A panic attack is characterized by a discrete period of intense fear accompanied by the abrupt onset of several cognitive and somatic symptoms. Cognitive symptoms may include but are not limited to racing thoughts, preoccupation with health concerns, catastrophic misinterpretation of somatic symptoms, or believing one is going insane. Somatic symptoms may include a choking sensation, racing heartbeat, sweating, “jelly” legs, nausea, shaking, chest pain, numbness, or feeling detached or unreal. Frightening physical symptoms are commonly prominent and scare many patients into seeking urgent medical care. Primary care providers can usually be reassuring, as panic attacks are often infrequent, self-limited, and not related to any serious mental or physical disorder. Panic attacks are categorized as follows:
Unexpected (untriggered or uncued);
Situationally bound (always environmentally or psychologically cued); or
Situationally predisposed (sometimes, but not invariably, cued).
Panic attacks can be comorbid with a number of other anxiety disorders including social and specific phobias, OCD, and PTSD. The presence and type of a panic trigger help clinicians make a correct diagnosis. Uncued panic attacks are characteristic of PD, whereas cued attacks suggest other psychiatric conditions such as the following:
Social phobia (attack triggered by fear of embarrassment in social situations);
Specific phobia (fear of places or things);
OCD (triggered by exposure to the object of an obsession, such as contamination); or
PTSD (triggered by an event resembling the original trauma).
Panic attacks are quite common; most people experience a subclinical or limited-symptom attack at some time. Only about 9% of the general population ever experiences a full-blown panic attack.
Panic disorder is diagnosed when panic attacks are uncued and recurrent and are followed by a month or more of persistent fear of another attack or avoidance of situations because of fear of having another attack. Lifetime prevalence in the community is 2–4%, and about 3–8% of patients who present to primary care physicians meet current criteria. Panic disorder is approximately twice as common in women as among men. Community-based studies also reveal that suicide attempts are more common among patients with PD than among patients with major depression.
Panic disorder is a potentially debilitating disease with major complications. It leads to agoraphobia, a fear of being in a place or a situation where escape or rescue might be difficult if another attack occurs, in 30–50% of cases, most often within 6 months of the first panic attack. This fear may cause many patients to avoid important activities of daily living, such as shopping or using public transportation. Patients who develop PD as adolescents often develop depressive disorders in early adulthood.
Effective treatment exists for many of the anxiety disorders and has proved to be effective in clinical trials at reducing anxiety symptoms and in improving health-related quality of life and employment patterns. Appropriate treatment may also reduce substance use among patients who self-medicate with alcohol, benzodiazepines, or other substances in an effort to ameliorate their symptoms.
Initial management of the anxiety disorders begins with providing the patient with a clear understanding of the problem. This tends to ease anxiety, increase the strength of the therapeutic alliance, and the subsequent likelihood that the patient will adhere with the treatment plan. It may be helpful to emphasize the biological nature of PD, as most patients find it reassuring and destigmatizing to know that they have a recognized, treatable biological syndrome that typically has a good prognosis. Patients should also be referred to self-help books, support groups, and cognitive behavioral resources, which are widely available (see “Suggested Readings”).
In tailoring the treatment of PD to the patient, several factors should be weighed, including the degree of avoidance present, the severity of physical manifestations, and the comorbidity of other psychiatric disorders. The clinician must balance patient education and supportive counseling with patients’ beliefs about the cause of their symptoms. For example, if the physical symptoms are attributed to a cardiac problem, correcting this misinterpretation and emphasizing the biological basis of PD may help the patient accept the diagnosis and thus improve adherence to treatment. The primary physician has a vital role to play in many of the treatments, such as patient education, advice to avoid possible triggering substances (such as caffeine and cold medicines), supportive counseling, and initial pharmacotherapy, which can appropriately be incorporated into routine office visits.
Patients with PD often focus on the somatic symptoms of the disorder, thus presenting to medical settings with chest pain, dizziness, abdominal concerns, and other unexplained complaints. Iatrogenesis and unnecessary medical costs can and often do result from unnecessary procedures and treatments. The dilemma for clinicians, therefore, is to decide whether and how extensively to evaluate the patient’s specific symptoms.
One clinical strategy is to evaluate conservatively those symptoms that are potentially catastrophic, involve objective findings, or present as a classic constellation of symptoms. While the investigation is proceeding, the patient can be treated for PD and the symptoms periodically reassessed. Effective pharmacological treatment can reduce the cognitive and physical symptoms of panic and lessen the patient’s belief that the problem is caused by an undiscovered medical condition.
Medications used to treat PD include antidepressants, most commonly SSRIs and SNRIs, but tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) can also be used. Benzodiazepines (alprazolam, clonazepam) relieve symptoms rapidly, usually within the first week of treatment, and they have a relatively wide therapeutic index. Their main disadvantages are their potential for misuse and dependence, a high incidence of rebound panic attacks when the medication is discontinued, and interference with exposure-based CBT. In contrast, SSRIs, SNRIs, and TCAs are not associated with dependence and may have a synergistic effect with CBT, but generally take 3–4 weeks or longer before reaching maximum effectiveness. In addition, some antidepressants may exacerbate symptoms of anxiety during the first 1–2 weeks of administration.
A benzodiazepine can also be used in combination with either an SSRI or an SNRI (to avoid a “serotonin syndrome,” SSRIs and SNRIs should not be used in combination). Given the availability of several potential first-line agents believed to be of similar efficacy (Table 26-4), the clinician is advised to first inquire about past personal and family experience with pharmacotherapy, side effects, brand preference, and insurance formulary restrictions before suggesting a particular medication.
Table 26-4.Preferred anxiolytic medications for use in medical outpatients. ||Download (.pdf) Table 26-4. Preferred anxiolytic medications for use in medical outpatients.
|Generic Name ||Class ||Starting Dosage ||Step-up Dose ||Target Dose ||Top Dose/day ||Comment |
|First-line Agent |
|Citalopram ||SSRI ||10 mg qd ||10–20 mg/qd ||20–40 mg/day ||40 mg ||Possibly fewer cytochrome P450 drug interactions |
|Duloxetine ||SNRI ||20 mg qd ||20 mg/day ||30 mg bid or 60 mg qd ||60 mg bid ||FDA-approved for depression |
|Escitalopram ||SSRI ||5 mg qd ||5–10 mg qd ||10–20 mg/day ||20 mg ||Enantiomer of citalopram; possibly fewer cytochrome P450 drug interactions; FDA-approved for GAD |
|Fluoxetine ||SSRI ||10 mg qd ||10 mg/day ||20–40 mg/day ||80 mg ||Most activating of SSRI class; slower onset of action; FDA-approved for depression, PD, OCD, and bulimia |
|Paroxetine ||SSRI ||10 mg qd ||10–20 mg/day ||40 mg/day ||40 mg ||FDA-approved for depression, PD, GAD, PTSD, OCD, social anxiety; slightly sedating |
|Sertraline ||SSRI ||25 mg qd ||25 mg/day ||100 mg/day ||200 mg ||FDA-approved for depression, PD, OCD, PTSD, social anxiety |
|Venlafaxine XR ||SNRI ||37.5 mg qd ||37.5 mg qd ||75–150 mg qd ||225 mg ||FDA-approved for depression, PD, GAD. Social anxiety; may increase blood pressure at higher doses |
|Second-line Agent |
|Fluvoxamine ||SSRI ||50 mg qd ||50 mg bid ||50 mg bid ||300 mg ||FDA-approved for OCD, social anxiety (extended release) |
|Bupropion SR ||NDRI ||100 mg/day ||50 mg bid ||150 mg bid ||450 mg ||FDA-approved for depression; favored if comorbid depression; may induce seizures at higher doses in seizure-prone individuals |
|Nefazodone ||SARI ||100 mg bid ||50 mg bid ||150 mg bid ||600 mg ||Sedation prominent at start; FDA-approved for depression; possible hepatotoxicity |
|Alprazolam ||BZD ||0.25 mg bid–tid ||0.25 mg bid ||0.25 mg prn ||4 mg ||Short onset and duration of action; FDA-approved for anxiety and PD |
|Lorazepam ||BZD ||0.5 mg tid–qid ||0.5 mg qd ||1.0 mg tid ||10 mg ||Short onset and duration of action; FDA-approved for anxiety |
|Clonazapine ||BZD ||0.5 mg bid ||0.5 mg qd ||1.0 mg bid ||4 mg ||Longer onset and duration of action; FDA-approved for PD and anxiety |
|Third-line Agent |
|Buspirone ||Other ||5 mg tid ||5 mg qd ||20–30 mg bid ||60 mg ||Moderate efficacy compared to SSRIs; no antidepressant effect; FDA-approved for GAD only |
|Mirtazapine ||NaSSA ||15mg qhs ||7.5–15 mg qd ||45–60 mg qd ||60 mg ||Approved for treatment of depression. Commonly used for comorbid depression and anxiety; common adjunct with other antidepressants; inverse relationship between dose and sedation |
A common practice is to initiate treatment with a low daily dose of a generically available SSRI (e.g., escitalopram, 5 mg orally each day), titrating the dose slowly upward to 20 mg daily over 1–2 weeks as tolerated until symptom relief or the maximum dosage is attained, whichever arrives first. If the panic symptoms are particularly troublesome or if they worsen in the initial week of therapy, a benzodiazepine such as alprazolam or clonazepam can be added for more rapid control of symptoms and then tapered off and discontinued when the SSRI or SNRI commences effect. As with treatment of major depression, to avoid symptom relapse experts currently recommend that anxiolytic pharmacotherapy be continued for a minimum of 9–12 months, and longer if the symptoms are particularly disabling or recurrent, or per patient preference and ability to tolerate relapse.
Adjunctive cognitive behavioral interventions (e.g., relaxation training, challenging catastrophic thinking, and gradual exposures) can treat both the physical manifestations and avoidance behaviors and substantially decrease the likelihood of symptom relapse following discontinuation of pharmacotherapy. Patients should be helped to gradually face the situations and activities they feared and fully experience the physical sensations they once believed indicated a serious medical problem. For example, the patient in Case Illustration 1 would be encouraged to drive, shop, and manage other tasks outside her home while experiencing and eventually managing her shortness of breath, racing heartbeat, and sensation of fainting. If patients are at first overwhelmed by the prospect of doing this, they can first initiate exposure mentally, using relaxation techniques and guided imagery. The patient should be instructed to imagine a frightening but tolerable aspect of the activity (in this case, driving) while doing a relaxation exercise and to repeatedly visualize successfully coping with the activity. In some cases, it may be necessary to enlist the assistance of a cognitive behavioral therapist who can design and manage successive “exposure” exercises for overly frightened patients. Cognitive behavioral therapy and antidepressant medications have been found equally efficacious with combined CBT and antidepressants showing a modest advantage.
Specific phobias and social anxiety disorder (formerly known as social phobia) are characterized by episodic anxiety in response to specific precipitants. Stimuli for specific phobias include places, things, or events, such as airplane flights, heights, insects, snakes, or rodents. Affected individuals are aware that their fears are exaggerated or unreasonable; nonetheless, when exposed to the precipitant, patients experience intense, excessive fear subsequently leading to avoidance behaviors. Specific phobias are perhaps the most common but least disabling of the various anxiety disorders. Although many individuals have at least one, most experience only minor related dysfunction, and therefore seldom seek medical care. Indeed, when care is sought, the diagnosis is usually evident from the history and requires no further testing.
Social anxiety disorder involves excessive fear of embarrassment, failure, or humiliation before others. Social anxiety disorder is classified into one of the two subtypes—nongeneralized and generalized. The more common nongeneralized subtype may be manifested as a fear of speaking, performing, eating, or writing in public. Less often, it presents as a generalized type of anxiety that disables the patient in a wide range of social situations. Its physical symptoms include blushing, profuse sweating, trembling, nausea, and difficulty talking. Marked anticipatory anxiety can also cause avoidance behaviors that significantly disrupt patients’ functioning.
CASE ILLUSTRATION 2
Charlie, a man in his mid-thirties, presents to his primary care provider complaining of severe palpitations, sweating, and tremulousness. The symptoms occur when he is waiting in the customs line. As he approaches the front of the line, fear of evaluation and fear of talking with the customs official intensifies until the symptoms occur. Sometimes he flees to the end of the long line before he feels ready to face the customs official. Charlie realizes this cycle is silly and laughs anxiously as he describes it. This symptom is a major problem for him because his occupation is writing travel books. He has begun avoiding travel and is increasingly worried about his ability to meet writing deadlines and to continue working. A conservative medical workup is unrevealing, and the primary care provider makes the diagnosis of specific social anxiety disorder, prescribing a trial of alprazolam to be used a short time before standing in the customs line. Charlie is also given a self-help book and a tape on relaxation techniques and the use of guided imagery as a way of visualizing success in the customs line. Charlie uses these treatment approaches successfully on his next trip and realizes that the problem is controllable. He incorporates them into his routine work schedule, and within 2 months has returned to full occupational functioning.
Treatment of specific phobias and social anxiety disorder almost always involves some form of CBT, such as systematic desensitization, in which the patient is gradually exposed to the feared object or situation. Generally accepted pharmacotherapy guidelines have not been established for specific phobias. As noted in Case Illustration 2, patients with phobia and specific social anxiety disorder are often prescribed short-acting benzodiazepines (or beta-blockers) to be taken prior to an anticipated exposure to the phobic stimulus. Benzodiazepines are often given for exposures to infrequent events that have no complex performance requirements (e.g., traveling by commercial airplane). Patients should be informed of the risk of anterograde amnesia, or blackouts, associated with some of these drugs. Sertraline, paroxetine, fluvoxamine (extended release), and venlafaxine have all been Food and Drug Administration (FDA)-approved for the treatment of social anxiety disorder. Therapeutic effects typically occur within 2–6 weeks but may take up to 12 weeks. Although less data are presently available, the other SSRI and SNRI medications may be similarly effective at treating this disorder.
Patients with OCD experience regular, intrusive, anxiety-provoking thoughts—called obsessions—or are driven to repeatedly perform seemingly unnecessary or bizarre rituals—called compulsions. Aggression, sex, and religion are common obsessional themes. Compulsions may involve mental tasks, such as counting or praying, or they may involve physical rituals, such as repeated hand-washing or checking the state of an object. In patients with both obsessions and compulsions, the ritualized compulsions are usually performed to control the anxiety generated by the obsessive thoughts (e.g., obsessive fear about germs is eased by compulsive hand-washing). Although patients’ level of insight is typically high—they generally experience obsessions and compulsions as intrusive, upsetting, and silly—such insight may diminish acutely when they are faced with the focus of an obsession. They may also become so preoccupied with their obsessions and compulsions that they become extremely anxious, slow, and disabled. In one instance, a patient wrung her hands so constantly she could not cook, work, or sleep. Another washed his hands every 10–15 minutes, which interfered significantly with his normal business and social activities.
Until the introduction of effective pharmacotherapies for OCD, the disorder was markedly underrecognized in both primary care and psychiatric practice. About 1–3% of the general population develops OCD during their lives. The disorder has been found to have a distinct biological component, a finding supported by the efficacy of biological therapies that selectively inhibit the reuptake of serotonin at CNS neurosynapses, and twin studies that show a significantly higher percentage of monozygotic twins with diagnostic concordance than dizygotic twins. Additionally, there is a distinct and reciprocal association between OCD and Tourette syndrome, a neurologic disorder involving persistent motor and verbal tics.
Psychotherapy for OCD often involves a form of CBT called “exposure with response prevention” in which the patient is exposed to the anxiety-provoking obsessions or situation but does not engage in the subsequent compulsions or other maladaptive strategies to manage the anxiety. Patients are taught alternate ways of coping with the anxiety including diaphragmatic breathing and progressive muscle relaxation. The cognitive behavioral therapist may also guide the patient in identifying faulty beliefs and assist the patient in testing those beliefs. The belief, “something terrible will happen if I don’t check my lock a hundred times a day,” is first rationally examined, then a behavioral test of that belief is collaboratively designed and executed—much as a scientist would design and run a test for any hypothesis.
Selective serotonin reuptake inhibitors inhibit presynaptic reuptake of serotonin and are effective in treating OCD. In addition, clomipramine, the only TCA with this quality, is also effective. Selective serotonin reuptake inhibitors have the advantages of ease of dosing and low toxicity in overdose. FDA-approved SSRIs for treatment of OCD include fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft). The dual SNRIs (venlafaxine and duloxetine) may also have efficacy in OCD. However, neither has yet been FDA-approved specifically for treatment of OCD. A recent meta-analysis recommends antipsychotic (haloperidol and risperidone) augmentation of SSRIs for treatment-refractory OCD.
Posttraumatic Stress Disorder & Acute Stress Disorder
Posttraumatic stress disorder (PTSD) and acute stress disorder (ASD) are the common mental sequelae of catastrophic trauma. Acute stress disorder involves symptoms that occur within the first month after trauma. Posttraumatic stress disorder is essentially the same syndrome, but beginning or persisting beyond a month. Severe trauma of either ASD or PTSD entails exposure to actual or threatened death, serious injury or sexual violation. Patients subsequently develop a mix of flashbacks, nightmares, persistent avoidance of stimuli resembling (concretely or symbolically) the precipitating event, numbing of general responsiveness (restricted range of affect, feelings of interpersonal estrangement, anhedonia), and persistent signs and symptoms of physiologic arousal. Secondary depression, panic attacks, substance abuse, unexplained physical symptoms, and aggressive behavior may also be present.
Epidemiologic studies suggest that about one-third of the population suffers some trauma, placing them at risk for PTSD, and one-fourth of those at risk will develop PTSD, usually within 1 year following exposure to the event, although on occasion, it may develop years after the event. While men experience more lifetime trauma, women in the general population are more likely to develop PTSD. Women have a 10% lifetime prevalence of PTSD, double that of men. The prevalence of PTSD is considerably higher among certain groups including 18% among professional firefighters, 34% in adolescent survivors of motor vehicle crashes, 48% in female rape victims, and 67% in former prisoners of war.
CASE ILLUSTRATION 3
Jacques was a successful accountant with no psychiatric history until he had mitral valve surgery at the age of 42 years. Subsequently, he became totally dysfunctional, losing jobs and clients. He now also suffers flashbacks about the postoperative period of pain and confusion. Jacques gradually became depressed, and his obnoxious, angry behavior alienated both friends and providers.
Jacques’ primary care physician noted a change in his demeanor during a conversation at a routine follow-up visit to monitor his chronic anticoagulation therapy for his replacement valve. The physician asked Jacques how work was going for him since his return following surgery. Then Jacques began to disclose his personal fears and perceived failures triggered by the traumatic brush with serious illness and fear of a stroke caused by his replacement valve. His doctor then helped Jacques recognize the role of the surgical trauma event in his life and explained the potential for improvement with psychotherapy and pharmacotherapy for his symptoms. Jacques subsequently accepted referral to an established multidisciplinary treatment program for PTSD.
Treatment of PTSD typically begins with a detailed evaluation and development of a treatment plan to meet the unique needs of the survivor. This is best accomplished with a multidisciplinary team that may include the primary care physician, a mental health professional, an addiction specialist, a social worker, and possibly community-based referral resources such as theme counseling groups (e.g., veterans groups and abuse-survivor groups). PTSD-specific treatment typically begins after the patient has been safely removed from the crisis situation. If the patient is still being exposed to trauma (e.g., ongoing domestic violence), or is severely depressed, experiencing extreme panic, suicidal, or is in need of drug or alcohol detoxification, then it is important to address these issues as a part of initial treatment.
It is generally helpful to label the problem as PTSD and thus legitimize the manifestations, as patients often blame themselves or others. Thus, the physician might say to the patient, “The kinds of feelings, thoughts, and problems you’re having are not unusual—in fact they’re fairly common among people who have gone through a catastrophe.” Support groups of persons who have suffered similar trauma help patients feel understood and normalize their symptoms as they share their experiences and solve problems together. Cognitive-behavioral therapy is the nonpharmacological treatment of choice for PTSD where patients are taught behavioral skills to manage their autonomic hyperarousal, and then are guided through repeated and desensitizing retellings of their traumatic experience.
Pharmacotherapy can reduce the anxiety, depression, and insomnia often experienced by patients with PTSD. Although no particular drug has emerged as a definitive treatment for PTSD and its associated flashbacks and nightmares, currently, only sertraline and paroxetine have been FDA-approved for the treatment of PTSD. Initial trials of venlafaxine have shown promising results. Benzodiazepines have also been used to treat the anxiety, hyperarousal, and insomnia of PTSD. However, early and prolonged use of benzodiazepines to treat ASD may actually be associated with a higher rate of subsequent PTSD. Thus, it is recommended that benzodiazepines be reserved for time-limited treatment of extreme arousal, insomnia, and anxiety.
Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) consists of almost constant, nonepisodic worry and anxiety that affects patients for more than 6 months and interferes with normal functioning. The worry and anxiety are difficult for the patient to control and are associated with edginess or restlessness, easy fatigability, difficulty concentrating, irritability, muscle tension, or sleep disturbance. Worries typically involve multiple domains and may include concern about routine life circumstances, with the magnitude of worry being out of proportion to the severity of the situation. Symptoms must not be due to the physiologic effects of a medical problem, such as hyperthyroidism or abuse of a medication or drug. Patients with GAD usually complain of feeling “up-tight” or constantly nervous. Physical symptoms such as muscle aches, twitching, trembling, sweating, dry mouth, headaches, gastrointestinal symptoms, urinary frequency, and exaggerated startle often accompany the disorder and are often the patient’s presenting complaint.
General anxiety disorder has a lifetime prevalence of 4–6%, and two-thirds of those affected are women. The disorder tends to have a chronic, fluctuating course that worsens under stress. Approximately half of all cases are comorbid with depression.
Short-term supportive psychotherapy can be helpful. Many patients with GAD have focal life conflicts or stressors for which psychotherapy may be helpful. Basic primary care strategies include empathic listening; encouragement; and assisting patients to identify problems, discuss possible solutions, and solve the problem. Cognitive behavioral techniques can be used to help patients examine the catastrophic beliefs that underlie their unrealistic worries. Biofeedback and relaxation techniques are useful for improving patient control over muscle tension and other physiologic signs of anxiety.
Several SSRIs and benzodiazepines, venlafaxine, and the nonbenzodiazepine anxiolytic buspirone are all FDA-approved for treatment of GAD. Benzodiazepine therapy at doses lower than those required for PD is usually rapidly effective with few adverse effects. Sedation is the most common side effect but diminishes over time. Tolerance to therapeutic effects is minimal. Minimum effective doses should be used, but care must be taken not to undertreat patients out of fear of making them drug dependent. As with benzodiazepine treatment for other anxiety disorders, rebound symptoms of anxiety are the rule as medication is discontinued. Often a lengthy (a month or more) taper is required.
Buspirone is a nonsedating medication specifically indicated for patients with GAD. It alleviates the symptoms of this anxiety disorder but like the SSRIs and venlafaxine has a similarly slow onset of action to reach efficacy. Unlike these other medications, buspirone also requires twice daily dosing, which may adversely affect patient adherence. Importantly, it only has moderate efficacy compared with the SSRIs, and it lacks an antidepressant effect placing it at a disadvantage for patients with comorbid depression.
Adjustment Disorder With Anxiety
Adjustment disorder with anxiety should be considered in patients who are responding with maladaptive anxiety to a recent situational stressor but who do not meet the criteria for another mental disorder. The stressor may be a medical event (e.g., surgery, hospitalization, onset of an illness), but most often is a personal crisis such as a divorce, financial problems, or a job change. Symptoms usually begin within 2 months of the onset of the stressor and significantly impair social or occupational functioning. If symptoms persist for more than 6 months, then another diagnosis, such as GAD, is usually more appropriate. Sleeplessness and the physiologic aspects of anxiety predominate, and the patient may seek care for somatic complaints. Eliciting the history of the stressful life event and ascertaining the relationship of symptoms to that event help to establish this diagnosis.
The fundamental management of adjustment disorder with anxious mood is supportive counseling, in which the patient discusses the stressful event and the provider helps the patient actively identify and solve problems and/or find ways to more effectively manage the stress (e.g., more effectively access social supports or engage in pleasant activities). Patients with adjustment disorder are generally well cared for by a primary care physician who has learned the details of the precipitating event and can incorporate brief supportive strategies into the office visit. Structured relaxation exercises and stress management or other support groups may also be helpful. Sometimes a brief trial of benzodiazepine (less than 3 weeks) can help improve patient coping by reducing the debilitating stress-related symptoms (e.g., insomnia or overwhelming fear). Referral to mental health professionals may help if patients do not respond quickly, are severely incapacitated, show a repetitive pattern of maladaptive coping, or specifically request a therapist.
Many studies suggest that there is a substantial group of primary care patients who present with relatively minor complaints of anxiety and depression. Although they do not satisfy criteria for a mental disorder, they do experience associated poor functioning. Often psychosocial stressors or chronic medical problems exacerbate the emotional symptoms. Generally speaking, effective management should emphasize supportive psychosocial rather than pharmacological interventions.