Coun 555 Week 8 Anxiety First DraftPresentation Transcript
WEEK 8 Basic Psychopharmacology for Counselors and Psychotherapists Chapter 7 TREATMENT OF ANXIETY DISORDERS Instructor Jeff Garrett Ph.D.
Objective: To explore the symptoms associated with anxiety conditions, the general concept of anxiety, and its role in behavior. A biological explanation for panic states is explored along with the various treatment options and cautions.
Topics to be addressed · Symptoms and causes of anxiety disorders· Panic disorder with or without agoraphobia· Generalized anxiety disorder· Posttraumatic stress disorder· Obsessive-compulsive disorder· Adjustment disorders and other phobic conditions· Social anxiety disorder· Treatment reminders and cautions
SYMPTOMS AND CAUSES OF ANXIETY DISORDERS - Second only to depression and alcohol abuse, anxiety disorders are commonly presented in both mental health and medical/fact surgical settings.- Anxious patients frequently over-use medical services.- The pathophysiology of most anxiety disorders is rather complex and most likely linked to abnormal regulation of neurotransmitters such as serotonin, GABA, and glutamate.- A strong comorbidity exists among anxiety disorders, and while they often have similar symptoms, the manifestation or presentation might be different.
SYMPTOMS AND CAUSES OF ANXIETY DISORDERS - Since the symptoms of most anxiety disorders are similar, the pharmacological treatment is the same.- Anxiety disorders typically include the following symptoms in various forms and intensity: trembling, general nervousness or tension, shortness of breath, diarrhea, hot flashes, feelings of depersonalization, worry, agitation, initial insomnia, poor concentration, tingling, sweating, rapid heartbeat (tachycardia), frequent urination, and dizziness.
Therapists should … - Assess intensity and duration and quality of symptoms.- Rule out medical etiology (e.g., cardiovascular problems)- Rule out substance abuse etiology (e.g., withdrawal).- Determine the type and nature of the anxiety and a likely diagnosis
Anxiety disorders are now categorized as follows: - Panic disorder or PD (with or without agoraphobia).- Agoraphobia with or without panic disorder.- Generalized anxiety disorder or GAD.- Posttraumatic stress disorder or PTSD.- Obsessive-compulsive disorder or OCD.- Social anxiety disorder.- Adjustment disorder with anxious mood.- Simple phobias.
PANIC DISORDER WITH OR WITHOUT AGORAPHOBIA What happens during a Panic Attack- Anxiety is caused when the brain perceives a threat of danger.- In reaction to the fight-or-flight response, the limbic system goes on red alert.- The body responds to a series of physiological reactions:- the limbic system sends signals to the hypothalamus and the locus ceruleus;- they in turn send signals to the pituitary, the thyroid, and the adrenal cortex.- As a result, various hormones such as cortisol and adrenaline are produced, readying the body for attack; but with panic disorder, it is a false alarm.
The Biology of Panic Disorder - A dysregulation of the limbic system, serotonin depletion, excessive glutamate, and insufficient amounts of GABA may all be to blame.- When large amounts of cortisol and adrenaline are produced, the patient is in a constant or chronic state of arousal.- The effects of stress on the body cause these hormones to suppress immune functions and increase blood pressure.
Chloride-ion channels - On the surface of about 40 percent of nerve cells in the brain are tiny gateways or receptor sites called chloride-ion channels.- Chloride ions, which have a slightly negative charge, are found in the fluid surrounding each cell.- The ion channel can be activated or opened when stimulated by the naturally occurring neurotransmitter GABA.- As the channel opens, the chloride ions are drawn in.- When the cell is infused with negative ions, the cell hyperpolarizes or relaxes. This causes a calming effect.- Benzodiazepines also bind at the chloride-ion channels causing a calming effect.- This effect is also true for alcohol.
Three Phases of the Chloride-Ion Channel (See Figure 7.1. on page 54.) Phase 1: Chloride ion channel is closed (patient anxious)Phase 2: GABA binds to receptors: Channel begins to open.Phase 3: Benzodiazepine binds to receptors: Channel fully opens (patient relaxed)
Three Stages of Treatment for Panic Disorder Stage 1. Stop the panic (immediate relief). - Benzodiazepines are the drugs of choice for quick relief of panic symptoms. Alprazolam (Xanax), lorazepam (Ativan), and oxazepam (Serax) offer the fastest relief based on their short half-lives.- The therapist should inquire about any history of substance abuse, because these patients often enjoy the "high" they get from benzodiazepines and may abuse them.- The longer-acting benzodiazepines like clonazepam (Klonopin) are less likely to be abused than alprazolam (Xanax) or lorazepam (Ativan).- The prescriber must include an appropriate antidepressant along with the benzodiazepine.- The benzodiazepine will control panic, and within one to two weeks the antidepressant will begin to work. At this time, the benzodiazepine should be gradually withdrawn.- Psychotherapy may be attempted at any time during this process once the patient is calm enough to focus and concentrate in the session.
Three Stages of Treatment for Panic Disorder Stage 2. Regulate the limbic system with drugs that increase serotonin.- Once panic has been controlled with benzodiazepines, the use of various antidepressants will increase serotonin and help to regulate the limbic system.- The newer SSRIs offer better relief with fewer side effects.- The antidepressant should maintain patients if they are not abusing alcohol or other drugs. - The antidepressant should maintain patients if they are not abusing alcohol or other drugs.
Three Stages of Treatment for Panic Disorder Stage 3. Provide appropriate psychotherapy to educate the patient and reduce anticipatory anxiety or self-defeating behaviors. - Cognitive-behavioral treatment for panic disorder is effective.- For patients with panic disorder and agoraphobia, or agoraphobia without panic disorder, the use of in vivo (real-life) techniques are helpful.- With panic disorder it is very important for the therapist to address all three stages.
GENERALIZED ANXIETY DISORDER - GAD is closely related to depression.- The best medications for GAD include venlafaxine (Effexor), buspirone (Buspar), and most of the SSRIs such as fluoxetine (Prozac) and paroxetine (Paxil).- If the patient has serious trouble relaxing, buspirone or paroxetine may be better because they have a more relaxing and calming effect.- Buspirone is a nonbenzodiazepine, antianxiety drug that has properties more similar to an antidepressant.- Benzodiazepines is not the best approach because it does not teach patients to manage their condition.- GAD responds well to a combination of medication and psychotherapy.- Therapist should educate the client regarding anxiety and meds (e.g., Antidepressants take longer to work).
POSTTRAUMATIC STRESS DISORDER. - Historically, benzodiazepines and neuroleptics have been used to treat PTSD.- Today, considering reported overall efficacy and side-effect profiles, clinicians have found much success with SSRIs.- Psychotherapy is used in combination with medicine to treat PTSD.
OBSESSIVE-COMPULSIVE DISORDER - The treatment of choice for OCD involves, the use of SSRls (e.g., fluoxetine [Prozac])- In some cases the obsessions are severely intrusive, and the patient may complain of racing thoughts and insomnia. Low-dose, atypical neuroleptics such as risperidone (Risperdal) could be added along with a sleep aid if needed.- Psychotherapy alone has not been shown to be very effective;- Behavioral and cognitive-behavioral treatments along with medication offer the best possibilities.
SOCIAL ANXIETY DISORDER - The use of SSRIs and MAOIs offers the best results for social anxiety.- In some cases when the patient reports only situational anxiety, for example, when he or she has to speak publicly, the use of beta-blockers like propranolol (Inderal) or clonidine (Catapres), an alpha agonist, might prove helpful.- In these cases the patient may take the medication an hour before the speech and notice less sweating, heart palpitations, and general anxiety without the need to take medication on an ongoing basis.- Tricyclics, benzodiazepines, and buspirone (Buspar) offer little benefit in the long run.- Psychotherapy, especially behaviorally based treatments, are helpful in allowing the patient an opportunity to see the connection between environments and the fears they produce.- Cognitive rehearsal and role plays may assist the patient in a more lasting recovery.
ADJUSTMENT DISORDERS AND OTHER PHOBIC CONDITIONS Adjustment Disorders- Psychotherapy is recommended (e.g., grief counseling).- In most cases the symptoms will remit within six months.- If significant anxiety persists, a low-dose SSRI could be used for four to six months.- If the patient is agitated and cannot relax enough to work or concentrate, sedating antidepressants like paroxetine (Paxil), trazodone (Desyrel), or amitriptyline (Elavil) could be used.Phobic Conditions - Use CBT for simple phobias (e.g., fear of cats, spiders, or elevators),- CBT and exposure techniques are preferred rather than medication for phobias.
TREATMENT REMINDERS AND CAUTIONS Diet - Avoid excessive sugar, stimulants such as sodas, candy, cigarettes.MedicineFor most anxiety disorders, the four "Bs" are used.1. Benzodiazepines such as diazepam (Valium), alprazolam (Xanax), lorazepam (Ativan), and clonazepam (Klonopin);2. Barbiturates such as pentobarbital (Nembutal) and secobarbital (Seconal), which may potentiate GABA, but are very sedating and habit forming;3. Buspirone (Buspar) for GAD;4. Beta-blockers for specific forms of social anxiety.