Anxiety Disorders
Kathryn J. Zerbe, M.D.
Kathryn J. Zerbe, M.D., is Jack Aron Professor in Psychiatric Education and Women's Mental Health, The Menninger Clinic, Topeka, Kansas.
This activity is made possible by an
unrestricted educational grant from
the Novartis Foundation for
Gerontology.
Educational Objectives
Upon completion of this Cyberounds®, the participant should be able to:
- List the diverse presentations of anxiety disorders in a primary care practice
- Discuss the medical mimics of anxiety disorders
- Initiate pharmacotherapy with the most effective agents.
Anxiety disorders are the most prevalent of the psychiatric disorders. They are two to three times more frequent in women than in men, negatively influence the quality of a person's life, lead to costly medical workups and cause general deterioration in overall health and well-being. Clinicians often do not realize the full impact of these disorders -- the economic cost, for example, of anxiety disorders has been estimated at $47 billion dollars.1 Fortunately, anxiety disorders are highly treatable conditions for the majority of sufferers.
Anxiety is the unpleasurable affect, usually accompanied by physiological sensation, that is characterized by worry, doubt and painful awareness that one is powerless to control situations. In contrast to fear, anxiety is irrational. The anxious person is hypervigilant, tense and insecure in most situations. Their heightened negative state leads to some of the somatic complaints that can be particularly prominent. These include excess sweating, trembling, dizziness, palpitations, shortness of breath, gastrointestinal upset, hot flashes, dry mouth, increased urination, fatigue and restlessness.
The anxiety episodes can become so intense that individuals believe they are actually "going crazy" or will die.
Anxiety disorder frequently occurs after a major life event (e.g., loss of a spouse, physiological stress resulting from physical illness) but a third of patients with diagnosed panic disorder, for example, will have some recurrent panic attacks in their sleep, and about 4% of patients will have more attacks while they are sleeping than when awake. In fact, some patients first experience the illness with a panic attack that interrupts their sleep, sometimes resulting in extensive cardiovascular workups because the patient awakens believing she is having a heart attack.
The common types of anxiety disorders are listed in Table 1.
Table 1. Common Anxiety Disorders
Based on the American Psychiatric Association Diagnostic and Statistical Manual,
DSMIV, 1994, Washington, DC, American Psychiatric Press.
Generalized anxiety disorder (GAD): excessive worry and tension; childhood or early adulthood onset; chronic; highly treatable.
Panic: paroxysm of sudden fear together with physiological symptoms (palpitations, chest pain, choking, vertigo, trembling, shaking);distortion in light/sound intensity common; last only a few seconds or a few minutes.
Posttraumatic stress disorder (PTSD): anxiety that results from severe stress, characterized by re-living stress and nightmares; chronic; sexual childhood trauma implicated.
Phobia: avoidance because of fear or panic; common phobias are fear of animals (e.g., snakes, mice) and heights.
Social phobia: fear of humiliation or embarrassment producing avoidance of social situations.
Agoraphobia: fear associated with being away from a safe person or safe place ("adult separation anxiety").
Obsessive-compulsive disorder (OCD): repetitive intrusive, unwanted, and disturbing thoughts (often sexual or aggressive) combined with rituals and behaviors to reduce anxiety provoked by the obsessions; older age onset (e.g., Shakespeare's Lady Macbeth); many types, including eating disorders, compulsive shopping, premenstrual dysphoria.
In the primary care setting, it is very difficult to make an accurate diagnosis of an anxiety disorder because, in contrast to patients who seek out a mental health specialist, primary care patients tend to see their problem as organically based. To varying degrees, these patients resist the idea that they may have an emotional disorder, and they may become angry with you for even suggesting it! They also may ignore therapeutic suggestions.2,3,4 As a result, primary care clinicians will need to be attuned to both the overt and subtle manifestations of anxiety disorders, to understand some of their beguiling aspects, to rule out medical conditions that mimic anxiety and to have a working knowledge of the pharmacological and psychosocial treatment options now available.
Clinical Example: "The Dilemma of Mr. A."
One day Mrs. A., wife of Mr. A. for 30 years, calls you because "something seems different" about her husband. She describes him as "cranky" and always complaining about "feeling sick." He has refused to come in for his annual physical because he is terrified that you will not find anything new. Although he still goes to work and is productive, Mrs. A. tells you she almost has to push him to go out of the house. While at home, he "fiddles and has the jitters" and recently confided to their son and daughter-in-law that he thinks, "I might drop over dead one of these days from a heart attack. Every now and again I feel like my heart is just going to burst through my chest. I almost pass out. I breathe so fast, get sick to my stomach, and my legs start to give way."
As you hear these symptoms, you suspect that an anxiety disorder might be the culprit but other diseases, particularly cardiac ones, will have to be ruled out in a thorough evaluation. Yet, the first problem you face is getting the patient to come see you for a routine visit.
Why Patients Don't Seek Help
Some patients find it painful to seek help for their anxiety. Prominent reasons include a sense of personal defect, lack of knowledge, fear of having an emotional problem and inaccurate evaluation.
Sense of Personal Defect
Many patients view emotional problems as a sign of personal weakness, and this precludes them from seeking help. A patient may much prefer to have a physical problem rather than to blame him- or her-self for a "weak will." Even those who seek help may not take their prescribed medicine and, instead, try to "get better on my own."
For this and other reasons, many patients are reluctant to disclose their difficulties, so the physician must be specific when asking about these conditions.2 Because patients feel greater anguish at a psychiatric rather than a medical diagnosis, they will sometimes become angry or haughty when their primary physician suggests that they have an emotional illness. No matter how effective the treatment is, or potentially can be, an alienated patient will not return.
Thus, when an anxiety disorder is suspected, it is most helpful if the physician provides a great deal of education about the disorder and its treatment to reduce any shame the patient may feel. The primary care physician has a potentially advantageous position since he or she is a "medical" doctor and can so make anxiety seem more a straightforward and very treatable condition, especially since patients who do get treatment feel as though they are living for the first time.
"More about Mr. A.: Forming the Alliance"
Let's say you are able to persuade Mr. A. to come in for an evaluation of "the jitters" and the problem that he increasingly has of leaving the house. He has been in your practice for years and a simple call from you office assistant reminds him of the need for a yearly exam. As you review his file, you are reminded that anxiety disorders (including agoraphobia) occur more often in women than in men, taking an enormous toll on work productivity and home life. Nevertheless, you realize that anxiety disorders are still prevalent, and often go undiagnosed, in men. You form an alliance with Mr. A. by telling him you will have to ask a lot of questions about his physical symptoms and review his medical history, medications, including over-the-counter medications ones, and then do some diagnostic tests.
Drugs and Medical Conditions Contributing to Inaccurate Evaluation
Other medical conditions that present with anxiety must always be ruled out.5 Drugs of abuse (e.g., amphetamines, cocaine), caffeine and alcohol may all precipitate anxiety attacks. Although numerous medical conditions mimic many of the symptoms of anxiety, some disorders in particular must be ruled out: coronary conditions, such as angina pectoris, dysrythmias, valvular disease-especially mitral valve prolapse-and congestive heart failure,6 are frequently accompanied by dread and apprehension; hyperthyroidism, systemic lupus erythematosus, anemia, as well as respiratory conditions, such as asthma, chronic obstructive pulmonary disease and pneumonia.
Because there are many medications, both prescription and over-the counter, that can precipitate anxiety, the primary care provider must ask the patient, specifically, about any medicine they might be taking. A nutritional history should also be carefully taken with careful attention paid to the amount of caffeine (in coffee, soda, diet soda, chocolate and some aspirin preparations (e.g., Excedrin®) likely to be circulating in a person's system. Even small amounts of caffeine in some at-risk individuals can precipitate or exaggerate anxiety.
"Making the Diagnosis and Informing the Patient"
After you have completed the medical evaluation, you find Mr. A. to be in essentially good health. You are particularly relieved that the cardiac symptoms were not associated with positive findings on stress test, etc. You instruct him to limit his use of caffeinated beverages because these can precipitate or exacerbate an anxiety reaction. You reassure Mr. and Mrs. A. that no overt physical problem, such as coronary artery disease, seems to be the cause of his difficulty. While both the patient and his spouse take the news well, you now wonder about how to approach telling the patient he has an emotional disorder, namely anxiety. You consider referring the patient to a mental health professional for some cognitive-behavioral and relaxation therapy, but you wonder if he will comply with your suggestions. You give him a trial of one of the SSRIs for treatment of his anxiety, but underscore the importance of also seeking therapy.
Managing Anxiety
Although some doctors may find it helpful to determine the patient's particular anxiety disorder, it is more useful to make a "ballpark" diagnosis and engage the patient in therapy. In reality, most patients with an anxiety disorder have another comorbid psychiatric condition, e.g., depression, alcoholism, and more than one anxiety disorder.7,8,9 Rarely, does a patient present with a pure anxiety disorder.10
"Referring Mr. A. to a Psychiatrist: Problems and Pitfalls"
One of the reasons you consider referring Mr. A. to a mental health professional, despite his reluctance, are the substantial comorbid risk factors that often accompany an anxiety disorder. You run through each of these in your mind and attune yourself to them in your next follow-up appointment with Mr. A. Specifically, you are worried that the patient may have a hidden alcohol or substance abuse problem that he has never mentioned, may be depressed, or even suicidal. You doubt these considerations because you know the patient, but you also realize psychiatric issues are often hidden or disavowed by patients in a primary care (or any!) setting.
Risk Factors to Assess Prior to Treatment
The primary care clinician must first decide whether the patient has other serious, frequently encountered, comorbid risk factors which may require immediate intervention: depression, addiction, suicidal behavior, genetic and family factors, preoccupation with physical disease, anger, shame, and life events (including trauma).
Depression
When anxiety and depression occur together, greater functional impairment results. Prognosis is poor unless the syndrome is recognized, therapy initiated and compliance maintained.11,9,12 In this regard, it is important to talk with a close family member of the patient, as they are often the first to notice a change of mood or function. Treatment will help to allay concerns about the medically unexplained somatic symptoms and thus avoid unnecessary and expensive workups that can further add stress to the patient and their family.
Alcohol and Substance Abuse
About 15% of patients with an anxiety disorder also suffer from a substance abuse disorder.13 More common is the substance-abusing patient who also has an anxiety disorder. The patient's attitude toward taking medication helps to differentiate the two. Patients who are addicted tend to want higher doses of prescribed medication ("It's not relaxing me enough, Doc"), 8,13,14 while anxious patients, in contrast, worry about taking medications ("It's very hard for me to do everything I need to do if I'm drowsy"). The purely anxious patient needs to be reminded that first-line anti-anxiety drugs, tri-cyclics (TCAs) and SSRIs, are nonaddicting.
The clinician should take a careful lifetime history of the patient's substance use. In particular, try to determine whether the patient abused alcohol or drugs prior to the onset of anxiety. Contrary to popular medical mythology, few individuals drink to "treat" their anxiety,13 but successful management of anxiety may have an impact on alcohol consumption. If the patient suffers from anxiety and substance abuse disorder, they will need to be referred to appropriate mental health professionals and community resources (e.g., Alcoholics Anonymous, Narcotics Anonymous). Serious addiction should be treated first, before anxiety, because it is progressive and potentially fatal.
Suicide
There is a high incidence of suicide attempts among anxious patients, particularly those with panic disorder, which is often underestimated by medical professionals. This is not surprising, as the anxiety these patients experience is unbearable! Suicide attempts related to anxiety disorders appear to be more frequent in women than in men, particularly in women who are single, divorced, or widowed.15,16 Once again, the primary care professional will need to consult with a mental health clinician and consider safe environment alternatives (e.g., hospitalization) for the patient.
"Does post-traumatic stress play a role in Mr. A's problem?"
Most clinicians have empathy for a patient like Mr. A. because we have experienced anxiety in our own lives. Mr. A. casually remarked to your office assistant that he was never involved in combat or the armed forces, but "I sure did have an angry father who was always beating up on all of us kids." You overhear this remark in passing, and begin to wonder what specific life events or early trauma might be playing a factor in Mr. A.'s ''anxiety problem." All the more reason to underscore the value of some psychotherapeutic sessions.
Momentarily, you flash to a forgotten anxiety experience of your own. You were a 3rd year medical student presenting for the first time at the bedside to a revered but demanding professor. Although you prepared long into the night for your review of the clinical findings, your thoughts blocked as you began to speak. You trembled, your face flushed, and you felt certain you would collapse before you even got a word out. With a great deal of effort, you were able to override your autonomic nervous system but still felt humiliated in front of the patient and your colleagues. In fact, you could barely review the history of the case, let alone answer any of the gruff professor's queries about the disease process and established treatments. In retrospect, you realize you had a mild anxiety attack that was self-limiting but emotionally agonizing nonetheless.
These small traumatic events are part of the professional development of each of us. Through empathy, they give us a tincture of what patients with a bonafide anxiety disorder go through almost every day of their lives. Just consider how difficult living would be if you had to struggle, day after day, from moment to moment, with the embarrassment, rapid breathing, sweating, nausea, and inadequacy you confronted for only a few moments during "professor's rounds" as a student. For many patients these attacks can even seem to "come out of the blue" or wake them from a sound sleep (e.g., nocturnal panic attacks.) No wonder, you think, anxiety disorder patients have such a high rate of suicide: Anxiety is a horrible condition to try to live with because of its multiple physiological and psychological sequels! Fortunately, the new pharmacologic and psychotherapeutic treatments go far to alleviate the suffering that is caused by the anxiety disorders, as we will now review.
Life Events and Trauma
A significant minority of individuals who experience loss develop pathological reactions resembling anxiety or depression. The primary care physician must be able to intervene during the time of bereavement or catastrophic loss by listening empathetically and attentively. Patients will not discuss their feelings unless given permission to talk, and even a few minutes of face-to-face interaction can help the individual feel less alone and more cared for by the doctor. The elderly are particularly prone to anxiety and depression after the death of a spouse with whom they have spent most of their lives.
Murrey et al. found that 48.5% of women with an anxiety disorder in their sample had a history of childhood sexual abuse.17 Although sexual abuse has most frequently been linked with posttraumatic stress disorder, these investigators were surprised to find high rates of panic disorder, obsessive-compulsive disorder, and depression in this group. Moreover, samples of battered women,18 Vietnam war veterans19 and victims of political persecution20 also had an increased incidence of anxiety.
Anxiety may be prolonged and potentiated where there is a dearth of caretaking in the environment. For example, the patient may live alone or have few social interactions and even fewer close ties. In such cases, these patients should be encouraged to reach out for support; try to put yourself in their shoes. Since fear is the overriding emotion coloring the patient's experience, any way the clinician can help the patient feel safe enough to acknowledge that fear is an important first step. The physician needs to reach out, and not turn away from, the anxious individual, who benefits enormously from another human being who seriously listens to his or her concerns, neither laughing them off as ridiculous nor seeming to feel they are terribly unusual.
Educate the Patient About the Range of Available Treatments
At present, there are three highly effective and specific treatment modalities for anxiety disorders: (1) medication;21,22,23 (2) cognitive-behavioral therapy;24,25,26,27 and (3) psychodynamic treatment.28,29,30 The family or primary care physician in the position of initially suggesting such treatment should understand and be able to explain the approach of each type of treatment in a general way. However, it is best to refrain from "prescribing" a specific treatment since patients and anxiety disorders respond to different treatments differently, making it impossible to know, at initial intake, which interventions will most benefit a specific patient.
For more information on psychological and pharmacological treatment of anxiety, click here.
As clinicians, we are in a privileged position to help patients gain a better understanding and relief of the anxiety they may be experiencing. The medical professional can attain considerable satisfaction from making the diagnosis of anxiety and helping patients, who may be riddled with shame about anxiety and might otherwise suffer in silence without effective treatment.
Summary
Anxiety disorders are the most prevalent psychiatric disorders. They take a high toll on the sufferer's family and professional life, yet their substantial morbidity has been underappreciated.
The clinician must emphasize the accurate evaluation of the patient, especially focusing on differentiating anxiety from the many medical conditions that mimic it. Patients don't often seek help because they lack knowledge and are afraid of the associated stigma. Medical professionals need to pay especial attention to comorbidities (e.g., depression and substance abuse, suicide).
Both medical professional and patient need to be aware of the behavioral and pharmacological treatments now available that offer relief to the great majority of sufferers, but both should realize that the therapy will likely be long-term. Working with the patient, we can help them sort out stressful life events that precipitate attacks and emphasize the practice of problem-solving skills to relieve their anxiety. In this way, the medical professional can positively affect the quality of life for both the patient and their family.
For more information on anxiety disorders, as well as other psychiatric disorders, Dr. Zerbe has written Women's Mental Health in Primary Care, which is available at bookstores and on the Web.
references
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