Anxiety Disorders

Essentials of Diagnosis

• Persistent excessive anxiety or chronic fear and associated behavioral disturbances

• Somatic symptoms referable to the autonomic nervous system or to a specific organ system (eg, dyspnea, palpitations, paresthesias)

• Not limited to an adjustment disorder

• Not a result of physical disorders (eg, hyperthyroidism), other psychiatric conditions (eg, schizophrenia), or drug abuse

General Considerations

• Anxiety disorders include

  • Generalized anxiety disorder (GAD)

  • Panic disorder

  • Phobic disorder

• GAD

  • Everyday activities trigger symptoms

  • Symptoms present on most days for at least 6 months

• Panic disorder

  • Symptoms occur in recurrent episodes with unpredictable triggers

  • Somatic symptoms are often marked

• Phobic disorder

  • Symptoms occur predictably

  • Follows exposure to certain objects or situations

Demographics

• About 7% of women and 4% of men will meet criteria for GAD over a lifetime

• Prevalence of panic disorder: 3–5%, 25% with coincident obsessive-compulsive disorder

Symptoms and Signs

• Anxiety or fear

• Apprehension or worry

• Difficulty concentrating

• Insomnia and fatigue

• Irritability

• Feelings of impending doom

• Recurrent thoughts or fears

• Repetitive actions and rituals

• Avoidant behaviors

• Sympathomimetic symptoms

  • Tachycardia

  • Hyperventilation

  • Tremor

  • Sweating

• Somatic symptoms

  • Paresthesias

  • Dizziness

  • Nausea

  • Chest pain

  • Palpitations

Differential Diagnosis

• Hyperthyroidism

• Pheochromocytoma

• Sympathomimetic drug use

• Myocardial infarction

• Hypoglycemia

• Adjustment disorder

Laboratory Tests

• Serum thyroid-stimulating hormone

• Complete blood count

• Toxicology screen (if drug abuse is suspected)

• Blood glucose

Imaging Studies

• Chest radiograph may be indicated

• Head CT may be useful in dissociative symptoms to rule out temporal lobe lesion

Diagnostic Procedures

• ECG

• Electroencephalogram may be useful in dissociative symptoms to rule out temporal lobe lesion

Medications

• See Table 25–1

• GAD

  • Antidepressants (including the selective serotonin reuptake inhibitors [SSRIs] and serotonin norepinephrine reuptake inhibitors [SNRIs]) are safe and effective; they appear to be as effective as the benzodiazepines without the risks of tolerance or dependence

  • SSRIs, such as escitalopram and paroxetine, are FDA-approved

  • SNRIs

    • Venlafaxine (start 37.5–75.0 mg once daily orally)

    • Duloxetine (start 30 mg once daily orally)

    • Some patients may find the more noradrenergic SNRIs such as levomilnacipran too activating to tolerate

  • Buspirone

    • Sometimes used as an augmenting agent in the treatment of depression and compulsive behaviors

    • Also effective for generalized anxiety

    • Usually given in a total dose of 30–60 mg/day in divided doses

    • Higher doses are sometimes associated with side effects of gastrointestinal symptoms and dizziness

• Panic disorder

  • SSRIs

    • Fluoxetine

    • Paroxetine

    • Sertraline

  • SNRI

    • Venlafaxine

  • Benzodiazepines

    • Clonazepam and alprazolam

    • Use early in the course of treatment in combination with antidepressant

    • Once the antidepressant has begun working after 4 or more weeks, the benzodiazepine may be tapered off

• Panic attacks

  • Beta-blockers

    • Propranolol, 40–160 mg/day orally

    • Can mute the peripheral symptoms of anxiety without significantly affecting motor and cognitive performance

    • Blocks symptoms mediated by sympathetic stimulation (eg, palpitations, tremulousness) but not nonadrenergic symptoms (eg, diarrhea, muscle tension)

    • Does not cause depression as a side effect and can be used cautiously in patients with depression

    • SSRI or SNRT antidepressants have been used in conjunction with β-blocker in resistant cases

• Phobic disorder

  • Antidepressants

    • SSRIs (paroxetine, sertraline, fluvoxamine)

    • Monoamine oxidase inhibitors

    • SNRIs (eg, venlafaxine)

  • Beta-blockers

    • Propranolol 20–40 mg orally 1 hour before exposure for specific phobias (eg, performance)

  • Gabapentin (300–3600 mg/day depending on response versus sedation) for social phobia

Therapeutic Procedures

• Behavioral/cognitive therapeutic techniques

  • Frequently used in conjunction with medical therapies

  • Relaxation techniques (particularly effective for physiologic symptoms in panic disorder)

  • Desensitization strategies (graded exposure to phobic object)

  • Emotive imagery (imagining anxiety-provoking situation while using relaxation techniques)

  • Acceptance and commitment therapy (ACT)

    • Has been used with some success in anxiety disorders

    • Individuals are encouraged to keep focused on life goals while they "accept" the presence of anxiety in their lives

• Social therapeutic techniques

  • Support groups

  • Family counseling

  • School, vocational counseling

• Exercise, both aerobic and resistance training, have demonstrated effects in reducing anxiety symptoms across many anxiety disorders

Follow-Up

• Every 1–2 weeks until stabilized, then as agreed upon with patient

Complications

• Alcohol and substance abuse

Prognosis

• Usually long-standing and difficult to treat

• All disorders relieved to varying degrees by medication and behavioral techniques

When to Refer

• Refer to a psychiatrist

  • If the diagnosis is in question

  • To receive recommendations on therapy

  • If first-line therapy has failed

  • If patient presents with management problems