UBC Objectives: Mental Health & Priority Topic: Anxiety

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Diagnose common mental health problems
• Generate appropriate differential diagnoses for common mental health presentations taking into consideration medical, psychiatric, environmental, and emotional issues
• Demonstrate knowledge of indications, contraindications, side effects, and monitoring requirements, of medications used in mental health conditions
  

Key Feature 2b: When working up a patient with symptoms of anxiety, and before making the diagnosis of an anxiety disorder: Identify:

1. Other co-morbid psychiatric conditions
2. Abuse
3. Substance abuse

Skill: Clinical Reasoning
Phase: Diagnosis, History

Key Feature 2c: When working up a patient with symptoms of anxiety, and before making the diagnosis of an anxiety disorder: Assess the risk of suicide.
Skill: Clinical Reasoning
Phase: History, Diagnosis

Key Feature 4: Offer appropriate treatment for anxiety:

1. Benzodiazepines (ex: deal with fear of them, avoid doses that are too low or too high, consider dependence, other anxiolytics).
2. Nonpharmacologic treatment

Skill: Clinical Reasoning
Phase: Treatment

Key Feature 5: In a patient with symptoms of anxiety, take and interpret an appropriate history to differentiate clearly between agoraphobia, social phobia, generalized anxiety disorder, and panic disorder.
Skill: Clinical Reasoning
Phase: Diagnosis, History

Here I will review the diagnostic criteria per the DSM 5 for 4 of the more common types of anxiety disorders, along with a basic approach to treatment.

Agoraphobia

1. Marked fear or anxiety about 2 (or more) of the following 5 situations:
   1. Using public transportation (ex: automobiles, buses, trains, ships, planes)
   2. Being in open spaces (ex: parking lots, marketplaces, bridges)
   3. Being in enclosed places (ex: shops, theatres, cinemas)
   4. Standing in line or being in a crowd
   5. Being outside of the home alone
2. The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (ex: fear of falling in the elderly; fear of incontinence).
3. The agoraphobic situations almost always provoke fear or anxiety.
4. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.
5. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.
6. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
7. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
8. If another medical condition (ex: inflammatory bowel disease, Parkinson's disease) is present, the fear, anxiety, or avoidance is clearly excessive.
9. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder - for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder), perceived defects or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder).

Social Phobia

1. Marked fear or anxiety about one or more social situations in which the individual is exposed to possibly scrutiny by others. Examples include social interactions (ex: having a conversation, meeting unfamiliar people), being observed (ex: eating or drinking), and performing in front of others (ex: giving a speech). Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.
2. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).
3. The social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
4. The social situations are avoided or endured with intense fear or anxiety.
5. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
6. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
7. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
8. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (ex: a drug of abuse, a medication) or another medical condition.
9. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
10. If another medical condition (ex: Parkinson's disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Specify if: Performance only (If the fear is restricted to speaking or performing in public.)

Generalized Anxiety Disorder

1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
2. The individual finds it difficult to control the worry.
3. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item is required in children.
   1. Restlessness or feeling keyed up or on edge.
   2. Being easily fatigued.
   3. Difficulty concentrating or mind going blank.
   4. Irritability.
   5. Muscle tension.
   6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
4. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
5. The disturbance is not attributable to the physiological effects of a substance (ex: a drug of abuse, a medication) or another medical condition (ex: hyperthyroidism).
6. The disturbance is not better explained by another mental disorder (ex: anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

Panic Disorder

1. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time 4 (or more) of the following symptoms occur: Note: The abrupt surge can occur from a calm state or an anxious state. Note: Culture-specific symptoms (ex: tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the 4 required symptoms.
   1. Palpitations, pounding heart, or accelerated heart rate
   2. Sweating
   3. Trembling or shaking
   4. Sensations of shortness of breath or smothering
   5. Feelings of choking
   6. Chest pain or discomfort
   7. Nausea or abdominal distress
   8. Feeling dizzy, unsteady, lightheaded, or faint
   9. Chills or heat sensations
   10. Paresthesias (numbness or tingling sensations)
   11. Derealization (feelings of unreality) or depersonalization (being detached from oneself)
   12. Fear of losing control or "going crazy"
   13. Fear of dying
2. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
   1. Persistent concern or worry about additional panic attacks or their consequences (ex: losing control, having a heart attack, "going crazy")
   2. A significant maladaptive change in behaviour related to the attacks (ex; behaviours designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations)
3. The disturbance is not attributable  to the physiological effects of a substance (ex: a drug of abuse, a medication) or another medical condition (ex: hyperthyroidism, cardiopulmonary disorders)
4. The disturbance is not better explained by another mental disorder (ex: the panic attacks do  not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).

Although the diagnostic criteria doesn't mention precipitating or perpetuating factors, it is important to assess whether or not the anxiety is in response to a trigger that is ongoing and that is a very real reason to feel anxiety, such as abuse. Asking about causes and aggravating factors is important in order to get at any modifiable factors, and if there is any underlying abuse, provides an opportunity to help the patient in terms of their safety. It's also important to assess a patient's risk of harming themselves by screening for suicidal ideation. Although it may be more common to think of suicide as a consequence of depression, people with anxiety also can also experience significant suicidal ideation as anxiety, even in the absence of depression, can cause significant deprecation in quality of life.

So now you've got a diagnosis of an anxiety disorder. How do you proceed to treat it? The rule of thumb first-line treatment for anxiety disorders is a serotonergic reuptake inhibitor (commonly an selective serotonin reuptake inhibitor [SSRI] because they tend to have less side effects than do the serotonin and norepinephrine reuptake inhibitors [SNRI]) and/or cognitive behavioural therapy [CBT].

Some additional considerations are as follows:

1. If the patient has opted for pharmacologic treatment, but has had a poor response to two different serotonergic reuptake inhibitors, consider trials of buspirone, pregabalin, gabapentin, a benzodiazepine, mirtazapine, nortriptyline, or phenylzine. 
2. There is fear of prescribing benzodiazepines as they can be quite addictive, but they are a third-line option that works, and if the benefits outweigh the risks, physicians still ought to prescribe them for a patient with refractory and significant anxiety. The risks do outweigh the benefits in a patient with a history of substance use disorder, however. As well, patients who develop rapid physical tolerance on a benzodiazepine, or who take more (thereby running out of their medications earlier) than planned, are not good candidates for ongoing benzodiazepine therapy.  It is important to find the right dose, but once effective, this should hold fairly stable.
3. When it comes to the duration of treatment for anxiety disorders, it is generally recommended that treatment continue for at least 12 months once symptoms are controlled. If the patient relapses following a trial of cessation after a 12-month period, consider lifelong therapy.