Non-pharmacological Treatment of Anxietyin the Primary Care Setting

Presented by: Jonathan Betlinski, MDDate: 12/18/2014

Disclosures and Learning Objectives

Learning Objective:

Be able to define and apply at least three evidence-based non-pharmacologic treatments for anxiety disorders

Disclosures: Dr. Jonathan Betlinski has nothing to disclose.

Detecting Anxiety Disorders in Primary Care

• Review anxiety screening tools

• Discuss first steps in treatment of anxiety

• Introduce Diaphragmatic Breathing

• Introduce Progressive Muscle Relaxation

• Introduce Cognitive Behavioral Therapy

• Topic for next time

Anxiety in the Primary Care Setting

• A 2007 study of patients from 15 clinics– 19.5% had at least 1 anxiety disorder– 8.6% PTSD– 7.6% Generalized Anxiety Disorder– 6.8% Panic Disorder– 6.2% Social Anxiety Disorder– 41% of those with Anxiety Disorders had

no current treatment

http://www.ncbi.nlm.nih.gov/pubmed/17339617

Indicated Screening for Anxiety: GAD-7

http://wiki.galenhealthcare.com/index.php/Galen_eCalcs_-_Calculator:_GAD-7_Gen._Anxiety_Disorder

http://www.integration.samhsa.gov/clinical-practice/GAD708.19.08Cartwright.pdf

GAD-7, PDSR, Mini-SPIN

• GAD-7 (10): 89% sens, 82% spec• Scores of 5, 10 and 15 indicate mild,

moderate and severe anxietyhttp://www.ncbi.nlm.nih.gov/books/NBK126694/

• PDSR (8.75): 89% Sens, 100% Spechttp://www.psychologie.tu-dresden.de/i2/klinische/mitarbeiter/materialien/pdsr.pdf

• Mini-SPIN (6): 89% Sens, 90% Spechttp://www.aafp.org/afp/2008/0815/p501.html

Treating Anxiety

• Start with a thorough medical work up– Neurologic– Endocrine (thyroid, pheo, carcinoid)– Mitral valve prolapse

• Evaluate for Substance Abuse– Both intoxication and withdrawal– Don't forget alcohol, caffeine and nicotine

• Evaluate for other psychiatric disordershttp://www.aafp.org/afp/2000/1001/p1591.html

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC427612/

Organic Anxiety

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC427612/

Features of Anxiety Secondary to Organic Causes

Differential Diagnosis: Anxiety Secondary to Organic Factors

Educate about the Cycle of Anxiety

http://www.jabfm.org/content/22/2/175.full.pdf+html

Treating Anxiety

• Educate about the cycle of anxiety– Address behavioral avoidance with gradual

exposure

– Address cognitive distortions with evidence

– Address physical symptoms with CB and PMRhttp://www.jabfm.org/content/22/2/175.full.pdf+html

• Regular exercise counteracts anxietyhttp://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.162.12.2376

• Avoid caffeine, alcohol, poor sleep hygienehttp://www.jabfm.org/content/22/2/175.full.pdf+html

http://www.cci.health.wa.gov.au/docs/Info-sleep%20hygiene.pdf

• Goal: Manage anxiety, not erase it

Diaphragmatic Breathing

• Increases parasympathetic tone– Slows heartrate– Decreases blood pressure– Increases oxygen– Decreases carbon dioxide

• Practice for five minutes twice daily• Use as neededhttps://www.youtube.com/watch?v=_mZbzDOpylA

http://www.anxietybc.com/sites/default/files/CalmBreathing.pdf

https://www.nmu.edu/wellness/sites/DrupalWellness/files/UserFiles/9.19_final.pdf

https://depts.washington.edu/hcsats/PDF/TF-%20CBT/pages/4%20Emotion%20Regulation%20Skills/Client%20Handouts/Relaxation/Ways%20to%20Relax%20by%20Using%20breathing.pdf

Progressive Muscle Relaxation

• Deliberately ordered tensing and relaxation of muscle groups

• 65% Panic-free at 12 weeks, 82% at 1 year• Keys for use

– Often helpful for bedtime relaxation– Practice the same system– Use a tape or video to help

http://www.ncbi.nlm.nih.gov/pubmed/7887873?dopt=Abstract

https://depts.washington.edu/hcsats/PDF/TF-%20CBT/pages/4%20Emotion%20Regulation%20Skills/Client%20Handouts/Relaxation/Ways%20to%20Relax%20by%20Using%20breathing.pdf

https://www.bcbsnc.com/assets/common/pdfs/Stress_Management_Belly_Breathing_U2979a.pdf

Cognitive Behavioral Therapy

• Cognitive component may be more effective than behavioral

• More effective than Supportive Therapy and Psychodynamic Therapy

• May outperform pharmacotherapy• Effects persist at least 6-12 months• Response rates of 56%• Cost-effectivehttp://www.aafp.org/afp/2000/1001/p1591.html

http://www.uptodate.com/contents/psychotherapy-for-generalized-anxiety-disorder

Cognitive Behavioral Therapy

• Usually lasts 6-15 sessions• Addresses the cognitive, physical and

behavioral symptoms of anxiety– Education

– Self-monitoring

– Relaxation training

– Cognitive Restructuring

– Imagery Exposure

– Situational Exposure

– Relapse Preventionhttp://www.uptodate.com/contents/psychotherapy-for-generalized-anxiety-disorder

Treatment of Anxiety in Primary Care

• Anxiety Disorders are very common• Anxiety Disorders commonly improve• Treatment starts with

– Thorough medical workup– Lifestyle modification– Behavioral management

• CBT, DB, PMR can be just as effective as medications—sometimes better!

The End!

Treating Anxiety

With Medication

01/08/15

• http://photography.nationalgeographic.com/photography/photo-tips/familiar-places-photos/#/japanese-maple-murawski_44192_600x450.jpg