteria for your anxiety disorders and determine whether or not the patient meets them. And even though they're di"erent, there's di"erences among all the anxiety disorders. The two cardinal features, the two things that have to be there are worry and physiologic anxiety. So that's the !rst thing for which you assess. Somebody who worries a lot, but never has panic attack-- I mean, never has that physiologic hypervigilance-- it's much less likely to be an anxiety disorder. Something else is making them worry. When you perceive worry or anxiety that may be excessive, you want to assess for the presence of both of those things recognizing that they're separate. Now, the patient certainly might have one that's more dominant than the other. Worry might be their primary concern. But when you ask the right questions, you will !nd out they have the occasional episodes of physiologic anxiety. Or they may come to you 6 of 14 11/2/24, 4:17 PM Key Points in the Diagnosis and Management of Anxiety Disorders Tran... https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533770-dt-... saying, I'm having panic attacks. I'm having panic attacks all the time. And that's their big complaint. But when you ask the questions you do !nd out they are a perpetual worrier. So sometimes you have to dig for it. And these don't necessarily present with the same level of intensity. But they are both there to some extent. Those are your cardinal diagnostic criteria. Once you deduce that the patient is experiencing both anxiety and worry, then we try to !gure out if it's actually an anxiety disorder or not. So now we have to look at the anxiety disorders and determine if our patient has symptoms of any of them before we make a diagnosis. So let's see, symptoms of anxiety. Oh, dear. I guess I'm beating this one up a little bit. Anxiety as a symptom and worry are the cardinal features. Yep. All the anxiety disorders manifest these symptoms. Yep. And numerous subtypes of anxiety are identi!ed. Each have symptoms that predominate. And that's another big yep. Here are some additional symptoms of anxiety. And notice how there's some overlap here. There's some overlap here with symptoms of mood disorder. There's some overlap here with symptoms of ADD. I mean, it's not a surprise. Many people with psychiatric disorders will have comorbidities just because it's the same neurotransmitters. It's just about di"erent pathways. And it's not a big shocker that if you have a problem in one pathway, you may have a problem in another pathway as well. And that leads to what appears to be overlapping symptoms. So these are the things that you assess for. Once you determine that worry and physiologic anxiety are present, you want to ask some other questions. Like does the patient have di$culty concentrating? Do they report a sense of fatigue? Because absolutely, people can be anxious and tired all the time. Arousal. Again, this is that hyper arousal. That exaggerated physiologic arousal. Do they have panic attacks? If they have panic attacks-- attock-- if they have panic attacks, are there triggers? Do they know what makes their panic attacks or do the panic attacks just come out of the blue? Are there any compulsive tendencies in the patient or obsessive? I know it doesn't say it on your slide. Muscle tension, and this is physical muscle tension. Particularly with one type of anxiety disorder, which is generalized anxiety disorder, it's very common for people to complain of pain, muscle pain. And sometimes they spend that whole trajectory with pain management. And they keep having pain and nobody can !nd out why. And then eventually, they land in your o$ce and you realize it is a physical 7 of 14 11/2/24, 4:17 PM Key Points in the Diagnosis and Management of Anxiety Disorders Tran... https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533770-dt-... manifestation of their anxiety. Irritability. Hyper irritability. Hey, this could be depression. It could be mania. It could be ADD, or it could be anxiety. Sleep disruption and phobic avoidance, just to name a few. So remember, physiologic anxiety and worry must be there, and then you are looking for the presence or absence of these additional things. The di"erence among types of anxiety disorders is not anatomic location of the malfunction, which is the case with pretty much everything else. Like, remember when we were talking about mood disorders, we said similar neurotransmitters, even a lot of overlap in neurotransmitters. But in depression, it's the locus coeruleus and the raphe nucleus. Whereas an elevated mood, it's prefrontal pathways. With most disorders, it's di"erent pathways. You might remember from 6026, psychotic disorders is about the mesolimbic pathway. Negative symptoms of schizophrenia is about the mesocortical pathway. Most disorders, there's an imbalance of neurotransmitter in speci!c pathways. But when we look at the anxiety disorders, di"erentiating among them is not based on anatomic location or the type of neurotransmitter. It's the same thing. It's the same pathways. The prefrontal, that corticosteroid ophthalmic cortical loop that I just talked about. And the amygdala brainstem. Those are the problems in all anxiety disorders. What di"erentiates one from the other is the nature and timing of the symptoms. The nature and timing of the malfunction. When do they start? When do they occur? Does something prompt them? Is there not something that prompts them? That's what's going to help you determine the di"erence between one and the other. So for instance, one type of anxiety disorder is generalized anxiety disorder or GAD. So here's your cardinal features. Remember, every anxiety disorder is characterized by these. Excuse me. And then these are all those other symptoms that may or may not occur. And you'll notice that some of them are real obvious to see and then others fade into the background. That's because the things that are more dominant on your screen are things that are more likely to occur in generalized anxiety disorder. Patients frequently will report that they are easily distracted. That they have trouble sleeping. They will report that physiologic arousal, tiredness. I mean, you get the idea. Patients with GAD, worry is the primary symptom. There will be a history of anxiety attacks, or panic attacks. If you really dig for it. But it's not the primary thing they complain about. 8 of 14 11/2/24, 4:17 PM Key Points in the Diagnosis and Management of Anxiety Disorders Tran... https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533770-dt-... So you see things like panic attacks expected or unexpected. Avoidance of certain things. They're faded here because they're not very common with GAD. So GAD, these are the symptoms that must be there. And then diagnostic criteria requires that at least one other of these things be there. And then you have to look at the timing and onset. And so this is your diagnostic criteria right from what you call it DSM-5. So we've already established this business anxiety and worry. At least one other symptom. Symptoms have occurred most days for at least six months. Generalized anxiety disorder is a chronic condition. So by de!nition the symptoms have to occur for a minimum of six months. Usually, you'll !nd out it goes back much longer than that. In fact, it's very common that when you start asking questions, you'll !nd that patients had these symptoms like going all the way back even to childhood, school age, or adolescence. But for whatever reason they just didn't present to care until now. And yes, like any other mental health disorder, there is some level of social or occupational impairment. And so that's typical of GAD. Virtually, always, you will !nd that it goes long back in their life cycle. It's just for some reason right now they have presented to you with it. And worry is the dominant symptom, although there will be some level of anxiety attack in their history. But sometimes you have to dig it out. OK, on the #ip side PTSD-- now, I have to say, full disclosure, DSM-5 does not consider PTSD an anxiety disorder. In DSM-5, or DSM-5-TR, PTSD got his own chapter somewhere else. But pretty much everybody who manages it still considers it a type of anxiety disorder. And that's why we are talking about it here. So let me get my laser pointer here. So with PTSD, notice again, your cardinal features worry and physiologic anxiety. But then the associated symptoms with PTSD not the same as they are for generalized anxiety disorder. Here the primary issues are physiologic hyper arousal, sleep disturbances, and avoidance. Basically, they're having these episodes of hyper arousal, a.k.a. #ashback, and they don't always know why. So they start avoiding things that they think might be triggering it. But these are the cardinal features. Not so much here, the fatigue. Not so much the muscle tension. Primarily with PTSD, this is the symptom presentation that you'll see. And in terms of diagnostic criteria, this doesn't have any-- like this isn't a chronic illness. This usually wasn't present since childhood. I mean, unless the traumatic event happened in childhood. What you do need to make a diagnosis of PTSD, you have your 9 of 14 11/2/24, 4:17 PM Key Points in the Diagnosis and Management of Anxiety Disorders Tran... https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533770-dt-... two cardinal features, anxiety and worry. And then there is some history of something truly awful happening to this patient or they witnessed it. But keep in mind what's truly awful to you and me isn't necessarily what's truly awful to somebody else. So it's what's awful to them. You'll see people have PTSD in response to things that you didn't necessarily think would be PTSD inducing. Like, I have one patient who has really, really awful PTSD as the consequence of a car accident. But it's not-- it wasn't like a big traumatic thing where-- didn't even go to the hospital. She had a-- she had an accident. She was OK. The car got !xed. But it really did produce in her a very signi!cant PTSD. So just keep in mind that it's what the patient experiences as awful, not us. And then something occurs to trigger them, and they relive the hyper arousal. And it's not always an obvious thing. I mean, it's not always like, oh, it's a car accident. So now every time I drive a car-- it could be. It just so happens from the patient I'm talking about, it is. But it might be something else that triggers it. And the theory about this-- this is where it becomes signi!cant. The physical relationship between the amygdala and the hippocampus. Remember, the hippocampus is where remote memories are stored. And the amygdala is that physiologic-- where you trigger that physiologic hyper responsiveness. And the theory with PTSD is that there is some maladaptive relationship so that the primitive sensory features of the amygdala will pick up certain sensory input, usually subconscious to the patient. And because of abnormal pathways, will express that deep memory that's stored in the hippocampus and produce the hyper arousal. And it's di"erent. I mean, by de!nition-- yeah, I don't have it on your slide. And I probably should. Although you'll certainly study more of it in your unit this week. But PTSD, by de!nition, the symptoms don't occur for at least one month after the event occurred. And it might be much longer than that. So if something really horri!c happens to me today, and tomorrow I'm reliving it, and having what seems like #ashbacks, that's not PTSD. That's di"erent. It's a di"erent diagnosis. So by de!nition, there is some time distance between the event and the expression of symptoms. At a minimum, that time distance is one month. And it might be a lot longer than that. And then we have panic disorder. So panic disorder is yet another type of anxiety disorder. You still have your cardinal features. You still have your worry and physiologic 10 of 14 11/2/24, 4:17 PM Key Points in the Diagnosis and Management of Anxiety Disorders Tran... https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533770-dt-... anxiety. But the other-- the cardinal features that distinguish panic disorder are unexpected panic attacks. And then just generalized avoidance. They don't know what they're avoiding because these panic attacks are unexpected. The patient truly has no idea what triggers them. They just come out of the blue. So they start avoiding things that they think might cause it. But since they don't really know what causes it, they just wind up avoiding all kinds of stu". And I mean, panic attacks, it's like migraines in that the actual event is bad. But your fear of the next one is almost just as bad because you don't know-- you don't know what's going to bring it on. And so with patients with panic disorder, the primary symptom is that physiologic hypervigilance, that panic attack. I mean, they genuinely believe they're going to die. Even if their cognitive brain knows they're not. There's a dissonance between cognition and emotional, and they start to have these physical symptoms and feel like they're going to die. Now, unlike generalized anxiety disorder, this is not a chronic illness. So you can see your diagnostic criteria here. We know our two cardinal features, they're a must have. The panic attacks are unexpected. Patient lives in fear of repeated attacks. And then just avoid whatever they think might trigger it. Notice that these have occurred for at least one month. And the onset typically, in the early 20s. Although certainly it could be onset in the 30s. This is usually a condition of young adulthood. It's not chronic. And very often, it comes out of the blue. Patients will have panic attacks for like 2, 3, even 6 months. And then it just stops. As quick as it came, it stops. And nobody really knows why. So that's panic disorder. But you can see how you can't just like call everything an anxiety disorder and call it a day. These things are quite di"erent. Now, the last anxiety disorder I want to tease out here is social anxiety. Notice that social anxiety is similar to panic disorder, but not identical. You still have your cardinal features. You still have avoidance. But in social anxiety, the patient knows why they're having a panic attack. It is related to some social exposure. So it's very di"erent. There was something else I was going to say. I can't remember what it is. It must have been a lie. But anyway, the two key things you're looking for here is that the patient knows why they have panic attacks. And so then logically they will avoid the things that they think trigger them. And when that avoidance gets to interfering with social or occupational function, well then you got a disorder. 11 of 14 11/2/24, 4:17 PM Key Points in the Diagnosis and Management of Anxiety Disorders Tran... https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533770-dt-... So here's your diagnostic criteria. Notice this one too. This does tend to be more chronic. Duration of at least six months. And when you ask the questions, the patients will often report that it's been going on for longer than that. But the big di"erence here is we know what's going on. So that's your social anxiety phenomena. So !nally, what are we going to do about it? Once we characterize appropriately the anxiety disorder, what do we do about it? Well, not all anxiety disorders are treated the same way. There de!nitely is some overlap, but they're not treated the same way. Remember one of my favorite phrases. If you treat somebody for something, and they don't get better, there's a good chance they don't actually have the thing that you are treating. So of course, when it comes to the pharmacotherapy, I will ask you to go back and revisit what you learned in 6026. Also keep in mind that all patients with anxiety disorders should be referred to a therapist. Some of them as a primary intervention and some of them as an adjunct intervention. But everyone should be referred to a therapist. Speci!cally, people with PTSD and people with social anxiety, medication is not the starting point. I know that when you go into clinicals, you will see people do it. And sometimes, there's an exception to every rule. There are certain circumstances where it's appropriate. But it certainly is the exception. Starting therapy at the time of diagnosis for PTSD and social anxiety, typically, should not be a drug. They should be a therapist who knows what they're doing in that particular area. Patients with PTSD-- I mean, if I see someone who comes to me with an anxiety symptom and I make that diagnosis, they are getting referred right to a therapist. We're not doing any SSRIs, no benzos, no nothing. They're going to a therapist and ideally one who is trained to treat patients with PTSD. And I know it's not always that easy. I mean, I work in the real world. I practice every Wednesday. I see patients. And some of them don't have insurance, or some of them don't have ready access. Or there's a three month wait list. Or whatever the case may be. I know that there are problems. But really, the better approach to the patient is to work with them to try to !nd a therapist that they can see quickly. EMDR, and we will talk a lot more about that in 6972. I have never had a patient that was referred to EMDR therapy that didn't get substantial bene!t with it. Like everything else, it's not a magic approach. It's not going to completely eliminate symptoms. But 12 of 14 11/2/24, 4:17 PM Key Points in the Diagnosis and Management of Anxiety Disorders Tran... https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533770-dt-... therapy really is the foundation of PTSD treatment. Ditto with social anxiety. This should start with a therapist. Now, in both of these cases, sometimes the patient will work with a therapist for a few months. And then the therapist might reach out to you. Or the patient comes back and says, my therapist said to come back and see you because we're still having some trouble, and she thought it might be time to talk about a medication. Now that, I mean, that does happen. And that's very appropriate. But with those two disorders, I would really encourage you to encourage your patient to see a therapist !rst. On the #ip side, patients with generalized anxiety disorder and panic disorder, those are patients for whom pharmacotherapy really is the foundation of therapy. A therapist will absolutely be helpful in helping them develop coping strategies, and mechanisms, and tools to manage their symptoms. And ideally, I mean, you can always really strive toward getting the patient in that place with a combination of pharmacotherapy and non-pharmacologic therapy that at some point, you can wean o" the drug therapy. But it's just more likely, especially by the time they get to a mental health practice, patients with GAD and panic disorder are more likely to be on medication for the long haul along with a non-pharmacologic intervention. And so the second bullet point I think already made that point in the last slide set. Once you decide that pharmacotherapy is what you're going to do, whether it's the initial intervention or an adjunct intervention. Pretty much all forms of anxiety disorder, once you get to that place where you're going to use a medication, you can start with an SSRI or an SNRI. Now, there is the occasional nuance. Like in PTSD, there is more research I think to support Zoloft than anything else. But half the time it comes down to what the patient's insurance will pay for. But if you can pick, Zoloft is the drug of choice for PTSD along with a therapist-- as an adjunct to a therapist. But whether it's GAD, panic disorder, or whatever, SSRIs or SNRIs, they are the two drugs that are appropriate to start all forms with. Some people will respond well to them. We like them because they're not controlled substances. They're not drugs of abuse. You don't get addicted to them. So when they work, they're awesome. But sometimes they're not enough. Patients with generalized anxiety disorder will do very well with buspirone if they actually have generalized anxiety disorder. And I know I don't need to beat that drum again. I did it 13 of 14 11/2/24, 4:17 PM Key Points in the Diagnosis and Management of Anxiety Disorders Tran... https://alt-5c5afaf83f339.blackboard.com/bbcswebdav/pid-2533770-dt-... quite a bit in 6026. The reason buspir is not successful in people is because they don't have GAD. They have some other problem. But true GAD that's not responding to an SSRI or you can't use one, buspirone is typically very helpful. Patients with panic disorder may require a short course of benzos. And I know it's de!nitely not trendy. Benzos are a controlled substance, and they're a drug of abuse, and therefore evil because we're in a very anti controlled substance world these days. But just imagine living every day where you suddenly and out of the blue have spells where your heart pounds, you can't breathe, your chest is tight and you think you're going to die. And I mean, there are people that are in that place. And sometimes they do need benzodiazepines at least as you transition to a non-benzodiazepine daily agent like an SNRI. Of course, there's a whole safety discussion. And again, don't have to revisit 6026. And beta blockers and antihistamines for social anxiety, for the patient in whom they're in therapy. They're working on it, but they're still not there yet. If they need to be exposed to a social circumstance, and they really are just having these almost panic attacks in a social setting, pre-medicating with a beta blocker, like 40 milligrams of inderal or 25 or 50 milligrams of the antihistamine Vistaril can be very e"ective. It is not recommended that we use benzos in these patients because we know where the panic attack is coming from. So the !rst goal is that a therapist helps them navigate that particular trigger. But then we don't want them to get in the habit of popping a Xanax every time they have to lead a meeting at work or something like that. Panic disorder is a little bit di"erent because the attacks are unexpected. There's just no rhyme or reason to it. But in social anxiety disorder, when you have to use a medication, we want to use one of these things that are not controlled. Remember with all disorders, all anxiety disorders, and all disorders. We're not looking for the complete and total obliteration of symptoms. I guess it would be nice, but it's just not a realistic expectation. We're just looking to help the patient get to that place where they can get through their day. And that's what these approaches to care use. So that's all I have to say about that. Enjoy your week, and I will see you next week in week 3. Print this page 14 of 14 11/2/24, 4:17 PM