Approach to the Patient with Anxiety
John J. Worthington III
Anxiety disorders are prevalent (the estimated lifetime prevalence is 29% in the general population) and a frequent precipitant of visits to the nonpsychiatric physician. Evaluation and management can be challenging because patients present with feelings of distress and concern about disease in the absence of objective evidence. Suffering no less from the subjective nature of their ailment, they fear something is amiss with their bodies and persistently seek an acceptable explanation and relief. The autonomic arousal accompanying anxiety may affect many organ systems and imitate physical disease. Moreover, anxiety and anxiety-like symptoms may be consequent to a variety of medical ailments and their treatments.
Anxiety is a normal human emotion. Distinguishing normal anxiety from pathologic anxiety and anxiety disorders often requires systematic evaluation and a thorough understanding of the individual patient’s physical and psychological status. Underrecognized and undertreated, anxiety disorders increase the cost of medical care and render patients vulnerable to further morbidity, including depression, hypochondriasis, demoralization, and varying degrees of disability. A comprehensive and empathic assessment of the anxious patient by the primary care physician permits a reasoned and often therapeutically effective approach to the difficult problems presented.
Definitions
Anxiety is the distressing experience of dread, foreboding, or panic accompanied by a variety of autonomic—primarily sympathetic— bodily symptoms. The distress, therefore, is both psychic and physical. Patients vary considerably in their tolerance to it. The new onset or exacerbation of anxiety often occurs in response to emotional or physiologic stimuli. Most individuals meet the challenge of universally anxiety-provoking situations with their personal strengths and styles of coping. When an individual’s capacity for coping is overwhelmed, excessive anxiety may emerge. Pathologic anxiety is distinguished from the normal case by its occurrence in the absence of an objective stimulus and by its duration or intensity.
Neurotransmitter Mechanisms
Several monoamine and neuropeptide neurotransmitters are implicated in the neurobiology of anxiety. Norepinephrine plays a prominent role in mediating anxiety states centrally. The locus caeruleus of the pons serves as the chief noradrenergic nucleus. Abnormal firing patterns in the locus caeruleus have been implicated in the pathophysiology of some anxiety conditions, such as panic disorder. In contrast, the inhibitory neurotransmitter γ-aminobutyric acid, which is ubiquitous in the brain, is implicated as serving an anxiolytic function within the limbic system. The resulting somatic manifestations of anxiety are principally mediated by the sympathetic nervous system.
Classification and Clinical Presentation
The classification of anxiety disorders is largely based on clinical features (Table 226-1). (The newly updated Diagnostic and Statistical Manual of Mental Disorders 5 [DSM 5].) In both its normal and pathologic forms, anxiety’s manifestations consist of affective, cognitive, behavioral, and somatic components. The affective component is characterized by the experience of dread, foreboding, or panic. In its normal form, the affective component is countered by cognitions that make sense of or seek to neutralize the distress. In the pathologic form, other components of the clinical presentation may be exacerbated by cognitions, such as catastrophizing. A variety of behaviors, such as avoidance or hypervigilance, reflect the anxious state or evolve in response to it. Typical psychological presentations might include complaints of apprehension, motor tension or agitation (restlessness, edginess, jitteriness), and heightened arousal (including hypervigilance, distractibility, impaired concentration, and insomnia). The somatic complaints are mostly those of autonomic hyperactivity and include systemic, cardiopulmonary, gastrointestinal, urinary, and neurologic symptoms (Table 226-2).
Adjustment Disorder with Anxious Mood
Most presentations of anxiety within the medical setting are normal reactions to anxiety-provoking situations. For a limited time period, a patient may suffer symptoms similar to those of a generalized anxiety disorder (GAD) (see later discussion). When a patient’s capacity for coping is overwhelmed, excessive anxiety may transiently emerge until the patient is able to adjust. This state is termed adjustment disorder with anxious mood and typically resolves in less than 6 months. Adjustment disorders also may be heralded by other manifestations, including depressed mood and misconduct.
Generalized Anxiety Disorder
This common condition is characterized by anxiety lasting longer than 6 months and worry extending beyond a specific subject. Typically, the patient ruminates with worries over a variety of concerns and may have been doing this for several
years with a waxing and waning course. GAD also includes an array of physical concomitants, including restlessness, fatigability, poor concentration, irritability, muscle tension, and insomnia. In addition to the persistent anxious state, the patient may describe more-discrete episodes of acute anxiety.
years with a waxing and waning course. GAD also includes an array of physical concomitants, including restlessness, fatigability, poor concentration, irritability, muscle tension, and insomnia. In addition to the persistent anxious state, the patient may describe more-discrete episodes of acute anxiety.
TABLE 226-1 Anxiety Disorders and Their Defining Features* | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Panic Disorder
Panic disorder is characterized by recurrent unexpected panic attacks, characterized by sudden spells of extreme anxiety accompanied by symptoms of sympathetic activation. They may be accompanied by feelings of impending doom, fear of dying, the sensation of panic, and the impulse to flee. These can occur in any anxiety disorder, but in panic disorder they occur unexpectedly, with at least one attack followed by no less than 1 month of persistent concern about having additional attacks, worry about the implications of the attack or its consequences (e.g., losing control, having a heart attack), or a significant change in behavior related to the attacks. Panic disorder is more common in women and in those with a positive family history of panic. Emergence of anxiety symptoms early in life, including a history of separation difficulties during childhood, also represents risk factors for panic disorder.
TABLE 226-2 Somatic Symptoms of Anxiety | ||||||||||||||
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Many patients become disabled by anticipatory fear of subsequent panic attacks and by phobic avoidant behavior patterns. They avoid places with restricted escape (e.g., crowds, theaters, tunnels, elevators), fearful of being trapped during an attack. In its most extreme form, agoraphobia (literally, “fear of the market place”), avoidant behavior may reach a point at which a patient is afraid to leave the safety of the home or to be left alone. In rare situations, agoraphobia has also been reported to occur in the absence of panic disorder. (More commonly, the patient whose family describes him or her as “never leaving the house” has depression with loss of interest in doing activities as a prominent symptom.)
The course of panic disorder includes times of frequent panic attacks interspersed with periods of less frequent episodes, complicated by phobic avoidance and anticipatory anxiety. The paroxysmal nature of panic attacks and the prominence of autonomic symptoms may mimic cardiac or neurologic disease, causing some patients to become hypervigilant, convinced of a serious underlying medical disorder, and “doctor shoppers” in search of such a diagnosis. Such persons may become demoralized, depressed, and debilitated. Suicide risk appears to be markedly increased in panic disorder, especially in patients with concurrent depression.
Phobias
A phobia is an irrational fear related to a specific stimulus. On exposure to that stimulus, the individual reliably manifests an anxiety response. A patient may suffer from a specific phobia of any specific stimulus. Although specific phobias commonly generate circumscribed symptoms, they may interfere with some aspect of a patient’s functioning due to avoidance of the phobic stimulus or perseverance in the face of great discomfort (e.g., fear of flying leading to difficulty with travel).
Social Anxiety Disorder (Social Phobia).
Patients with social anxiety disorder develop anxiety in situations in which they are the focus of attention or might be scrutinized publicly. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Such patients may experience performance anxiety or “stage fright” but also exhibit distress in more ordinary social settings. In the generalized type of social anxiety disorder, the fear includes most social situations (participating in small groups, dating, initiating or maintaining conversations, speaking to authority figures, attending parties, etc.). Social anxiety disorder needs to be distinguished from the more limited form of normal performance anxiety, which occurs in universally acknowledged anxiety-provoking situational settings (e.g., performing in front of a very large audience or as part of a very important event).
Obsessive-Compulsive Disorder
More common than previously recognized, obsessive-compulsive disorder (OCD) affects up to 3% of the population. It is characterized by obsessions and/or compulsions that are sufficiently severe to cause patients substantial distress or impair their ability to function.
Obsessions are unwanted intrusive thoughts of a bizarre, senseless, or extreme nature. The subject of obsessions typically includes sexual or violent themes, concerns about contamination, and preoccupations with organization or symmetry, which are very distressing to patients and may lead them to fear that they are “going crazy.” The recurrent and persistent thoughts, impulses, or images themselves become a source of anxiety.
Compulsions refer to repetitive behaviors that are performed in a stereotypical or ritualized fashion, usually in response to obsessions, sometimes in an effort to neutralize them.
Resisting the drive to perform compulsions causes escalating anxiety, whereas succumbing and performing them is accompanied by feelings of transient relief, followed by feelings of shame. Characteristic compulsions include hand washing (to neutralize contamination obsessions), checking behaviors (e.g., checking door locks and stove burners to counteract obsessions of uncertainty), and counting (to neutralize anxiety associated with other obsessions).
Resisting the drive to perform compulsions causes escalating anxiety, whereas succumbing and performing them is accompanied by feelings of transient relief, followed by feelings of shame. Characteristic compulsions include hand washing (to neutralize contamination obsessions), checking behaviors (e.g., checking door locks and stove burners to counteract obsessions of uncertainty), and counting (to neutralize anxiety associated with other obsessions).
The relationship between the compulsions and obsessions may also be nonsensical or irrational. Usually, patients retain insight regarding the nonsensical or extreme nature of their thoughts and behaviors, which distinguishes them from psychotic persons.
Because of the shame associated with the symptoms of OCD, it is not uncommon for patients to hide the disorder from friends, family, and doctors. OCD may come to the attention of primary care physicians when a patient’s obsessions involve preoccupations with his or her bodily functions (e.g., urinary or bowel obsessions) or susceptibility to disease (e.g., obsessions with contamination or fear of AIDS). Rarely, the compulsions may be performed to such extreme as to pose medical risk or sequelae (e.g., dermatologic complications of hand washing).
The age of onset of OCD is variable, with a bimodal distribution: a male-dominated peak in the preteen years and a femaledominated peak in the third decade of life. The clinical course is similarly variable; symptoms may arise at any age, wax and wane, and become exacerbated in times of stress.
The etiology and underlying pathophysiology of OCD are poorly understood. It has been related genetically to Tourette disorder and commonly occurs with depression. Associated disorders include body dysmorphic disorder (i.e., preoccupation with a defective body image) and trichotillomania (compulsive hair pulling).
Posttraumatic Stress Disorder
Several weeks after surviving exposure to an emotionally traumatic event or events (e.g., combat experience, natural disaster, physical assault, rape), the patient with posttraumatic stress disorder (PTSD) reports persistent reexperiencing of the traumatic event, via intrusive thoughts, vivid dreams, or “flashbacks.” Other characteristics requisite for the diagnosis include avoidance of stimuli associated with the trauma, hyperarousal (e.g., increased startle response), and persistence of symptoms for more than 1 month. In many cases, the symptoms may continue for years. Rarely, the syndrome emerges more than 6 months after the traumatic exposure and in such cases is designated PTSD with delayed onset.
Patients may present for medical assistance with primary complaints of anxiety or with concerns and questions regarding the neurologic underpinnings of their symptoms. Alternatively, PTSD may develop as a consequence of medical illness or procedures (e.g., amputation or cardiac defibrillation), which by their nature represent profound trauma. Medical settings may serve to trigger reexperiencing phenomena. It is important to be aware of the entity and sensitive to the needs of its sufferers.
Substance Abuse
Anxiety is often poorly tolerated, leading some patients to seek relief through the use or abuse of anxiolytic substances. A patient’s reliance on alcohol, benzodiazepines (BZDs), or any other sedating medication may reflect an unrecognized underlying anxiety disorder. Chronic use of sedating substances can lead to neural irritability and can cause or exacerbate anxiety after withdrawal. It often becomes difficult to differentiate the cause-and-effect relationship between substance abuse and anxiety. Patients with anxiety disorders are 50% more likely to be alcoholic, and, similarly, the prevalence of anxiety disorders is 50% higher in persons who suffer from alcohol abuse or dependence.
TABLE 226-3 Medical Causes of Anxiety | ||||||||||||||||||
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The medical differential diagnosis of the symptoms and signs associated with anxiety includes many conditions in which there is stimulation of the sympathetic nervous system (Table 226-3). Some reports suggest that undiagnosed medical ailments are responsible for a significant number of psychiatric referrals for “anxiety.” Unrecognized arrhythmias, endocrinopathies, and medication reactions may mimic anxiety disorders and vice versa.
Among the psychiatric disorders to be considered in the differential diagnosis of anxiety are the depressive disorders. They are among the most critical to recognize because they are common, treatable, carry a high risk of morbidity and mortality when untreated, and frequently coexist with symptoms of anxiety (see Chapter 227). Other psychiatric conditions presenting with anxiety as a prominent component include psychosis, dementias, and drug-related disorders.
The primary care physician’s evaluation of anxiety needs to include an assessment for medical causes as well as psychiatric diagnoses.
Assessment for Medical Causes
The list of possible medical causes is much too extensive to enable a workup that includes every possibility. A reasonable alternative is to focus on any medical conditions for which the patient is already under treatment. This includes a review
of the patient’s concerns, fears, and ongoing therapies. In addition, attention is directed toward the most important disorders commonly linked with anxiety, such as dysrhythmias (see Chapter 25), hyperthyroidism (see Chapter 103), and drug reactions or withdrawal (see Chapters 229 and 235). If the patient has a single prominent symptom or constellation of symptoms that implicate a single organ system, it is worthwhile medically to evaluate that focus in detail.
of the patient’s concerns, fears, and ongoing therapies. In addition, attention is directed toward the most important disorders commonly linked with anxiety, such as dysrhythmias (see Chapter 25), hyperthyroidism (see Chapter 103), and drug reactions or withdrawal (see Chapters 229 and 235). If the patient has a single prominent symptom or constellation of symptoms that implicate a single organ system, it is worthwhile medically to evaluate that focus in detail.
The presence of multiple physical symptoms (six or more), high patient rating of symptom severity, low patient rating of health status, physician perception of the patient encounter as difficult, and age less than 50 years are important clues for an underlying anxiety or depressive disorder. Such easily identified clinical features have been shown to be independent predictors of underlying psychopathology in patients presenting to primary physicians with bodily symptoms. Because there are effective treatments for anxiety disorders, a diagnostic trial of an anxiolytic medication might help to resolve a difficult diagnostic situation. The physician must of course bear in mind that the suppression of anxiety symptoms does not rule out a medical disorder and may even worsen it (e.g., use of BZDs for anxiety accompanying a severe asthma attack).
Assessment for Psychiatric Disorders
The physician should recall that anxiety symptoms are typically conceptualized in three dimensions: psychological, somatic, and behavioral.
Psychological
Patients suffering from an anxiety disorder may complain of somatic manifestations of anxiety but may omit history pertaining to the psychological experience. Therefore, it is important to inquire specifically about psychic manifestations such as fear, panic, the sensation of impending doom, or the impulse to flee. Reviewing the features of the various anxiety disorders sometimes helps the patient to construct a clearer clinical picture, but care must be taken not to prejudice the patient’s responses or appear too eager to make a psychiatric diagnosis.
Somatic
One also needs to determine the onset, quality, intensity, and duration of symptoms, being certain to include a compassionate inquiry into recent life events and situational stressors present at the time that the symptoms emerged.
Behavioral
Identifiable stimuli or exacerbating factors should be noted, as well as settings that create apprehension. Development of avoidant behaviors should be ascertained. If a particular precipitant is identified, it is helpful to inquire into its origin (e.g., a phobia of dogs arising from a remote history of a dog bite or avoidance of elevators as a consequence of having had a panic attack in one). Often, symptoms may have arisen spontaneously, contributing to the sense that they are autonomous (as in panic disorder or OCD).
Also useful is inquiry into strategies used to alleviate the symptoms. This may uncover additional history about substance use, avoidance, or compulsive behaviors. Family history is reviewed for similar symptoms, known anxiety disorders, and related disorders such as depression or substance abuse. History of childhood school phobia or early patterns of timidity may be informative. Finally, a thorough physical examination is essential, checking for undisclosed sequelae of repetitive behaviors (as in OCD).
PRINCIPLES OF MANAGEMENT (4,5,9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29 and 30)
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