Generalized Anxiety Disorder & Panic Disorder Jeannette Dagam, D.O. Department of Psychiatry The Ohio State University College of Medicine.

Generalized Anxiety Disorder & Panic Disorder

Jeannette Dagam, D.O.

Department of Psychiatry

The Ohio State University

College of Medicine

Objectives At the end of this module, you will know the following:

Identify etiological and diagnostic considerations in patients with anxiety disorders: Panic Disorder. Differential diagnosis Clinical Workup DSM 5 criteria Clinical Features Epidemiology Pathophysiology Course Treatment

Approach to the Patient with a Chief Complaint of Anxiety

History & Physical• Lethality Assessment• Past Psychiatric

History• Family Psychiatric

History• Medical/Surgical

History• Physical

Mental Status Examination

Appearance

Level of consciousness/alertness

Orientation/memory

Psychomotor abnormalities (agitation or retardation)

Suicidal or homicidal ideation

Hallucinations or delusional thought content

Insight

Judgment

Impulse Control

Laboratory and Diagnostic Testing

Standard workup Other testing to consider

Differential Diagnosis of Anxiety / General Medical Conditions

Endocrine

Neurologic

Infections

Cardiopulmonary disease

Cancers

Autoimmune disorders

Differential Diagnosis of Anxiety – Substance-Induced Disorders

Intoxication

Withdrawal

Surreptitious use medications

Side effects of medications

Differential Diagnosis of Anxiety / Other Psychiatric DisordersMajor Depressive Disorder

Schizoaffective Disorder or Schizophrenia

Delusional disorder or Paranoid Personality Disorder

Delirium

Adjustment Disorders with anxious or mixed features

Social Phobia

Obsessive Compulsive Disorder

DSM 5 CriteriaGeneralized Anxiety Disorder A. Excessive anxiety and worry (apprehensive expectation), occurring more days

than not for at least 6 months, about a number of events or activities (such as work or school performance).

B. The person finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months).

Note: Only one item is required in children.

(1) restlessness or feeling keyed up or on edge

(2) being easily fatigued

(3) difficulty concentrating or mind going blank

(4)irritability

(5)muscle tension

(6) sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

DSM 5 Criteria Generalized Anxiety Disorder D. The focus of the anxiety and worry is not confined to features of an Axis I

Disorder, e.g., the anxiety or worry is not about having a panic attack (as in panic disorder), being in embarrassed in public (as in social phobia), being contaminated (as in obsessive-compulsive disorder), being away from home or close relatives (as in separation anxiety disorder), gaining weight (as in anorexia nervosa), having multiple physical complaints (as in somatization disorder), or having a serious illness (as in hypochondriasis), and the anxiety and worry do not occur exclusively during posttraumatic stress disorder.

E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a mood disorder, a psychotic disorder, or a pervasive developmental disorder.

DSM 5 CriteriaPanic DisorderA. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur: Note: The abrupt surge can occur from a calm state or an anxious state. 1) Palpitations, pounding heart, or accelerated heart rate 2) Sweating 3) Trembling or shaking 4) Sensations of shortness of breath or smothering 5) Feelings of choking 6) Chest pain or discomfort 7) Nausea or abdominal discomfort 8) Feeling dizzy, unsteady, light-headed, or faint 9) Chills or heat sensations 10) Paresthesias (numbness or tingling sensations) 11) Derealization (feelings of unreality) or depersonalization (being detached from oneself) 12) Fear of losing control or ‘going crazy’ 13) Fear of dying

DSM 5 CriteriaPanic Disorder

Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

1. Persistent concern or worry about additional panic attacks or their consequences (.e.g., losing control, having a heart attack, or ‘going crazy’)

2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations)

C. The disturbance is not attributable to the physiologic effects of a substance (e.g., a drug of abuse, a medications) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders)

D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in OCD; in response to reminders of traumatic events, as in PTSD; or in response to separation from attachment figures, as in separation anxiety disorder ).

DSM 5 CriteriaPanic Attack Note: Symptoms are presented for the purpose of identifying a panic attack; however

panic attack is not a mental disorder and cannot be coded. Panic attacks can occur in the context of any anxiety disorder as well as other mental disorder (e.g., depressive disorders, PTSD, substance use disorders) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is identified, it should be noted as a specifier (e.g., “posttraumatic stress disorder with panic attacks”).

For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier.

An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

Note: the abrupt surge can occur from a calm state or an anxious state.

DSM 5 CriteriaPanic Attack 1) Palpitations, pounding heart, or accelerated heart rate 2) Sweating 3) Trembling or shaking 4) Sensations of shortness of breath or smothering 5) Feelings of choking 6) Chest pain or discomfort 7) Nausea or abdominal discomfort 8) Feeling dizzy, unsteady, light-headed, or faint 9) Chills or heat sensations 10) Paresthesias (numbness or tingling sensations) 11) Derealization (feelings of unreality) or depersonalization (being detached from oneself) 12) Fear of losing control or ‘going crazy’ 13) Fear of dying

Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

DSM 5 Criteria AgoraphobiaA. Marked fear or anxiety about two (or more) of the following five situations:

A. 1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).

B. 2. Being in open spaces (e.g., parking lots, marketplaces, bridges).

C. 3. Being in enclosed places (e.g., shops, theaters, cinemas).

D. 4. Standing in line or being in a crowd.

E. 5. Being outside of the home alone.

B. The individual fears or avoids these situations because of thoughts escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence).

C. The agoraphobic situations almost always provoke fear or anxiety.

D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

DSM-5 CriteriaAgoraphobia G. The fear, anxiety, or avoidance causes clinically significant distress or

impairment in social, occupational, or other important areas of functioning. H. If another medical condition (e.g., inflammatory bowel disease, Parkinson’s

disease) is present, the fear, anxiety, or avoidance is clearly excessive. I. The fear, anxiety, or avoidance is not better explained by the symptoms of

another mental disorder – for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder); and are not related exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder).

Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.

EpidemiologyGeneralized Anxiety Disorder (GAD)

Common in primary care settings

Higher prevalence in women

High comorbidity with other psychiatric disorders including substance abuse disorders

Heritability Generalized Anxiety Disorder

Familial Genetic loading

PathophysiologyGeneralized Anxiety Disorder

Biologically heterogeneous

Knowledge about the disorder

derived indirectly

GABA, serotonin and norepinephrine neurotransmitters interplaying within the limbic system

Epidemiology Panic Disorder

More common in women

Average onset in the 3rd decade of life

Various medical settings demonstrate prevalence rates

Heritability of Panic Disorder

First degree relatives at high risk

Earlier age of onset confers a higher risk

Twin studies

Biopsychosocial CorrelatesPanic Disorder

Decreased exercise tolerance, with increased oxygen consumption and increased production of lactic acid

Increased prevalence of Irritable Bowel Syndrome

Increased prevalence of Peptic Ulcer

Decreased resting pCO2

Increased sensitivity to anxiogenic effects of stimulants (e.g., caffeine)

Increased frequency of history of childhood Separation Anxiety Disorder

Increased frequency of asymptomatic mitral valve prolapse (MVP)

Mitral Valve Prolapse and Panic Disorder

Historically tagged as the culprit

Absence of significant differentiation between patient groups

Does not confer increased risk

Physiologic Challenge Studies Panic Disorder Panic Disorder patients have an increased sensitivity to the anxiogenic effects of

caffeine; however large doses of caffeine can induce panic attacks in anyone Panic Disorder patients have an increased sensitivity to the physiologic effects of

hyperventilation (which decreases pCO2 concentration) and often have Panic Attacks during voluntary over-breathing of room air. Hyperventilation, however, does not produce Panic Attacks in persons who do not have Panic Disorder

Panic Attacks are easily induced in many patients with Panic Disorder, but not in controls who do not have Panic Disorder, in response to: Injection of sodium lactate Breathing air in which CO2 is elevated Injection of isoproterenol, a beta-receptor agonist Injection of yohimbine, an alpha 2 – receptor antagonist Injection of cholecystokinin tetrapeptide Injection of flumazenil, a benzodiazepine receptor antagonist

Neuroanatomic correlatesPanic Disorder

Neurotransmitter/Neuromodulator Abnormalities in Panic Disorder

Norepinephrine in the locus ceruleus

Serotonin in midbrain neurons

GABA in the limbic system

Adenosine or Cholecystokinin at CNS sites not yet identified

CourseGeneralized Anxiety Disorder

The majority of individuals with GAD report that they have felt anxious and nervous all their lives

Over half of those presenting for treatment report onset in childhood or adolescence, onset occurring after age 20 years

is not uncommon

The course is chronic but fluctuating and often worsens during times of stress

Course Panic Disorder

Age of onset

Usual course

Onset of agoraphobia

CoursePanic Disorder

Agoraphobia

Naturalistic studies

Treatment

• SSRIs, SNRIs, TCAs, MAOIsAntidepressants

• Lorazepam, clonazepam, diazepam, etc.Benzodiazepines

• Buspirone• HydroxyzineOther Agents

• Cognitive Behavioral Therapy• Relaxation exercisesPsychotherapy

References

ISP Module for Psychiatry / OSU Dept. of Psychiatry Clinical Manual of Anxiety Disorders, edited by Dan J.

Stein, MD, PhD; American Psychiatric Publishing, Inc. 2004

DSM 5, American Psychiatric Association, 2013

Panic Disorder GAD Quiz

In Summary

Anxiety and panic are common features within many psychiatric conditions, but the focus, scope and intensity of one’s worry is important in determining whether an independent anxiety or panic disorder exists.

Anxiety as a trait has a familial association – panic disorder develops up to 8 times more often in first degree relatives.

Among the anxiety disorders, generalized anxiety disorder is the most biologically heterogeneous condition.

Effective management of anxiety disorders often involves both pharmacologic and psychological interventions.

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