Anxiety

Objectives

          1. Identify the common presentations of anxiety in an outpatient setting.
          2. Discuss the diagnostic criteria for generalized anxiety disorder.
          3. Discuss the common therapies available for the treatment of anxiety.

 


Chief Complaint

Anxiety disorders are very common among primary care patients. However, similar to depression, anxiety is poorly recognized by the patient and requires a high degree of suspicion for diagnosis. Patients with anxiety may present with a complaint of excessive worrying but they are more likely to report various somatic complaints, such as palpitations, insomnia or exhaustion, or gastrointestinal disturbances.


Past Medical History/Review of Systems

Chronic medical conditions are often comorbid with anxiety. Patients with hypertension, diabetes, or chronic obstructive pulmonary disease are more likely to develop an anxiety disorder, and vice-versa. Anxiety does produce physical symptoms which can be confused with the presentation of a wide variety of medical conditions, especially those highly associated with stress. Consider endocrine (thyroid disorders, pheochromocytoma, or disturbances in sugar metabolism), cardiovascular (dysrhythmias, CHF), and neurologic disorders.

The presentation of anxiety may be confused by the presence of comorbid psychiatric disorders as well, such as depression or substance abuse. In particular depression and anxiety are noted to often be comorbid and may need to be addressed separately.

Symptoms which are associated with anxiety include:

  1. Excessive physiologic arousal
    • muscle tension
    • irritability
    • fatigue
    • restlessness
    • insomnia
  2. Distorted cognitive processes
    • poor concentration
    • unrealistic assessment of problems
    • worries
  3. Poor coping strategies
    • avoidance
    • procrastination
    • poor problem-solving skills

    Gliatto, Michael F. Generalized Anxiety Disorder. Am Fam Physician. 2000;62:1591-600, 1602.

While investigating possible anxiety, remember that all normal humans eventually experience these symptoms to some degree. What makes the process pathologic is the length of time it occurs (at least six months) and the fact that the anxiety interferes with normal daily functioning.

Keep in mind, as well, that patients with anxiety will often present with complaints of one symptom but will not mention the others they are experiencing. Inquire specifically for each symptom when anxiety is suspected.


Current Medications

Common Medications that can Cause or Worsen Anxiety:
Drugs of Abuse Amphetamine-like drugs
  Anabolic steroids
  Cocaine
  Caffeine
  Opoids
  Withdrawal from alcohol or other drugs of abuse
Sympathomimetics Baclofen
  Pseudoephedrine
Antihypertensives beta-Adrenergic blockers
Neurologic and psychiatric medications Bromocriptine (Parlodel)
  Buproprion (Welbutrin)
  Methylphenidate (Ritalin)
Table 21-5, pg 349 - Nease, Don. Anxiety and Depression. In: Sloane, P, et al., eds. Essentials of Family Medicine. 4th ed. Lippincott Williams & Wilkins. 2002. pp 345-355.

 


Physical Examination

Physical examination in the work-up of anxiety should be directed at excluding possible medical conditions in the differential. Many of the conditions listed in the differential for anxiety are uncommon and exhaustive testing is not usually necessary in the absence of corroborating evidence from the history or physical examination.


Testing

There are no routinely recommended laboratory tests for evaluating anxiety. Your laboratory studies should be based on ruling out portions of the differential diagnosis and guided by suggestive findings in the history and physical examination.

Screening questionnaires filled out by the patient and reviewed by the physician may pick up symptoms of depression or anxiety. One of the more talked of ones is the PRIME-MD (The Primary Care Evaluation of Mental Disorders). Unfortunately I do not have an example of the questionnaire to show you, but you may find the following links to be helpful.


Diagnosis

Anxiety is a clinical diagnosis based on fulfilling the criteria listed by the DSM-IV.

Three of the six symptoms listed (in children - one symptom) must have been present more days than not for at least six months in order to diagnose Generalized Anxiety Disorder.


Appropriate Therapy

Psychologic

Education - There is still a very strong stigma associated with mental illness in our society. Many patients may resist the idea that their complaints stem from a psychiatric rather than medical diagnosis. Patient explanation of the disease process and reassurance that effective treatment is available can do much to reassure the patient and improve compliance.

Psychotherapy

Cognitive Behavioral Therapy (CBT) - This psychotherapeutic approach has been shown in studies to be effective in treatment of anxiety and depression. The method focuses on identifying and desensitizing worried thoughts.

Relaxation techniques - In conjunction with CBT or alone, relaxation techniques may be helpful in relieving some of the symptoms resulting from excessive physiologic arousal in anxiety.

Pharmacologic

Patients with significant impairment of daily functioning should be considered for pharmacologic therapy. It is recommended that treatment, once initiated, continue for at least six months in order to reduce the risk of relapse.

The following table is NOT comprehensive. It lists some of the more commonly used medications for anxiety.

Class Examples Indications Common Usage Side Effects (Not all side effects are listed here. Always review the possible side effects prior to prescribing a medication.)
Benzodiazepines

Alprazolam (Xanax)

Anxiety disorders, short-term relief of anxiety symptoms, panic disorder with and without agoraphobia

This class is the most effective at providing symptomatic relief quickly to patients. However, it has a large abuse potential and many physicians are increasingly wary of initiating therapy with this class. The most effective use of these agents may be in the short-term relief of symptoms while awaiting relief from a long-term agent.

Tolerance and dependence develop easily in this class of medications. Be wary of drug interactions. Patients with a history of substance abuse should avoid use of this class if possible. Warn the patient against driving and operating heavy machinery while taking medication. Taper the dosage slowly when discontinuing the medication in order to decrease the risk of withdrawal symptoms and rebound anxiety.

Chlordiazepoxide (Librium) Anxiety disorders, short-term relief of anxiety symptoms, withdrawal symptoms of acute alcoholism, preoperative apprehension and anxiety
Clonazepam (Klonopin) panic disorder with or without agoraphobia
Diazepam (Valium) Anxiety disorders, alcohol withdrawal, short-term relief of anxiety symptoms, adjunct prior to endoscopic procedures, surgical procedures, and cardioversion, adjunct therapy in skeletal muscle spasm
Lorazepam (Ativan) anxiety
Atypical Anxiolytic Buspirone (Buspar) Anxiety disorders, short-term relief of anxiety symptoms

Buspar is most commonly used for chronic anxiety in patients. It is especially helpful for patients who have relapsed after a course of therapy with a benzodiazepine. Its onset of action may be delayed as long as 2 to 3 weeks and patients may require short-term therapy with another agent in the interim.

Dizziness, headache, nausea, nervousness, lightheadedness, excitement.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Sertraline (Zoloft)

Panic disorder with or without agoraphobia, posttraumatic stress disorder

This class is perhaps the most popular for first line treatment of depression with or without anxiety. The comparatively favorable safety profile and low potential for tolerance make this a popular class for anxiety disorders as well.

For patients with comorbid depression, this class should be considered for first line therapy.

May be associated with undesirable behavioral changes (nervousness/anxiety, increased energy, restlessness/akathisia, insomnia, irritability/agitation, silliness/euphoria, disinhibition).

Sexual dysfunction may occur and can be extremely distressing to the patient.

Paroxetine (Paxil) Panic disorder with and without agarophobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder
Serotonin and Norepinephrine reuptake inhibitor Nefazodone (Serzone) Depression Although it is an off-label use, physicians are using Nefazodone to treat some cases of anxiety.

Use cautiously in patients with cardiovascular disorders. Has a risk of priapism, nausea, dry mouth, dizziness, postural hypotension, and constipation.

Monitor blood pressure closely - may cause sustained increases. Risks include sweating, nausea, constipation, anorexia, sexual dysfunction, and dream disturbance.

Venlafaxine (Effexor)

Depression, Generalized Anxiety Disorder

Venlafaxine was the first medication to have an official indication for both depression and anxiety. Unfortunately its cost may be prohibitive for many patients.

 


Goals of Therapy


Appropriate Follow-up

When first diagnosed and treatment initiated, patients need frequent follow-up. Depending on the medication used, relief from symptoms may take as long as 2-6 weeks. Patients may also benefit from encouragement, especially if resources for counseling are limited.

Once symptoms have begun to remit, the patient may be scheduled for follow-up at 2-4 month intervals. Reassess the patient's need for medication and consider tapering dose at 6-month intervals.


See Also - Depression


References/Links

AAFP Video CME Program - Generalized Anxiety

NIMH - Anxiety Disorders

Nease, Don. Anxiety and Depression. In: Sloane, P, et al., eds. Essentials of Family Medicine. 4th ed. Lippincott Williams & Wilkins. 2002. pp 345-355.

Gliatto, Michael F. Generalized Anxiety Disorder. Am Fam Physician. 2000;62:1591-600, 1602.


D.L. Powell, MD
updated 8/12/05


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