The experience of anxiety is ubiquitous in society. Anxiety can be part of an adaptive or protective response to threat (e.g., the fight-freeze-flight response) or a natural reaction to physical and emotional stress, but it can also be debilitating and a serious health concern. At its core, anxiety is a complex bio-psychosocial-spiritual experience that requires comprehensive assessment and treatment. Undiagnosed anxiety disorders contribute to inappropriate or overutilization of healthcare resources, but as many as 80% of the individuals with anxiety disorders can be significantly helped through appropriate treatment.
Etiology
Many factors contribute to both the development and experience of anxiety. These include genetic/neurologic predisposition, family history, acute and chronic stressors, resources for coping, comorbid conditions, and overall physical health. Extreme anxiety responses, known as anxiety disorders, are often comorbid with mood disorders or other chronic health conditions (e.g., coronary artery disease, cancer). These disorders usually include debilitating physical and emotional symptoms and may be due, at least in part, to primary medical problems such as hyperthyroidism or hypoxia. Consequently, anxious patients present to the emergency room or primary care setting with complaints that can be difficult to assess and diagnose.
Epidemiology
According to the National Institute of Mental Health (NIMH), 19 million Americans experience an anxiety disorder at any one time. Estimates of the prevalence of the various anxiety disorders vary from study to study but generally are as follows: generalized anxiety disorder (GAD)—4 million, 2.8% (women twice as likely as men); obsessive compulsive disorder—3.3 million, 2.3% (equally common among men and women); panic disorder—2.4 million, 1.7% (women twice as likely); posttraumatic stress disorder—5.2 million, 3.6% (women more likely than men); social anxiety disorder—5.3 million, 3.7% (equally common among men and women); and specific phobia—6.3 million, 4.4% (women twice as likely as men). The various anxiety disorders affect approximately 10% of primary care patients .
History
Patients with anxiety disorders frequently describe experiencing physical symptoms such as chest pain, dizziness, palpitations, fatigue, shortness of breath, sweating, muscle aches or tension, or a variety of gastrointestinal complaints. Common psychologic symptoms can include shakiness, nervousness, fear of dying or going crazy, or a sense of unreality or detachment from oneself.
Some patients attribute their anxiety to their physical symptoms (“Of course, I was anxious. I thought I was having a heart attackâ€). Consequently, the assessment of anxiety disorders should include the nature, frequency, and duration of the preceding symptoms and the extent to which the symptoms have impacted the individual's life and activity.
The patient should also be asked about precipitants of the symptoms, including stressors, medications (e.g., stimulants), and other drug use (e.g., caffeine, cocaine).
Questions about the patient's general medical condition are also appropriate.
Physical examination
As with all patients, those whose clinical picture is suspected of including a significant component of anxiety should be examined carefully.
P.44The extent of the physical examination should be dictated by the patient's personal health and medical history.
The examination may include the following: blood pressure (hypertension, hypovolemia), cardiovascular (angina, arrhythmia, congestive heart failure, valvular heart disease), respiratory (chronic obstructive lung disease, pulmonary embolism, pneumonia), and neurologic (tumor, encephalopathy, vertigo).
Patients frequently present with nervous agitation, intermittent eye contact, somewhat pressured speech, and, in the primary care context, a worried focus on the somatic concerns described in the preceding text.
Testing
Useful laboratory tests include serum calcium (hypocalcemia), hematocrit (anemia), and thyroid-stimulating hormone (hyperthyroidism/hypothyroidism). Depending on the clinical scenario, an exercise stress test to evaluate chest pain or other tests to rule out organic causes (such as drug screen, oximetry (hypoxia), glucose (hypoglycemia), and electrolytes) may be useful as well.
Differential diagnosis
GAD is characterized by persistent and excessive worry about a number of issues on most days for a period of at least six months. GAD usually begins by early adulthood, is exacerbated by situational stressors, and usually involves a combination of psychologic and physical symptoms.
Panic disorder, with or without agoraphobia, presents with recurrent panic attacks—discrete episodes of anxiety involving shortness of breath, fear of dying, impending doom or losing control, pounding heart, sweating, chest pain, paresthesias, trembling, and nausea. The panic attacks may be provoked by identifiable stressors or situations but often seem to “come out of the blue.†Individuals with panic disorder may be so fearful of being in a situation in which they have another panic attack and are unable to escape that they develop agoraphobia (an intense fear of being in open or crowded places, which often contributes to the individuals being reluctant to leave the perceived safety of their home).
Acute stress disorder (ASD) and Posttraumatic stress disorder (PTSD) are characterized by reexperiencing (through recollections, flashbacks, nightmares) an extremely traumatic and possibly life-threatening experience (e.g., rape, murder, motor-vehicle accident, war), followed by hyper-arousal, panic, depressed mood, sleep disturbance, and hyper-vigilance. The individual usually attempts to avoid these memories or the chance of being in danger again through numbing, dissociation, repression, and behavioral changes. The main distinction between ASD and PTSD is the duration of symptoms (i.e., in PTSD symptoms last longer than one month).
Specific phobia is excessive anxiety provoked by exposure to a specific feared object or situation. Common phobias include fear of animals or insects, natural environment (e.g., heights, storms, water), blood-injection-injury, or situations (e.g., tunnels, bridges, elevators, flying, driving).
Social phobia is an excessive anxiety provoked by exposure to social or performance situations and unfamiliar individuals or surroundings. As a result, individuals with social phobia avoid these types of situations.
Obsessive-compulsive disorder is characterized by obsessions that cause anxiety (e.g., germs on hands) and compulsions (behaviors aimed at reducing the anxiety such as hand-washing). The obsessions usually fall into one or more of the following categories: infection/contagion, safety, religiosity, sexuality, death/dying, orderliness.
Adjustment reaction with anxious features is a condition in which a patient experiences significant anxiety in reaction to a specific stressor such as a major life event or interpersonal conflict. To qualify for this diagnosis, the level of anxiety should be assessed as being more than expected under the circumstances. In addition to these conditions, the clinician should investigate the possibility of mood, substance abuse, and other psychiatric disorders .
Clinical manifestations
Most anxious patients present in the primary care setting with a primary focus on their bodies and somatic symptoms rather than “their
P.45minds.†But inevitably there is a significant component of worry, fear, apprehension, and so on in the background. Because an exclusive focus on physical complaints (e.g., chest pain, dizziness) can obscure the diagnosis, it is important to ask patients about their psychologic state, living situation, and current stressors, as well as evaluate them for underlying medical issues.
Etiology
Many factors contribute to both the development and experience of anxiety. These include genetic/neurologic predisposition, family history, acute and chronic stressors, resources for coping, comorbid conditions, and overall physical health. Extreme anxiety responses, known as anxiety disorders, are often comorbid with mood disorders or other chronic health conditions (e.g., coronary artery disease, cancer). These disorders usually include debilitating physical and emotional symptoms and may be due, at least in part, to primary medical problems such as hyperthyroidism or hypoxia. Consequently, anxious patients present to the emergency room or primary care setting with complaints that can be difficult to assess and diagnose.
Epidemiology
According to the National Institute of Mental Health (NIMH), 19 million Americans experience an anxiety disorder at any one time. Estimates of the prevalence of the various anxiety disorders vary from study to study but generally are as follows: generalized anxiety disorder (GAD)—4 million, 2.8% (women twice as likely as men); obsessive compulsive disorder—3.3 million, 2.3% (equally common among men and women); panic disorder—2.4 million, 1.7% (women twice as likely); posttraumatic stress disorder—5.2 million, 3.6% (women more likely than men); social anxiety disorder—5.3 million, 3.7% (equally common among men and women); and specific phobia—6.3 million, 4.4% (women twice as likely as men). The various anxiety disorders affect approximately 10% of primary care patients .
History
Patients with anxiety disorders frequently describe experiencing physical symptoms such as chest pain, dizziness, palpitations, fatigue, shortness of breath, sweating, muscle aches or tension, or a variety of gastrointestinal complaints. Common psychologic symptoms can include shakiness, nervousness, fear of dying or going crazy, or a sense of unreality or detachment from oneself.
Some patients attribute their anxiety to their physical symptoms (“Of course, I was anxious. I thought I was having a heart attackâ€). Consequently, the assessment of anxiety disorders should include the nature, frequency, and duration of the preceding symptoms and the extent to which the symptoms have impacted the individual's life and activity.
The patient should also be asked about precipitants of the symptoms, including stressors, medications (e.g., stimulants), and other drug use (e.g., caffeine, cocaine).
Questions about the patient's general medical condition are also appropriate.
Physical examination
As with all patients, those whose clinical picture is suspected of including a significant component of anxiety should be examined carefully.
P.44The extent of the physical examination should be dictated by the patient's personal health and medical history.
The examination may include the following: blood pressure (hypertension, hypovolemia), cardiovascular (angina, arrhythmia, congestive heart failure, valvular heart disease), respiratory (chronic obstructive lung disease, pulmonary embolism, pneumonia), and neurologic (tumor, encephalopathy, vertigo).
Patients frequently present with nervous agitation, intermittent eye contact, somewhat pressured speech, and, in the primary care context, a worried focus on the somatic concerns described in the preceding text.
Testing
Useful laboratory tests include serum calcium (hypocalcemia), hematocrit (anemia), and thyroid-stimulating hormone (hyperthyroidism/hypothyroidism). Depending on the clinical scenario, an exercise stress test to evaluate chest pain or other tests to rule out organic causes (such as drug screen, oximetry (hypoxia), glucose (hypoglycemia), and electrolytes) may be useful as well.
Differential diagnosis
GAD is characterized by persistent and excessive worry about a number of issues on most days for a period of at least six months. GAD usually begins by early adulthood, is exacerbated by situational stressors, and usually involves a combination of psychologic and physical symptoms.
Panic disorder, with or without agoraphobia, presents with recurrent panic attacks—discrete episodes of anxiety involving shortness of breath, fear of dying, impending doom or losing control, pounding heart, sweating, chest pain, paresthesias, trembling, and nausea. The panic attacks may be provoked by identifiable stressors or situations but often seem to “come out of the blue.†Individuals with panic disorder may be so fearful of being in a situation in which they have another panic attack and are unable to escape that they develop agoraphobia (an intense fear of being in open or crowded places, which often contributes to the individuals being reluctant to leave the perceived safety of their home).
Acute stress disorder (ASD) and Posttraumatic stress disorder (PTSD) are characterized by reexperiencing (through recollections, flashbacks, nightmares) an extremely traumatic and possibly life-threatening experience (e.g., rape, murder, motor-vehicle accident, war), followed by hyper-arousal, panic, depressed mood, sleep disturbance, and hyper-vigilance. The individual usually attempts to avoid these memories or the chance of being in danger again through numbing, dissociation, repression, and behavioral changes. The main distinction between ASD and PTSD is the duration of symptoms (i.e., in PTSD symptoms last longer than one month).
Specific phobia is excessive anxiety provoked by exposure to a specific feared object or situation. Common phobias include fear of animals or insects, natural environment (e.g., heights, storms, water), blood-injection-injury, or situations (e.g., tunnels, bridges, elevators, flying, driving).
Social phobia is an excessive anxiety provoked by exposure to social or performance situations and unfamiliar individuals or surroundings. As a result, individuals with social phobia avoid these types of situations.
Obsessive-compulsive disorder is characterized by obsessions that cause anxiety (e.g., germs on hands) and compulsions (behaviors aimed at reducing the anxiety such as hand-washing). The obsessions usually fall into one or more of the following categories: infection/contagion, safety, religiosity, sexuality, death/dying, orderliness.
Adjustment reaction with anxious features is a condition in which a patient experiences significant anxiety in reaction to a specific stressor such as a major life event or interpersonal conflict. To qualify for this diagnosis, the level of anxiety should be assessed as being more than expected under the circumstances. In addition to these conditions, the clinician should investigate the possibility of mood, substance abuse, and other psychiatric disorders .
Clinical manifestations
Most anxious patients present in the primary care setting with a primary focus on their bodies and somatic symptoms rather than “their
P.45minds.†But inevitably there is a significant component of worry, fear, apprehension, and so on in the background. Because an exclusive focus on physical complaints (e.g., chest pain, dizziness) can obscure the diagnosis, it is important to ask patients about their psychologic state, living situation, and current stressors, as well as evaluate them for underlying medical issues.
