UNIT XI: PSYCHIATRIC CONDITIONS

CHAPTER 56 Anxiety Disorders, With an Emphasis on Panic Disorder

Grace M. Nespoli, PhD, ACNP • Stephen Paul Holzemer, PhD, RN

Anxiety is often manifest as a cluster of nonspecific symptoms that occurs before, during, and after a number of life experiences. Anxiety becomes a disorder when it impairs a person’s interpersonal, occupational, or social functioning in the home, and places of work, recreation, and worship. The American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), identifies the following categories of anxiety disorders (APA, 2013), identified in Figure 56.1.

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) addressed obsessive–compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) in the anxiety category, but now are covered separately, and omitted from this chapter. Panic attacks function as a marker of severity of illness across a number of disorders. A specifier is applicable to all DSM-5 disorders. The mental health conditions discussed in this chapter are panic disorder (PD), agoraphobia, generalized anxiety disorder (GAD), specific phobia, social anxiety disorder (SAD), and anxiety disorders caused by another medical condition, or use of drugs or other substances. Neither selective mutism, a condition diagnosed in children, nor separation anxiety disorder, a condition that is no longer restricted to children and adolescents, is discussed in this chapter.

ANXIETY DISORDERS IN GENERAL—EPIDEMIOLOGY

The primary care provider will care for a large number of patients experiencing anxiety and anxiety d isorders. The prevalence and use of services seeking help are presented in Tables 56.1 and 56.2.

The prevalence of anxiety disorders is identified in Table 56.1, as well as age demographics. With the recent emergence of the DSM-5 criteria, data related to the category of any anxiety disorder include some of the DSMIV subcategories. The prevalence of social phobia, PD, and GAD relate to both diagnostic approaches. Of interest is the number of people for whom anxiety disorders are severely debilitating.

Use of services is reflected in Table 56.2. Categories include those who have used health care within a 12-month period, have received minimally adequate (health care) treatment, have used any (social or medical) service within 12 months, and have received minimally adequate health care and social services within the same time period. It is clear that many patients, and sometimes the majority, receive health care and social services, and of those small numbers, even fewer receive minimally adequate care or treatment (Asnaani & Hofman, 2012).

PANIC DISORDER

PD is a chronic, often debilitating condition that can have devastating effects on a person’s life, family, work, and social interactions. Because its symptoms mimic a variety of medical conditions, this disorder frequently goes undiagnosed, with rapid treatment delayed. The DSM-IV connected PD with agoraphobia, which is a separate diagnostic category in the DSM-5.

Anatomy, Physiology, and Epidemiology

Theories regarding the nature and etiology of PD range from the biological to the psychological, with exact associations unclear. Previous traumatic episodes in childhood may predispose a patient to PD (APA, 2013; Cummings, Caporino, & Kendall, 2013; Mondin et al., 2013). Environmental factors may aggravate the condition, as the patient copes with stress in life (Larzelere & Jones, 2008). PD has been found in cultures throughout the world with some confusion in culture-related behaviors that may not fit diagnostic categories. Age of onset of PD varies considerably but is usually between late adolescence and the mid-20s to 30s, declining in older age (APA, 2013).

FIGURE 56.1
Categories of anxiety disorders from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.

Source: Adapted from American Psychiatric Association (2013) and Grohol (2013).

Natural History of Illness/Comorbidity

Patients receiving ongoing, established treatments for PD show a higher rate of recovery, with many of these patients continuing to have mild to moderate symptoms. As would be expected, relapse rates are high after discontinuation of effective treatment. This suggests that PD is a chronic condition with a very low rate of spontaneous recovery. Comorbid conditions are other anxiety disorders like agoraphobia, major depression, bipolar disorder, alcohol misuse, and suicide. Comorbidity may be a marker of the severity of illness. Mitral valve prolapse and thyroid disease are more common among patients with PD, but the differences in prevalence are not consistent (APA, 2013; Cummings, Caporino, & Kendall, 2013; Gloster et al., 2011).

Diagnostic Criteria for PD

Recurrent unexpected panic attacks with four or more of the symptoms listed below (not including culture-specific symptoms such as uncontrollable screaming, crying, headache).

At least one of the attacks has been followed by one or more of the following for at least 1 month:

Persistent concern about having additional attacks

Worry about the implications of the attack

A significant maladaptive change in behavior to avoid future attacks

The disturbance is not better explained by another type of mental disorder.

The disturbance does not occur in relationship to the physiological effects of a substance, or other medical condition.

Symptomatology of Panic Attacks

Shortness of breath/smothering sensations

Dizziness, unsteady feelings, or faintness

Palpitations/tachycardia

Trembling/shaking

Sweating

Feelings of choking

Nausea/abdominal distress

Depersonalization (being detached from oneself)

Derealization (feelings of unreality)

Paresthesias (numbness or tingling sensations)

Flushes/chills

Chest pain or discomfort

Fear of dying

Fear of going crazy or doing something uncontrolled

Treatment Options, Expected Outcomes, and Comprehensive Management

Treatment options can be divided into pharmacological and psychological interventions; often these two modalities can be used concomitantly. The most common psychological interventions are cognitive-behavioral therapy (CBT), exposure therapy, and psychodynamic therapy. Pharmacological options can include benzodi-azepines (BDZs), selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), or monoamine oxidase inhibitors (MAOIs). Research does not support the need for concurrent combined treatment initially, but the use of combined therapy for condition maintenance seems reasonable. Figure 56.2 represents combined treatment.

The provider, in consultation with the patient, should select as the initial treatment one with demonstrated efficacy. Attitudes and concerns regarding various treatment options must be explored and decisions negotiated with the patient. Patients should be educated about the disorder and encouraged to reenter phobic situations gradually when medication alone is chosen as the initial treatment. Current practice suggests that an absence of any noticeable improvement after about 6 to 8 weeks of any treatment should lead to a reassessment, consultation, or change of modality (Choy, 2008).

FIGURE 56.2
Combined treatment.

Source: Adapted from American Psychiatric Association (2013) and Grohol (2013).

COGNITIVE-BEHAVIORAL THERAPY

CBT teaches patients to anticipate the situations and bodily sensations associated with their panic attacks. This awareness sets the stage for helping the patient to control the attacks. Specially trained therapists tailor CBT to the specific needs of each patient. The therapy usually includes the following components:

Informational overview of the cycle of anxiety and the anticipation of further anxiety episodes, and rationale for the treatment

Helping patients to identify and change patterns of thinking that cause them to misperceive common events or situations as dangerous and to think the worst. For example, the therapist can help the patient to replace alarmist thoughts such as, “I’m dying” with more appropriate ones, such as “I’m hyperventilating; I can handle this.”

Teaching the patient relaxation exercises to prevent or minimize the symptoms commonly felt during a panic attack

Helping patients becomes less fearful by safely and gradually exposing them to situations they previously avoided or found frightening. This step provides an opportunity to have patients practice their coping and relaxation skills in the anxiety-provoking event.

CBT is a short-term treatment, typically lasting 12 to 15 sessions over several months. It is thought that patients who undergo CBT demonstrate a high maintenance of treatment gains over time. Family members and others may participate by encouraging the patient to complete individual counseling or group activities, and become a monitor of behaviors that may suggest the need for medical and psychiatric intervention. In some locations, CPT may not be available due to the absence of providers skilled in this intervention. The use of phone and Internet contact between the therapist and the patient are increasing (Donegan & Dugas, 2012).

PHARMACOTHERAPY

Anxiety-disorder patients tend to be sensitive to medication and often experience exacerbation of their symptoms with medication, especially if too large an initial dose is used. It is generally recommended that low starting doses of selective SSRIs, selective norepinephrine reuptake inhibitors (SNRIs), and TCAs be used and that low doses be maintained for several days and gradually increased to a full therapeutic dose as the patient tolerates (APA, 2010, 2013; Marchesi, 2008). Insufficient evidence exists to recommend any of these pharmacological agents as superior to the others (APA, 2010, 2013). It is important to note that not advancing to full therapeutic dosages is common in treatment of PDs and is a frequent source of patient partial or nonresponse (APA, 2010, 2013). It is recommended that patients be informed of a time frame for positive response to avoid premature abandonment of treatment. There are limited data on optimum length of treatment after patient response to therapy has been achieved (Bandelow et al., 2012).

There is evidence that antipanic medication response continues during pharmacotherapy and that relapse is common after discontinuation of drugs (Marchesi, 2008). For responders to SSRIs or TCAs, data suggest that continuing medication for 6 months or more results in further symptom reduction and decreased risk of recurrence (APA, 2010, 2013). Patients with treatment-resistant PDs or prior relapse after treatment discontinuation may require longer treatment schedules. Once the decision has been made to discontinue medication, tapering over a period of several weeks or months is recommended (APA, 2010, 2013).

The concern for potential treatment-related increases in self-harming or suicidal behaviors associated with antidepressant medications requires clarification. Data primarily from studies on children and adolescents resulted in Food and Drug Administration (FDA) warnings applied to all antidepressants indicating the risk of increased suicidal thinking and behavior in patients younger than 25 years. In adults, antidepressant treatment does not appear to be associated with an increase in suicide risk (APA, 2010, 2013).

Pharmacological agents with proven benefits in numerous randomized controlled trials (RCTs) in treating PD include SSRIs, SNRIs, TCAs, and BDZs, and are recommended as first-line therapy (APA, 2010, 2013; Marchesi, 2008). Because of their favorable safety and side-effect profile, SSRIs and SNRIs are considered the best initial choice for PD (APA, 2010, 2013). Because of their larger evidence base, SSRIs are more likely to be chosen as first-line treatment (Marchesi, 2008).

Although TCAs have demonstrated effectiveness in PD, the side effects and greater toxicities associated with overdose limit their usefulness and are associated with higher dropout rates. The most studied TCA is imipramine and has demonstrated effectiveness in PD. In addition, clomip-ramine has considerable empirical support for use in PD (APA, 2010, 2013; Marchesi, 2008). Most common side effects of TCAs include anticholinergic effects, increased sweating, sleep disturbances, orthostatic hypotension and dizziness, fatigue and weakness, cognitive disturbances, weight gain, and sexual dysfunction. TCAs have been associated with significant or fatal arrhythmias and must be used with caution with the elderly population; they are contraindicated for patients with prostatic hypertrophy or narrow-angle glaucoma (APA, 2010, 2013). BDZs are appropriate for monotherapy only in the absence of co-occurring mood disorders. For dosing information for the use of antidepressants and benzodiazepines with panic disorder, refer to current drug guidelines. However, they may be used in combination with antidepressants for rapid symptom control (APA, 2010, 2013). Alprazolam has demonstrated efficacy in treatment of PD. Because of its short half-life this medication requires 3 to 4 times daily dosing and presents compliance problems for many patients and with missed doses can result in more rapid and profound withdrawal symptoms (APA, 2010, 2013). There is also a sustained-release form of alprazolam that may alleviate some of these dosing problems. Monoamine oxidase inhibitors (MAOIs), although an effective treatment for PD, because of their safety profile, are generally reserved for patients who fail first-line treatment (APA, 2010, 2013). MAOIs have serious drug-drug interactions resulting in serotonin syndrome causing hypertensive crisis that can be fatal. Symptoms include confusion, agitation, hyperthermia, as well as autonomic and neuro-muscular symptoms. Serotonin syndrome can occur when MAOIs are used with other antidepressants (particularly SSRIs); linezolid; analgesics (meperidine, fentanly, tramadol); over-the-counter (OTC) dextromethorphan; and other medications such as busiprone, as well as antimigraine medications. A recent meta-analysis (Mitte, 2005) comparing the efficacies of TCA, SSRI, and BDZ therapies demonstrated a similar effect in improving anxiety in both symptoms and frequency of panic attacks, as well as agoraphobia. In this same meta-analysis, SSRIs and TCAs were superior to BDZs in alleviating depression (Marchesi, 2008).

SSRIs available in the United States include fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, and escitalopram. Evidence does not exist for differential efficacy between agents in this class. Other agents used in the management of PDs include anticonvulsants, antipsy-chotics, antihypertensives, and buspirone. Limited data exist for the use of anticonvulsants in PD (APA, 2010, 2013). Only one RCT provided partial support to the fact that gabapentin is safe and efficacious for PD. Therefore, gabapentin should not be considered as first-line treatment for PD (APA, 2010, 2013). There is no evidence that first-generation antipsychotics (typical) are effective in PD and the risk of neurological side effects outweighs any potential usefulness (APA, 2010, 2013). There is limited positive evidence for the use of the second-generation antipsychotics (atypical) olanzepine and adjunctive risperidone. However, evidence is limited for efficacy and concern about second-generation side effects limits their ability to be broadly recommended. The antihypertensive beta-adrenergic blocking agents (e.g., propranolol, ateno-lol) are ineffective in PD but may help reduce somatic sensations in selected patients (APA, 2010, 2013). Buspirone as monotherapy is not effective for PD and there are no published data except case reports for its use as an augmentation strategy.

Additional concerns include the fact that, initially, SSRIs can be panicogenic. As such they need to be initiated at low doses and slowly tapered up. It is recommended that the initial low dose be maintained for 3 to 7 days and gradually increased in weekly increments. Both SSRIs and SNRIs are associated with discontinuation syndromes including dizziness, headache, and nausea, and require tapering over at least 7 to 10 days. Elderly patients with PD have higher rates of co-occurring mood disorders and recommendations for treatment are use of an antidepressant as first-line therapy. SNRIs are preferred in this population (Resch, 1999).

COMBINED THERAPY