Anxiety Disorders

Ashlee Hardesty, MD
Interdisciplinary Case Conference
August 17, 2015

Overview
Clues there may be an Anxiety Disorder
DSMV Anxiety Disorders
Treatment
Psychotherapy
Psychopharmacology

Which SSRI?
How to titrate?
Side effects?
Black box warning

Resources

National Comorbidity Survey

Replication Adolescent (NCS-A)
10,123 adolescents surveyed face-to-face

31.9%
Anxiety with median age of onset of 6
years old
Anxiety had lifetime prevalence of

Common Features of
Anxiety Disorders
Anxiety is a normal human emotion
1. Intense anxiety/worry thoughts that are uncontrollable
2. Is clinically significant
Causes clinically significant distress
Impacts function

3. Associated symptoms:

Restlessness
Fatigue
Poor concentration
Muscle tension
Trouble sleeping
**Somatic symptoms

DSM V Anxiety Disorders

Generalized Anxiety Disorder

Social Anxiety Disorder

Separation Anxiety

Panic Disorder

Specific Phobia
Selective Mutism
Agoraphobia
Anxiety disorder
NOS
***PTSD/OCD used to be,
not now

Diagnostic Assessment:
Free Resources

GAD-7 SCARED

GAD-7
Over the last 2 weeks, how often have you been
bothered
by the following problems?
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen

If you checked off any problems, how difficult have these made it for
you to
do your work, take care of things at home, or get along with other
people?
Not difficult at all __________
Somewhat difficult _________
Very difficult _____________ Extremely difficult __________

Anxiety Disorders

Treatment

AACAP Practice Parameters

Therapy alone is fine place to start for mild to moderate
anxiety
Therapy tends to take a little longer to see benefit
Improvement is sustained after therapy ends

SSRI medications are first line for moderate to severe anxiety.

FDA approved for child/adolescents

Fluoxetine
Sertraline
Escitalopram
Fluvoxamine
Often symptoms return when medication is stopped

Combination therapy and medications is most effective

treatment plan

Psychotherapy
Cognitive Behavioral Therapy

Psychopharmacology
1st line SSRI (fluoxetine, sertraline, citalopram,
escitalopram)
So which one?
Drug-drug interactions
Duration of action
Positive response to a particular SSRI by 1st degree
relative

2nd line Another SSRI (above and paroxetine)

3rd line alternatives (SNRIs, mirtazapine,
bupropion)

SSRI Dosing Chart

SSRI Side Effects

Initial Treatment
Titrate SSRI to effective dose
After 8
Partial Improvement weeks No Improvement
Increase med to max
Reassess diagnosis
dose
Add therapy
Add therapy
adherence,
adherence,
comorbidities
comorbidities
Switch to another SSRI
Consider augmentation
Improvement
Discontinue med in 9-12 months to assess
for continued indication

Black Box Warning

All SSRIs have black box warning for
increased suicidality
Rates of suicide went UP after this warning
came out (rates of prescribing SSRI went down,
more untreated illness)

Monitor for suicidality throughout treatment.

SSRIs and Anxiety:

Manage Expectations!
You help set the expectations for medication:
It will dial down the pervasiveness and intensity, it is
not an anxiety-zapping pill
It will take minimum of 6 weeks at a therapeutic
dose
Start low and go slow!
Anxiety disorders typically need higher doses
Initial side effects:

Increased anxiety
Nausea
Tired/activating
Headache
Flu like symptoms

Thats It!

 Johnny is a 12yo boy with symptoms of GAD.

6-month history of excessive worries, mood irritability, school
avoidance and frequent complaints of headaches.
Mom adds his grades have dropped.
No past history of psychotherapy or pharmacotherapy.
Mom has GAD and takes paroxetine.
Parents want to try an SSRI.
GAD-7: 16 out of 21, very difficult

2 weeks later
Both Johnny and Mother report no improvement and
no observed side effects including no suicidal ideation.
Mother and Johnny agree to increase fluoxetine to
20mg today and to 30mg in two weeks.
RTC in 4 weeks.
Mother asks, How will I know if the med is working?
Johnny adds, What is the best dose for me?

4 weeks later
Johnny is on 30mg and reports taking his medications

every day.
He is feeling less anxious and is having easier time getting

to school and has even noticed less headaches.

However, he also reports getting angry easily, and feels

hyper.
Mother agrees that he has been more irritable and has

noticed he is having harder time falling asleep.

2 weeks later
Johnny reports a worsening in symptoms.
GAD-7 score suggests less than 25% improvement.
Mother reports Johnnys grades have dropped since

entering middle school.

When Johnny is asked if there have been any recent

stressors at school or home and he reports that his mom

has a new boyfriend and they have been spending several
nights a week at his house over the past month.

 Is the diagnosis correct? Remember differential.

If yes,
Try a second SSRI (sertraline)
Psychoeducation and Therapy:
Consider 504 plan to help with school impairment.
Maternal Anxiety / Parental Stressors / Family Chaos