Anxiety
Anxiety: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Thomas L. Campbell
Anxiety disorders, which are among the most common problems seen in primary care, occur in approximately 10% of patients. Anxiety disorders are associated with significant impairments in physical and emotional health, comparable to the impact of common chronic medical illness (e.g., diabetes and coronary heart disease). Anxious patients are often high utilizers of healthcare services and they generate high healthcare costs. The effective recognition and management of anxiety disorders can reduce medical and psychiatric morbidity and lower healthcare costs (1).
Approach.
Most anxious patients in primary care present with somatic rather than psychological symptoms and may have associated comorbid conditions, either medical or psychiatric illness. These factors can obscure the diagnosis of anxiety and lead to excessive medical workup and improper treatment. For patients who present with chest pain, dizziness, or chronic abdominal pain, it may be particularly challenging to differentiate organic illness from anxiety disorders. Of 40% to 60% of patients with atypical chest pain and normal coronary angiograms, 20% of patients referred for dizziness, and 30% of patients with irritable bowel syndrome have been found to have panic disorder (2).
First, determine whether a patient’s anxiety is dysfunctional, that is, whether it is excessive and interferes with normal functioning. “Normal” anxiety is a useful defense that helps us escape from current or future dangers (i.e., fight or flight reaction). Next, determine whether the anxiety symptoms are secondary to organic causes (e.g., an ingested substance such as caffeine or amphetamines) or a medical illness (e.g., hyperthyroidism, hypoxia), or whether they are associated with another psychiatric disorder (e.g., depression, substance abuse). The onset of anxiety symptoms after the age of 35 years, lack of personal or family history of an anxiety disorder, and absence of precipitating events are indicative of a possible organic anxiety syndrome. Of patients with an anxiety disorder, 50% also have major depression.
History.
The most common physical symptoms associated with anxiety disorders include palpitations, shortness of breath, dizziness, sweating, and abdominal and chest pain. Common psychological symptoms can include shakiness, nervousness, fear of dying or going crazy, derealization, or depersonalization. Some patients attribute their anxiety to their physical symptoms (“Of course, I was anxious. I thought I was having a heart attack”).
The assessment of anxiety disorders should include the nature, frequency, and duration of symptoms, precipitants, and impact of symptoms. A careful review of all medications (esp. stimulants, sympathomimetics, xanthines) and use of legal (e.g., caffeine) and illegal (e.g., cocaine) substances is essential. Comorbid medical and psychiatric illnesses should be assessed. The following symptoms should be specifically solicited: discrete episodes of severe anxiety (panic), intense fear of social settings, specific fears or phobias, obsessions or compulsions, and nightmares or flashbacks.
Physical examination.
The extent of the physical examination or medical workup depends on the age of the patient, severity of symptoms, and presence or suggestion of comorbid medical illnesses (3). Although many patients with chronic medical illnesses may suffer from anxiety, relatively few medical illnesses
directly cause anxiety. These include hyperthyroidism, hyperparathyroidism, tachyarrhythmias, and hypoxia from any cause (esp. chronic obstructive pulmonary disease).
Testing.
Laboratory and other medical tests depend on clinical suspicion and the presenting physical symptoms. Hematocrit, thyroid stimulating hormone, and serum calcium are often all the laboratory testing that is necessary. Older patients who present with physical symptoms, especially chest pain, may need more extensive medical evaluation before assuming that the symptoms are caused by the anxiety disorder. For example, an anxious patient with atypical chest pain, aged more than 40 years or with cardiac risk factors, may need an exercise stress test before assuming the chest pain is not cardiac.
Diagnostic assessment.
Once it has been determined that the patient has a primary anxiety disorder, the following specific disorders should be considered (4) (Table 3.1).
A. Adjustment reaction with anxious features describes a condition in which the patient is experiencing clinically significant anxiety in reaction to a specific stressor, such as a major life event or interpersonal conflict. This diagnosis, which describes a more severe form of “normal” anxiety, responds to reassurance and short-term anxiolytics.
B. Panic disorder is characterized by recurrent, spontaneous, and discrete episodes of intense anxiety associated with symptoms of autonomic arousal (panic attacks). Patients usually present with physical symptoms such as chest pain, dizziness, and shortness of breath. They may also develop anticipatory anxiety or agoraphobia, in which they avoid situations that may precipitate a panic attack (such as crowds). Panic disorder is usually very responsive to medication (antidepressants or benzodiazepines). Panic attacks can also be experienced in association with other anxiety disorders.
C. Generalized anxiety disorder (GAD) is a chronic condition of at least 6 months duration, in which exists persistent, excessive worry or anxiety about several areas of life, often including physical health. These patients may be excessively worried about physical symptoms (i.e., hypochondriasis) and become high medical utilizers. Many patients on chronic benzodiazepines have generalized anxiety disorder. Often coexisting with other anxiety disorders, depression, or substance abuse, GAD is difficult to treat, but responds to medication and psychotherapy.
D. Obsessive-compulsive disorder is characterized by recurrent, intrusive thoughts (obsessions) and compulsive behaviors or rituals. These symptoms must be specifically elicited, as these patients rarely present with these complaints. Handwashing is a common compulsion, and patients may present with severe hand dermatitis from repeated washings.
E. Posttraumatic stress disorder (PTSD) causes persistent reexperiencing of traumatic or violent events through flashbacks or nightmares with associated autonomic arousal. Patients avoid any stimuli that may be associated with the trauma. It is often associated with irritability, hypervigilance, and sleep disturbance. It occurs most commonly in veterans, refugees, and victims of domestic violence and child abuse. Substance abuse, depression, and other anxiety disorders are often associated with PTSD. No reliable effective treatment exists for PTSD, although antidepressants seem to be helpful.
F. Social phobias occur in patients who suffer severe anxiety in social settings, especially when they are exposed to unfamiliar people. These patients usually avoid any social situations. Social phobias respond well to cognitive-behavioral therapy and serotonin-selective reuptake inhibitors.
G. Specific or simple phobias are characterized by marked and persistent fears of specific situations or objects that interfere with the patient’s life. Common phobias include fear of heights, closed spaces, flying, and specific small animals (e.g., spiders, snakes). They often develop in childhood as a result of a traumatic event associated with the situation or object. They are treated by cognitive-behavioral therapy.
References
1. Barlow DH. Anxiety and its disorders. New York: Guilford Press, 1988.
2. Stern TA, Herman JB, Slavin PL. MGH guide to psychiatry in primary care. New York: McGraw-Hill, 1998.
3. Knesper DJ, Riba MB, Schwenk TL. Primary care psychiatry. Philadelphia: WB Saunders, 1997.
4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994.
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Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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