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University of Iowa Family Practice Handbook, 3rd Edition, Chapter 15

Psychiatry: Anxiety Disorders

Nora R. Frohberg, M.D. and Robert L. Herting, Jr., M.D.
Department of Family Medicine
University of Iowa
Peer Review Status: Externally Peer Reviewed by Mosby

  1. Overview
    1. Definition of anxiety. Unpleasant and unwarranted feelings of apprehension, sometimes accompanied by physiological symptoms.
    2. Types of anxiety disorders.
      1. Generalized anxiety disorder
      2. Panic disorder
      3. Agoraphobia
      4. Social or simple phobias
      5. Obsessive compulsive disorder
      6. Posttraumatic stress disorder
    3. Differential diagnosis of anxiety disorders.
      1. Psychiatric.
        1. Anxious depression
        2. Drug abuse or withdrawal (alcohol, benzodiazepines)
        3. Stimulant use (caffeine, amphetamines)
        4. Some personality disorders
      2. Medical.
        1. Cardiovascular (such as mitral valve prolapse, angina, cardiac arrhythmias, CHF, HTN, MI).
        2. Respiratory (such as asthma, COPD, hyperventilation, hypoxia, PE).
        3. Endocrine (such as hypoglycemia, hyperthyroidism, menopause, pheochromocytoma, Cushing's syndrome).
        4. Neurologic (such as delirium, multiple sclerosis, partial complex seizures, postconcussion syndrome, vestibular dysfunction).
        5. Drugs (such as theophylline, bronchodilators, steroids, calcium-channel blockers, neuroleptics, anticholinergics).
        6. Gastroesophageal reflux.

  2. Generalized Anxiety Disorder (GAD)
    1. Overview. Probably the most common anxiety disorder in primary care with lifetime prevalence of 5%. Gradual onset with peak onset in the teen years. High risk for other comorbid psychiatric disorders
    2. DSM-IV diagnosis.
      1. Excessive anxiety and worry on most days for at least 6 months, about a number of issues.
      2. Difficulty controlling the worry.
      3. The anxiety and worry are associated with at least 3 of the following 6 symptoms for the past 6 months:
        • Restlessness or feeling on edge
        • Irritability
        • Being easily fatigued
        • Difficulty concentrating
        • Muscle tension
        • Sleep disturbance
      4. Focus of the anxiety and worry does not relate to another major emotional disorder (for example, worry is not about having a panic attack as in panic disorder).
      5. Anxiety causes significant distress or impairment in functioning.
      6. The symptoms are not attributable to substance use or a medical condition and are not present only during the course of a mood, psychotic, or developmental disorder.
    3. Treatment.
      1. Therapy.
        1. Psychotherapy. Most patients with mild symptoms can be treated with supportive counseling and education without need for medication.
        2. Other therapies. Relaxation training and cognitive therapy.
      2. General measures. Regular exercise and avoidance of caf-feine and alcohol.
      3. Medications.
        1. TCAs. Imipramine 25 to 150 mg/day. Does not become effective for 2 to 3 weeks. Most beneficial in patients with comorbid depression or sleep disturbance.
        2. Antihistamines. Hydroxyzine (Atarax, Vistaril) 50 to 100 mg QID may be used PRN, as an adjunct to other medications, or as an alternative therapy for patients with addiction potential.
        3. Benzodiazepines. Usually of short-term use with no long-term efficacy proved. Use lowest dose that alleviates anxiety. Longer half-life drugs may be easier to taper. May cause rebound anxiety with taper or withdrawal. Examples: alprazolam (Xanax) 0.25 to 0.5 mg PO TID initial dose; rarely need to exceed 4 mg/day. Diazepam (Valium) 2 to 10 mg PO BID to QID. Lorazepam (Ativan) 1 mg PO BID or TID initially; rarely need to exceed 10 mg/day. Use lower doses than above in the elderly.
        4. Buspirone. May be less effective than other agents. Start 5 mg PO TID and increase to typical dose of 20 to 30 mg/day. Takes 2 weeks to be effective. Nonsedating. Little abuse potential.
        5. SSRIs. Clinically appear helpful but not well studied yet. Use in doses similar to those for panic disorder (see below). In select patients may add a benzodiazepine for first several weeks of treatment, since it has a quicker onset of action and avoids potential initial side effect of increased anxiety with SSRIs.
        6. Beta-blockers. Propranolol (Inderal) may help physical symptoms (not FDA approved) but has no effect on psychic component of anxiety.

  3. Panic Disorder
    1. Overview. Estimated lifetime prevalence is greater than 3%.
    2. DSM-IV diagnosis. Recurrent unexplained panic attacks (discrete periods of intense fear).
      1. At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:
        1. Concern about having future attacks
        2. Worry about consequences of the attack
        3. Change in behavior related to the attacks
      2. Panic attacks are not substance induced, related to a general medical condition, or better accounted for by another mental disorder.
      3. During the attack at least 4 of the following symptoms develop quickly and peak within 10 minutes:
        • Palpitations or tachycardia
        • Trembling or shaking
        • Feelings of choking
        • Nausea or abdominal discomfort
        • Feeling dizzy, unsteady, or faint
        • Fear of losing control or going crazy
        • Derealization (feelings of unreality) or depersonalization (being detached from oneself)
        • Sweating
        • Feelings of dyspnea
        • Chest pain or discomfort
        • Fear of dying
        • Paresthesias
        • Flushing or chilling
    3. Treatment.
      1. Medications.
        1. SSRIs are the drugs of choice (currently only Paxil is FDA approved for this indication). Recommended dosage ranges: Paxil (paroxetine) 10 to 50 mg/day, Luvox (fluvoxamine) 25 to 300 mg/day, and Prozac (fluoxetine) 5 to 60 mg/day. Start at lowest dose and may increase after first week as tolerated (such as Prozac 10 mg PO QOD for week 1, 10 mg QD for week 2, and then 20 mg QD for week 3). Monitor for initial paradoxical anxiety secondary to drug side effect, which usually resolves with time.
        2. Tricyclic antidepressants. For example, start imipramine at 10 to 25 mg QHS and increase by 10 to 25 mg every 3 or 4 days until effective, side effects predominate, or initial target dose of 150 to 200 mg QHS is reached. If no response after 4 to 6 weeks at target dose, may increase to maximum dose of 300 to 400 mg QHS as tolerated. Clinical experience has shown that serotonergic TCAs are more effective than noradrenergic TCAs.
        3. Benzodiazepines have a quicker onset of action than other drugs; may use as a short-term adjunct to SSRIs if initial paradoxical anxiety arises. They may be used long term if patients fail treatment or are unable to tolerate SSRIs or TCAs.
        4. MAOIs are reserved for patients who do not respond to SSRIs or TCAs because of serious adverse drug reactions. Before starting, consider consulting a psychiatrist.
        5. Propanolol is not a first-line agent for panic disorder but is very effective for physical symptoms of panic attacks associated with performance anxiety.
        6. Buspirone (Buspar) has demonstrated little efficacy in patients with panic disorders.
      2. Psychotherapy.
        1. Supportive therapy is always included.
        2. Addition of cognitive therapy may be beneficial.

  4. Agoraphobia
    1. Overview. Age of onset most often in 20s and 30s. More common in women. Often occurs with panic disorders.
    2. DSM-IV diagnosis criteria require:
      1. Fear of being in place or situations from which escape might be difficult or embarrassing in the event of suddenly developing a panic attack or panic-like symptoms.
      2. The situations are avoided, or else endured with considerable anxiety about having panic-attacks symptoms, or require a companion.
      3. Anxiety and avoidance are not better accounted for by another mental disorder.
    3. Treatment.
      1. Agoraphobia with panic attacks. Choices include SSRIs, TCAs, benzodiazepines, or MAOIs. See section on panic disorder above. Medications in combination with behavioral therapy most beneficial.
      2. Agoraphobia alone. Systematic desensitization with expo-sure to real-life feared situations is the treatment of choice. Consult a psychologist.

  5. Specific and Social Phobias
    1. Overview. Social phobia has a lifetime prevalence of 13% with onset most common in the midteens. Specific phobias are more common in females, and impairment is usually minimal.
    2. DSM-IV criteria.
      1. Persistent fear of humiliation or embarrassment in certain social situations (social phobia) or irrational fear of other circumscribed stimuli (specific phobia).
      2. Exposure to the particular stimulus provokes anxiety, which may include a situationally bound panic attack.
      3. The person usually realizes that the fear is excessive.
      4. The fear results in avoidance of the stimulus that interferes with patient's social environment or produces significant distress.
      5. The fear or avoidance is not attributable to substance use, a general medical condition, or another mental disorder.
    3. Treatment.
      1. Systematic desensitization and exposure (for specific phobias) and cognitive behavioral therapy (for social phobias).
      2. Beta-blockers may be effective in treating performance-anxiety symptoms.
      3. Drugs used in generalized social phobias include SSRIs (doses higher than those used in depression) or an MAOI (such as phenelzine).

  6. Obsessive-Compulsive Disorder (OCD)
    1. Overview. Lifetime prevalence of 2.5%. Onset usually in adolescence or early adulthood.
    2. DSM-IV diagnosis. Obsessions or compulsions that significantly interfere with daily functioning because of distress or time consumption.
      1. Obsessions. Recurrent, persistent thoughts that are experienced as intrusive and inappropriate. The person recognizes the thoughts as a product of his or her own mind and attempts to ignore or suppress them.
      2. Compulsions. Repetitive, purposeful behaviors performed in response to an obsession or according to certain rules. These are designed to neutralize or prevent discomfort. In general, recognized by the patient as unreasonable.
    3. Treatment. Generally not curative but can obtain significant improvement.
      1. Behavior therapy uses the technique of exposure and response prevention to limit the amount of dysfunction resulting from the obsessions or compulsions.
      2. Medications.
        1. Clomipramine (Anafranil). Start with 25 mg, and titrate up to 100 to 250 mg daily. Give in divided doses with meals to minimize GI side effects, or at bedtime to minimize sedation.
        2. SSRIs have better side effect profiles than clomipramine does. Start at low dose and titrate to doses higher than those used for depression (such as fluoxetine [Prozac] start 20 mg daily; usual daily dose 40 to 80 mg). If a therapeutic trial with one SSRI fails, another one may be efficacious.
      3. Cingulotomy. A last resort for severe treatment-resistant patients. May benefit up to 80% of patients receiving the surgery, but results may be inconsistent.

  7. Posttraumatic Stress Disorder (PTSD)
    1. Overview. Lifetime prevalence 1% to 14%. PTSD can occur at any age. Symptoms usually begin within 3 months after the inciting trauma.
    2. DSM-IV diagnosis criteria. PTSD occurs in individuals who experienced an extraordinarily distressing event (combat, sexual abuse or rape, natural disasters) involving self or others. In addition, the person's response includes intense fear or helplessness.
      1. Characterized by persistent reexperiences of the event in at least one of the following ways:
        • Intrusive, recurrent recollections of the event
        • Recurrent distressing dreams of the event
        • Sudden sense of reliving the experience (flashbacks, hallucinations)
        • Intense distress with exposure to symbols or representations of the event (such as anniversaries)
      2. Results in avoidant behavior of stimuli associated with the trauma or decreased responsiveness to the external world (psychic numbing).
      3. Associated with 2 or more symptoms of increased arousal (insomnia, irritability, anger, poor, concentration, hypervigilance, or exaggerated startle).
      4. The disturbance lasts more than 1 month and causes significant distress or functional impairment.
    3. Treatment.
      1. Supportive therapy that is appropriate for grief reaction.
      2. Group therapy may be helpful.
      3. Individuals may benefit from medical treatment (such as treating depressive or anxiety symptoms).

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