Anxiety Disorders: We Can Help!

Normal vs Abnormal

Anxiety is a normal reaction to stress, and may be beneficial in some situations (alerts us to danger, motivates preparation, helps us pay attention, etc.)

Anxiety disorders differ from normal feelings of nervousness or anxiousness, and involve excessive fear or anxiety 

• What’s excessive? Anything out of proportion to the situation, age inappropriate, or hindering ability to function normally

Anxiety disorders ranked #7 on a list of 25 physical and mental health conditions causing the most disability and injury in 2016. (Major depressive disorder ranked #2!)

Anxiety disorders

Multiple types per the DSM-5: 

• Separation anxiety disorder
• Selective mutism
• Phobias
• Social anxiety disorder
• Panic disorder
• Agoraphobia
• Generalized anxiety disorder (GAD)
• Substance/medication-induced anxiety disorder
• Anxiety disorder due to another medical condition

Key points:

• Patients commonly meet criteria for ≥1 anxiety disorder
• Narrowing the diagnosis to a specific disorder is essential for determining appropriate psychotherapy
• DSM-5 diagnostic criteria for each disorder generally requires that symptoms occur on more days than not for ≥6 months
• Many other psychiatric disorders have features of anxiety, including PTSD and OCD, among others

Prevalence

• Based on data from 2001-2004, the lifetime prevalence of any anxiety disorder among adolescents was 31.9% overall 
• Based on data from 2001-2003, the past year prevalence of any anxiety disorder among adults was 19.1% overall, of which 33.7% was moderate and 22.8% was serious
• Based on data from 2004 and 2009, approximately 40% of adult women and 26% of adult men develop some type of anxiety disorder during their lifetime

Disparities

The American Psychiatric Association offers a number of insights on mental health disparities, including anxiety, in underrepresented minorities.

• Compared with the general population, African Americans are less likely to be offered either evidence-based medication therapy or psychotherapy for mental health issues
• LGBTQ+ individuals are 2.5 times more likely to experience depression, anxiety, and substance misuse compared with heterosexual individuals
• About 1 in 3 asylum seekers and refugees experience depression, anxiety, and/or PTSD
• Lack of cultural understanding by healthcare providers may contribute to underdiagnosis or misdiagnosis of mental illness, including anxiety, in people from diverse populations
• People of color are less likely to receive mental health care. For example, in 2015, among adults with any mental illness, 48% of whites received mental health services, compared with 31% of blacks and Hispanics, and 22% of Asians

Screening

In 2014, JAMA’s Rational Clinical Examination series looked at GAD and panic disorder and found that the GAD-7 screening questionnaire, based on a 2006 study by Spitzer et al, performed well as a screening tool in the primary care setting. 

Interpretation:

• 0-4 = Minimal or no anxiety
• 5-9 = Mild anxiety
• 10-14 = Moderate anxiety
• 15-21 = Severe anxiety

Fun fact #1: The GAD-7 actually has 8 questions!

• 8. If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
  • This question is a good indicator of patient’s global impairment, though not included in the final calculation of points

Fun fact #2: A shortened version of the GAD-7 exists—the GAD-2 uses the first two questions of the GAD-7! 

Stats Stats Stats

Generalized anxiety disorder (GAD):

• GAD-7 (cutoff score of 10): sensitivity 89%, specificity 82%, positive LR 5.1
• GAD-2 (cutoff score of 2): sensitivity 95%, specificity 64%

Any anxiety disorder:

• GAD-7 (cutoff score of 8): sensitivity 77%, specificity 82%
• GAD-2 (cutoff score of 2): sensitivity 86%, specificity 70%

History

The GAD-7 focuses on feelings of anxiety and worrying, but we shouldn’t stop there…

• Clarify associated symptoms: fatigue, poor concentration, poor sleep, HA, GI upset, muscle tension, suicidal ideation (SI), etc
  • We often associate SI with depression, but patients with anxiety are also at risk. A 2005 JAMA Psychiatry study found that patients with an anxiety disorder had an adjusted odds ratio (AOR) of 2.32 for SI and 3.64 for suicide attempts. And the AOR was even higher in patients with both an anxiety disorder and another mood disorder: 4.64 for SI and 10.05 for suicide attempts!
• Determine the presence of comorbid conditions: depression, bipolar disorder, substance use disorder, etc
• Review other factors: anxiety-provoking situations, medications (including any recent changes), substance use, trauma, etc

Anxiety disorder due to another medical condition

The DSM-5 points out that an anxiety disorder is diagnosed only when symptoms are not attributable to the physiological effects of a substance/medication or to another medical condition, and are not better explained by another mental disorder.

We should remember that there are MANY conditions that can present with anxiety early on in the course of illness:

• Endocrine: thyroid/parathyroid disease, pheochromocytoma, hypoglycemia
• Cardiovascular: CHF, PE, arrhythmia, angina, MI, valvular disease
• Pulmonary: asthma, COPD, OSA, lung cancer
• GI: IBS, pancreatic cancer, Wilson’s disease
• Metabolic: B12 deficiency, porphyria
• Neurological: CNS neoplasms, vestibular dysfunction, encephalitis, seizures, multiple sclerosis, Parkinson’s disease, Alzheimer’s disease
• Substance use: psychoactive effects, withdrawal, toxin exposure

Management of GAD

Treatment focuses on psychotherapy and/or pharmacotherapy, and should be pursued via shared decision-making with patients. 

• Consider treatment availability, patient preference, adverse effects, and cost
• There are no head-to-head RCTs comparing first-line medications with CBT for management of GAD. Furthermore, meta-analyses have found conflicting results on which therapy is best due to a variety of issues including the basic difference in controls (most pharmacotherapy trials use a pill placebo while psychotherapy studies often use a waitlist control), which limits our ability to make valid comparisons 

Psychotherapy

Psychotherapy for GAD typically involves cognitive-behavioral therapy (CBT), which focuses on developing various cognitive coping skills through self-monitoring, relaxation, cognitive restructuring, imagery exposure, exposure to anxiety-provoking situations, etc. 

Pharmacotherapy

First line: SSRI, SNRI

• Extensive data for escitalopram, sertraline, paroxetine, venlafaxine, and duloxetine
• 2003 Cochrane review: NNT = 5

Adjunctive therapy: buspirone or pregabalin (off-label use)

• Either drug may be used as first-line therapy in patients who don’t tolerate a first-line medication

Educate patients on timing!

• 4 weeks = average time to onset of clinical action
• Continue treatment for >12 months after remission has occurred

Options in presence of resistance to first-line medications:

• Hydroxyzine
  • 2010 Cochrane review: conflicting evidence 
  • Use for short-term or immediate control of symptoms until maintenance therapy is effective
• Benzodiazepines
  • Preferred as second-line adjunct therapy, often for crises; occasionally used as monotherapy
  • Only consider in absence of prior substance use and minimal depressive symptoms
• Other possibilities: mirtazapine, quetiapine, imipramine

Blog post based on Med-Peds Forum talk by Matt Lorenz, MP Core Faculty