More About Mood Disorders
Anxiety disorders are as prevalent and disabling as depression; they affect about 19.1 million adults in the United States at some point during their lifetimes.1-3 Because of the high suicide risk associated with depression, patients who have anxiety may attract less attention from their primary care providers. Thus, anxiety disorders often go undiagnosed and untreated.
At least 60% of patients with symptoms of anxiety disorders seek treatment in a primary care setting. These symptoms need to be distinguished from normal anxiety and fear, which are healthy emotional reactions to daily stressors related to interpersonal, social, educational, and vocational demands. Patients who present with anxiety symptoms that occur in the absence of an identified cause or stressor and that have lasted for an extended period of time and are accompanied by a deterioration of overall functioning probably have an anxiety disorder that warrants treatment.3,4
In this 2-part series, I review the diagnosis and treatment of anxiety disorders in the primary care setting. Here I discuss the clinical presentation, the relevant diagnostic studies, and the differential diagnosis. In Part 2, I will summarize the available treatment options.
Risk factors. Among the risk factors for anxiety disorders are the following5:
• Past personal or family history of anxiety disorders.
• Increase in stressful psychosocial life events.
• Lack of social support network.
• Lack of or maladaptive coping strategies.
• Unresolved grief.
• Advanced or terminal illness.
• Acute or chronic pain.
Physical manifestations of anxiety. The physical symptoms of anxiety disorders may include shakiness; trembling; muscle aches; sweating; cold or clammy hands; dizziness; vertigo; fatigue; racing or pounding heart; hyperventilation; sensation of lump in throat; choking sensation; dry mouth; numbness and tingling of hands, feet, or other body part; upset stomach; nausea; vomiting; diarrhea; decreased sexual desire; and sleep disturbances.5
Psychological and social manifestations of anxiety. These may include jitteriness, tension, unrealistic or excessive worry, exaggerated startle reactions, and ritualistic behaviors. Some patients with anxiety disorders may fear being away from home, and they may stop going to work or attending public gatherings.6 Some may also demonstrate an irrational fear of strangers; others may be afraid of falling asleep because of recurrent disturbing dreams or nightmares. In addition, persons with anxiety disorders are often apprehensive and worry that something bad may happen to themselves or to their loved ones. They often feel impatient, irritable, and easily distracted.
The baseline examination for anxiety of new onset includes a detailed physical and psychosocial symptom profile that encompasses the following7:
• Inquiry about recent stressful events.
• History of intake of illicit drugs, alcohol, nicotine, caffeine, herbal preparations, and over-the-counter drugs.
• Current medication history.
• Past psychiatric history, including comorbid mood disorders and psychotic disorders.
• Family history of anxiety disorders.
• Current medical status.
• Assessment of suicidal and homicidal ideation or intention.
• Baseline laboratory evaluation.
The selection of initial laboratory tests depends on the presence of abnormal physical findings.8 Guidelines for ordering tests and studies are outlined in Table 1. Imaging studies are not initially indicated in the diagnosis of primary anxiety disorders unless specific medical conditions need to be ruled out. If intracranial pathology is suspected, a head CT scan or MRI scan may be required.
1. Sadock BJ, Sadock VA. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2007.
2. Lépine JP. The epidemiology of anxiety disorders: prevalence and societal costs. J Clin Psychiatry. 2002; 63(suppl 14):4-8.
3. Young RS, Gillan E, Dingmann P, et al. Army health care operations in Iraq. Conn Med. 2008;72:13-17.
4. Grubaugh AL, Cain GD, Elhai JD, et al. Attitudes toward medical and mental health care delivered via telehealth applications among rural and urban primary care patients. J Nerv Ment Dis. 2008;196:166-170.
5. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:593-602.
6. Wittchen HU, Beesdo K, Bittner A, Goodwin RD. Depressive episodes—evidence for a causal role of primary anxiety disorders? Eur Psychiatry. 2003;18:384-393.
7. Gabbard GO. Treatments of Psychiatric Disorders. 3rd ed. Vols 1 & 2. Washington, DC: American Psychiatric Publishing; 2001.
8. Liebowitz MR. Medications: achieving remission in the anxiety disorders. Presented at: 25th Annual Meeting of the Anxiety Disorders Association of America; March 17-20, 2005; Seattle.
9. Brewerton TD. The DIVINE MD TEST. Resident and Staff Physician. 1985;31:146-148.
10. Kendrick T. Depression in adults: GPs are not so bad at diagnosis. BMJ. 2008;336:522.
11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
12. American Psychiatric Association. Practice Guideline for the Treatment of Patients With Panic Disorder. Washington, DC: American Psychiatric Association; 1998.
13. Campbell-Sills L, Stein MB. Guideline Watch: Practice Guideline for the Treatment of Patients With Panic Disorder. Arlington, VA: American Psychiatric Association; 2006.
14. Kroenke K, Spitzer RL, Williams JBW, et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146:317-325.
15. Khouzam HR, Ghafoori B, Nichols EE. Use of a religious hymn in remission of symptoms of social phobia (social anxiety disorder): a case study. Psychol Rep. 2005;96:411-421.
16. Khouzam HR. Obsessive-compulsive disorder. What to do if you recognize baffling behavior. Postgrad Med. 1999;106:133-141, 161.
17. Khouzam HR, Donnelly NJ. Posttraumatic stress disorder. Safe, effective management in the primary care setting. Postgrad Med. 2001;110:60-62, 67-70, 77-78.
18. Khouzam HR, Tan DT, Gill TS. Handbook of Emergency Psychiatry. Philadelphia: Mosby; 2007.