Anxiety

Anxiety is characterized by excessive unease and apprehension, usually in association with an event that may have an unknown outcome. It is a normal reaction and a positive motivating factor in many situations. Anxiety becomes a problem when it interferes with everyday personal, social, and/or occupational functions, or when it develops into panic attacks or compulsive behavior. This ultimately can lead to symptoms and psychologic distress that are incapacitating.

In the primary care setting, anxiety often is a symptom of an underlying disorder, such as a medical or a psychologic problem (Box 48-1). The practitioner must obtain a comprehensive history and perform a complete physical examination of the patient to assess the possible causes and effects of the anxiety. Symptoms of anxiety vary with the subtype of anxiety experienced. The physical symptoms of anxiety are listed in Box 48-2.

Elements of the history that are particularly important in evaluating anxiety include the following:

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is defined as excessive anxiety and worry about life circumstances that are difficult to control. It was responsible for 12.3 million office visits to primary care providers in 1998. Twice as many women as men suffer from GAD. As many as 50% of patients with major depression will meet diagnostic criteria for GAD, and one study found this to be true in 62% of patients.

The anxiety associated with GAD is unrealistic, generalized, and persistent. It is present on more days than not for longer than 6 months. The patient often complains of somatic symptoms such as restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep problems. Patients generally lack the insight to connect their symptoms with their reported worries and present life stresses. A self-assessment tool called the GAD-7 has been shown to be a reliable screening tool for GAD.

Panic Disorder

A panic attack is an unexpected severe, acute exacerbation of psychic and somatic symptoms of anxiety accompanied by intense fear or discomfort that is not triggered by a particular situation and that the individual cannot “sit out.” It starts abruptly and reaches a peak within 10 minutes, with at least four of the following symptoms: palpitations, tachycardia, sweating, shaking or trembling, shortness of breath, choking, chest pain or discomfort, nausea or abdominal distress, dizziness or faintness, feeling unreal or detached from oneself, fear of going crazy, fear of dying, paresthesias, and chills or hot flashes. Typical presentations include cardiovascular symptoms (40%), neurologic symptoms (40%), or GI symptoms (30%).

A panic attack becomes a panic disorder when the patient worries about having another attack and about what will happen if that should occur. Also, changes in behavior are seen with multiple attacks and result in frequent medical or emergency room visits. Because panic attacks consist of a wide array of symptoms, two thirds of patients are prompted to seek a medical rather than a mental health provider. And, in most cases, patients are unsatisfied with the lack of definitive diagnosis. This results in an enormous utilization of health care resources; one study reported that 70% (40/57) of patients saw an average of 10 physicians before receiving a diagnosis of panic disorder.

Phobic Disorders

This is the most common mental health disorder in the United States. A patient who has a phobia displays a persistent and irrational fear of a clearly definable situation, object, or activity. Exposure to the feared stimulus results in intense anxiety and avoidance that interfere with the patient’s life. Three main groups of phobic disorders have been identified:

Specific phobias can be normal in children, and many persist in a mild form in adults. Incapacity depends on the frequency with which the situation is encountered and the amount of interference with function that results.

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a situational preoccupation with thoughts or acts that occur despite the patient’s efforts at resistance. Obsessions are persistent thoughts, ideas, or images that intrude into conscious awareness. Compulsions are urges or impulses for repetitive intentional behaviors that are performed in a stereotyped manner in an attempt to reduce anxiety. The patient realizes that these are senseless and intrusive but is unable to stop. Insight and resistance may not be present in children who have OCD. It occurs in approximately 3% of the population in the United States. Onset in children and adults occurs around the ages of 10 and 21, respectively, and it develops earlier in males than in females. The impact on a patient’s quality of life can be devastating; one study noted that 13% of patients attempted suicide.

Posttraumatic Stress Disorder

Patients with posttraumatic stress disorder (PTSD) have recurrent anxiety precipitated by exposure to or memory of some past traumatic situation. They may have recurrent dreams or suddenly may act or feel as if the event is recurring. The patient will have increased arousal and hypervigilance, leading to flashbacks and severe anxiety with an enhanced startle reaction (positive symptoms of PTSD). As a means of compensating for this intense arousal, patients may be withdrawn in an attempt to avoid reminders of the trauma. The result is a sense of numbness and emotional blunting (negative symptoms of PTSD). These patients have experienced a catastrophic event that would be clearly distressing to anyone. Onset follows the trauma after a latency period of a few weeks to months, but not longer than 6 months, and the condition lasts for at least 1 month. In a study of 368 primary care clinic patients, nearly two thirds were witnesses to or were the victims of a traumatic event; 12% of these individuals were given a diagnosis of PTSD. More than four times as many women as men develop PTSD. Traumatic events reported in women include molestation and physical assault.

Insomnia

As many as 30% of adults report problems with sleep; these are seen more commonly in women. Sleep disorders are a symptom and not a diagnostic entity; thus, a comprehensive review of the patient’s history and a thorough physical examination is required to rule out all possible causes of the sleep disturbance. Research suggests that people who routinely experience problems going to sleep have an increased risk of myocardial infarction and may have a higher risk of mortality during sleep from all causes.

Sleep disorders are categorized into the following four groups to facilitate diagnosis and management:

Insomnia may be associated with depression, manic disorders, alcohol or other drug abuse, heavy smoking, caffeine use, an adverse effect of many drugs, and specific medical conditions. Medications that may contribute to insomnia include the psychotropic drugs and CNS stimulants such as OTC cold medicines and theophylline. Medical conditions associated with insomnia include delirium, respiratory distress, pain, and hyperthyroidism. Certain sleep disorders such as sleep apnea are made worse by insomnia medications. The only sleep disorder discussed in this chapter is insomnia because it is the one disorder that these medications are used to treat. Insomnia generally is classified as short term, 7 to 10 days, and long term.

The appropriate and effective treatment of insomnia is under widespread debate. Some data suggest that sedative hypnotics do not provide as much relief from insomnia as promised. A common definition of insomnia is that the patient takes 30 minutes or more to fall asleep and the patient gets less than 6½ hours of sleep. Even when the drugs work better than placebos—and they don’t always—data submitted to the FDA show that people still don’t fall asleep in less than 30 minutes, and they still don’t sleep much longer than 6 hours—and they may have grogginess or other side effects as well. These products are also intended for short-term use, although many patients take them for years. For those patients who demand other, more effective medications for insomnia, antipsychotics that produce heavy sedation have been used. There is growing unrest among many clinicians about the long-term use of these powerful drugs in patients who have no mental problems and for whom they are not intended.

The practitioner must rule out all possible causes of a sleep disorder and must determine the type of disorder that is present before prescribing any type of medication. The patient should be encouraged to practice good sleep hygiene principles, such as avoiding stimulating food and drink before retiring, having nighttime rituals that are relaxing, and not using the bed for reading, work, or other non–sleep-associated activities. Clinicians must also reevaluate the practice of renewing prescriptions intended for short-term use for long periods of time.