Anxiety disorders are far and away one of the most frequent of mental health disorders. Often they are not recognized and/or treated within the context of the primary care setting, even though they tend to be chronic conditions that have significant impact on patients’ health and well-being.
Anxiety is a universal and highly adaptive experience, as it keeps us alert to real life dangers. Excessive and/or chronic anxiety, however, can be problematic as it reduces a person’s ability to function. Timely and effective intervention for anxiety disorders can have a dramatic positive impact on a patient’s life.
Core symptoms: The central psychological features of the anxious patient are feelings of nervousness and thinking that is constricted and dominated by worry. Other features may include ruminations, poor concentration, racing thoughts, panic and feelings of exhaustion. Physical features may include signs of over-arousal such as restlessness, muscle tension, sweating, tremor, pain, dizziness, and others. Some patients present with concern about psychological and emotional symptoms; others may present with predominantly with physical health complaints. Many suffer quietly. Acute and chronic anxiety can have significant negative impact on health conditions.
Multiple Subtypes: Anxiety disorders have many faces and it can be helpful to differentiate among the types.
Social Anxiety Disorder: shyness, embarrassment, physical distress associated with exposure
Obsessive Compulsive Disorder: thinking and action constricted, with distress and impaired functioning
Post-Traumatic Stress Disorder: past trauma exposure with ongoing distress, remembering, distress, arousal
Acute Stress Disorder: recent trauma–distress, arousal
Generalized Anxiety Disorder: pervasive and excessive worrying, typically without clear precipitant or trigger
Panic Disorder: florid episodes of intense anxiety with inter-episode apprehensiveness and anticipation
Adjustment Disorder: anxiety experienced in context of acute stressor which resolves as patient adapts or stressor abates.
1) Simply asking a patient about their level of emotional distress is an important first step in reaching a diagnosis and developing a collaborative treatment relationship.
2) Is the anxiety acute or is it chronic? Most patients report lifelong challenges with their anxiety symptoms.
3) Are there current life stressors—relationships, job, financial, other? Does the patient have natural supports or others (counselors, clergy, etc.) who can help?
4) Was there prior trauma or abuse? It is best to ask this question openly and directly to see if it could be a factor in the patient’s current symptom profile.
5) Is there a family history of similar problems? If so, what helped them?
6) Is there an underlying medical problem? The list is long but endocrine and other conditions may be of note.
7) Are symptoms being triggered by a medication given for a medical or another psychiatric illness?
8) Is substance abuse a contributing factor or a risk factor?
9) Are there other psychiatric issues—depression, mood problems, personality difficulties, etc.?
Treatment: Optimal treatment often entails a combination of education, psychotherapy and/or medication intervention. Psychotherapy alone can be highly beneficial with a focus on faulty thinking patterns, self-calming strategies, social engagement and other activities. Educational resources may prove useful even without formal therapy referral.
Psychopharmacology: SSRIs and SNRIs are the first line of long term medication treatment for most of the anxiety disorders– use with a low starting dose and slow gradual up-titration, as needed and tolerated. Monitoring symptom progression and side effects is necessary early on, but if treatment is effective, routine follow ups for refills can be done more episodically.
Judicious use of anxiolytic agents such as the benzodiazepines can be an important element in psychopharm management— occasional use of low dose, short acting agents is often quite helpful, but ongoing and increased use of these medications can lead to dependence and other problems. A patient needing to take multiple daily doses of a short acting agent for a sustained period needs attention. In some cases, routine use of longer acting agents may be appropriate, with periodic trials of dose reduction planned.