Charles Hart Enzer, M.D.

5599 Kugler Mill RoadCincinnati, OH 45236-2035

513-281-0074Email:  cenzer@gmail.comWebSite: 

homepages.uc.edu/~enzerch

Child - Adolescent - Adult - Family – Psychiatry

Anxiety--

Rational Evaluation Leads to  Rational Management

Objectives:

•Appreciate that Anxiety may not be a disorder •Rapid Assessment for Anxiety Disorders •Learn the Hierarchy of the Differential Diagnosis of Anxiety Disorders

"Prescribing Is So Easy, Understanding People So Hard."

Kafka, Franz. (1917) A Country Doctor. The Penal Colony, Stories and Short Pieces

“Patient Has Anxiety”What is Your Next Step?

• Click to Add Text

What Is the Treatment for Anxiety?

•What Does Hunger Tell Me?–Eat Food

•What Does Thirst Tell me?–Drink?

•What Does Tiredness Tell Me–Get Some Rest

•What Does Anxiety Tell MeGalvanize to Action

•Symptoms are Not Enough for Diagnosis–Impairment Is Required

Normal Fear vs Normal Anxiety

Normal Fear• Physiologic and

Emotional Response to Recognized Sources of Danger

• Basic Survival Mechanism– Pain– Threat of Danger

• One of Innate Emotions • Promotes Fight or

Escape/Avoidance• Ready To Cope with

Present Danger(s)

Normal Anxiety• Apprehension, tension, or

uneasiness from anticipation of danger

• Normal reaction to stress – Galvanize to Action

• Ready To Cope With Upcoming Negative Event(s)

- Pathologic Anxiety -

• When Anxiety Interferes with Effectiveness

• And/or when Anxiety Interferes with Achievement

• And/or when Anxiety Interferes with Satisfactions

• And/or when Anxiety Interferes with Emotional Comfort

• Mood Condition That Occurs Without An Identifiable Triggering Stimulus

Anxiety + Impairment

- Pathologic Anxiety -

• Anxiety Disorders Double the Death Rate

• The Suicide Rate of Some Anxiety Disorders is the Same as the Suicide Rate for the Depressive Disorders

Decision Tree for Anxiety

Learning to Think LikeA Psychiatrist

Apprehensive Anticipation•Future Danger and/or Misfortune

•Accompanied by•Feeling of Dysphoria and/or•Somatic Tension

•Focus of Anticipated Danger May be•Internal or•External

Anxiety:

Symptoms of Anxiety, Fear, Avoidance or Increased Arousal

Due to the Direct Physiological Effect of a General Medical Condition

YesAnxiety Disorder due to a General Medical Condition

293.89

Due to the Direct Physiological Effect of a

Substance (Drug, Alcohol, Caffeine, Medication)

Substance Induced Anxiety

Disorder291.8, 292.89

No

Yes

No

Recurrent, Unexpected

Panic Attacks Plus 1 Month of Worry, Concern about Attacks or

Change in Behavior

Anxiety about Being in Places

from which Escape Might be Difficult or Embarrassing in the Event of Having a Panic

Attack

Panic DisorderWith

Agoraphobia300.21Yes

Yes

Panic DisorderWithout

Agoraphobia300.01NoNo

Agoraphobia [Anxiety about Being in Places from Which Escape is Difficulty and/or

Embarrassing

Anxiety about Separation for Attachment Figure – Onset

in Childhood

Fear of Humiliation or Embarrassment in

Social or Performance Situations

Social Phobia300.23

Separation Anxiety Disorder309.21

Agoraphobia without History of

Panic Disorder300.22

No

No

No

Yes

Yes

Yes

No

Fear Cued by Object or Situation

Obsessions or Compulsions

6-Month Period of Excessive Anxiety

or Worry Plus Associated Symptoms

Generalized Anxiety Disorder

300.02

Obsessive Compulsive

Disorder300.3

Specific Phobia300.29

No

No

No

Yes

Yes

Yes

No

Occurs Exclusively

During a Mood or

Psychotic Disorder

No

Yes

See Mood or Psychotic Disorders

Acute Stress Disorder

308.3

Anxiety in Response to a

Severe Traumatic Event

Posttraumatic Stress Disorder

309.81

Reexperiencing of Event, Increased

Arousal with Avoidance of

Stimulus Associated with Traumatic Event

Duration of More than One Month

No

No

Yes

No

No Yes

Yes

Anxiety that Does not Meet Criteria for One of

the Above Anxiety Disorders and Develops

in Response to a Stressor

Clinically Significant Symptoms that Do

not Meet Criteria for a Specific Anxiety

Disorder

Anxiety Disorder not Otherwise

Specified300.00

Adjustment Disorder with

Anxiety309.24

No

Yes

Yes

No

No Anxiety Disorder (Symptoms of Fear, Anxiety or Avoidance that Are not Clinically Significant)

No

Think Like a Psychiatrist

• Since the era Rudolf Ludwig Karl Virchow (13 October 1821 – 5 September 1902), mere symptom treatment represents a scientifically untenable position in all areas of medicine, psychiatry included

• Looking alike, primary and secondary psychiatric symptoms are etiologically diverse

• They demand serious differential diagnostic effort

• Secondary psychiatric symptoms caused by undetected medical illness will not respond to psychotherapy

• Secondary psychiatric symptoms may be aggravated by psychotropic medications

Think Like a Psychiatrist

• A survey of 4500 psychiatric patients in different times and geographical locations, showed 30 - 50% of patients suffered from previously undiagnosed significant medical abnormalities.

• About 30% of the physical illnesses produced symptoms showing direct relation to the psychopathology of the patient

– Predisposing to the Mental Disorders

– Precipitating the Mental Disorders

– Perpetuating the Mental Disorders

Anxiety from Medical Disorders

Cardiovascular Disorders• Acute Anemias• Arrhythmias• Congestive Heart Failure• Pulmonary Embolism

Endocrine Disorders• Hyperadrenocorticism• Hyperthyroidism• Hypoglycemia• Pheochromocytoma

Metabolic Disorders

• Porphyria

• Vitamin B12 Deficiency

Neurologic Disorders

• Encephalitis

• Neoplasms

• Vestibular Dysfunction

Pain

Respiratory Disorders

• Chronic Obstructive Pulmonary Disease

• Hyperventilation

• Pneumonias

Substance-Induced Anxiety Disorder

• Sedative, or Hypnotic, or Anxiolytic

Adverse Reaction to Medications

• ePocrates Hand Held = #301

• ePocrates Online Alternative Drugs = #86

• ePocrates Online Drugs = #266

• www.pdr.net = #603

Drugs of Abuse During Intoxication or Withdrawal•Alcohol•Amphetamine•Amphetamine-like•Caffeine•Cannabis•Cocaine•Hallucinogen•Phencylcline•Phencylcline-like

Managing Anxiety

1. Suspend Moral Judgment

2. Examine Comprehensively

3. Inform about the Findings

4. Make Recommendations

5. Provide Specific Treatments when Indicated

Doctoring: Sequence is Crucial

Managing Anxiety DisordersRational Evaluation

1. Consider Anxiety Secondary to Medical Condition

2. Consider Anxiety Secondary to Substance(s)

3. Decision Making Tree to Sort out the 50+ Disorders

4. 5 – 45 Seconds Evaluation for Suicide

5. Use Medications On Label Only for Specific Disorder

6. When Will it be Reasonable to Expect a Response

7. For Treatment Failure, Psychiatric Consultation

Managing Anxiety DisordersRational Treatment

The Hippocratic Oath • We Do Not Promise to Cure

• We Do Not Promise to Treat

• We Promise Not to Harm

Managing Anxiety DisordersRational Treatment

1. Review the Advantages of Medical Psychotherapy

2. Review the Advantages of Medication

3. Use Medication On Label Only for Specific Disorder

4. Review the Counter-Indications

5. Review the Cautions

6. Review the Adverse Effects

7. Review the Approved Duration of Treatment

•Managing Anxiety DisordersRational Treatment

•The Shorter the Half-life•The Greater the Addictiveness

•The Faster the Onset•The Greater the Addictiveness

•Sedatives•Hypnotics•Anxiolytics

Managing Anxiety DisordersChoosing a Psychiatric Consultant

• The Psychiatrist is Curious

• The Psychiatrist is Thorough

• The Psychiatrist Enjoys Working with Patients Who Have Failed Treatment

Now, Go Forth:

1.Learn2.Practice3.Learn4.Practice5.. . . ..

And Do No Harm