Issues of Anxiety in Primary Care Patients 11/21/2019

Anxiety is a normal and adaptive aspect of life for everyone. A little bit helps keep us safe, but excessive anxiety can be harmful. It can be a sign of a psychiatric disorder and/or it can be a trigger for (or a symptom of) an organic illness. Many medications can trigger anxiety symptoms. Understanding how and why anxiety may be manifest in a variety of medical and behavioral health conditions can be quite helpful in all aspects of medical care.

Anxiety Disorders are common: Unfortunately, many individuals experience elevated levels of anxiety and the overall prevalence of anxiety disorder is significant: the prevalence for Generalized Anxiety Disorder (GAD) patients in the general primary care population is in the 3-8% range; that of Post-Traumatic Stress Disorder (PTSD) is 3-7% and that of Panic Disorder is around 5%, with some overlap for co-morbidity across these disorders.

Anxiety’s impact on physical health: Each of the anxiety disorders have both psychological and physiological impact, with findings that show increased risk for GI, respiratory, cardiac, neurological, and other health disorders. While the specific etiologic links between anxiety disorders (and many other psychiatric disorders) and these various medical conditions is not clear, possible mechanisms of action include excessive sympathetic activation, alteration of inflammatory response, altered hypothalamic-pituitary-adrenal functioning, and problematic behaviors such as substance abuse or reduced compliance with medical treatment. In these situations, appropriate treatment of the anxiety disorder with psychotherapy and/or medication may be of double benefit—improving psychosocial functioning and reducing risks to physical health status.

Anxiety presenting as a medical disorder: The somatic signs and symptoms of anxiety can mimic organic ailments – these include tachycardia, palpitation, sweating, flushing, dry mouth, dizziness, tremor, muscle tension, headache and fatigue. Patients with panic disorder in particular not infrequently present with complaints of a suspected heart attack or other catastrophic illness.

Anxiety as a presenting symptom in organic illness: The primary care patient may experience symptoms of anxiety as part of their coping with being ill, but it is not uncommon for anxiety to present as a consequence of an underlying medical problem. Among the illnesses where patients may present with anxiety as a significant part of their clinical presentation include: cardiac illnesses (valvular disease, arrhythmia, angina, etc.); endocrine disturbances (diabetes, thyroid, pheochromocytoma, etc.); GI ailments (GERD, IBS, ulcer); neurologic conditions and others.

Anxiety as a side effect of commonly used medication used in treating organic ailments: Examples include: hormones, anti-migraine agents, steroids, sympathomimetics, NSAIDS, Class I and Class V antiarrhythmics asthma medication and OTC medications that contain caffeine. Some psychotropics also may contribute to anxiety.

Take home: Be alert to the many faces and places where anxiety needs to be considered—

  •  as primary mental health disorder,
  •  as a symptom of an organic ailment,
  •  as an impersonator of an organic ailment, or
  •  as a side effect of medication prescribed.

Reference: “Managing Anxiety in the Medically Ill”, Dong, Noorani, et al in Psychiatry Times, January 2015,

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