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Sun 9 Sep 2007 04:00 AM

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Diagnosing and treating anxiety disorders

Physicians can play a critical role in helping to manage anxiety disorders, the most common class of psychiatric disorder.

Patients with anxiety disorders often suffer in silence, either believing that worrying is simply part of their personality or because they are embarrassed to ask for help. At the same time, physicians often fail to pick up on the clues that a patient is chronically anxious because they don't know what questions to ask or feel competent or confident enough to make an assessment.

Further complicating matters, the symptoms of anxiety often are masked by other mental or physical conditions, such as depression. As a result, although anxiety disorders are more common than any other class of psychiatric disorder, they are often undetected and untreated.

Anxiety disorders are often undetected and untreated.

Anxiety disorders comprise a number of different forms of nervous distress that come on suddenly and impede daily routines. They include generalised anxiety disorder, obsessive-compulsive disorder, panic disorder, social phobia and other phobias, and post-traumatic stress disorder. Untreated, these conditions can interfere with treatment of physical disorders and contribute to missed workdays, poor functioning, and diminished health-related quality of life.

"Primary care physicians can play a critical role in helping patients live healthier, happier, and more productive lives," says Timothy Peterson, PhD, associate director of the Massachusetts General Hospital's Department of Psychiatry and assistant professor of psychiatry at Harvard Medical School. "Primary care physicians tend to be the first to see mental health problems and are in a position to screen patients and diagnose anxiety disorders early on."

He adds that it is important for physicians to learn the evidence-based treatments and help to remove the stigma from mental illness and accept a medical model of treatment, including prescription medications.

In this "In Practice" article, Peterson provides an overview of how to diagnose and provide evidence-based treatments for anxiety disorders.

Recognising Anxiety Disorders

First, says Peterson, it is important to routinely ask patients about their mental state. "It is very common for providers to not ask these questions. But just like assessing for any other area of health, if you don't ask about it you won't uncover any problems."

Beyond a verbal check-in, physicians should have patients fill out validated rating scales such as the Beck Anxiety Inventory and Beck Depression Inventory. These inventories quickly assess the severity of patient anxiety and reduce the overlap between anxiety and depression through a series of questions that address physiological and cognitive components of anxiety by asking patients to rate subjective, somatic, and panic-related symptoms.

"Some clinics in the US have all patients fill out the inventories at their first visit," Peterson notes.

If an anxiety disorder is present, appropriate lab tests may be needed to determine whether anxiety is due to a physical disorder or drug. It is also important to determine whether anxiety is a symptom of another mental disorder. A family history helps in making a diagnosis because some patients seem to be predisposed to the same anxiety disorders their relatives have.
Specific Disorders

Patients with generalised anxiety disorder worry excessively, with almost daily anxiety about many activities or events, and this anxiety lasts for six months or more. These patients also experience at least three of the following: restlessness, unusual fatigability, difficulty concentrating, irritability, muscle tension, or disturbed sleep. The cause of generalised anxiety is unknown, but it commonly coexists with one or more psychiatric disorders, including major depression, specific phobia, social phobia, and panic disorder. Women are twice as likely to be affected by generalised anxiety disorder as men.

Obsessive-compulsive disorder is characterised by anxiety-provoking ideas, images, or impulses (obsessions) and by urges (compulsions) to do something that will reduce that anxiety. Typically, people with OCD will perform repetitive, purposeful rituals to balance their obsession, for example hand washing, checking locks, or hoarding. Often patients will hide these rituals out of embarrassment. Depression is a common secondary feature of OCD.

A panic attack is the sudden onset of a discrete, brief period of intense discomfort or fear, accompanied by physiologic or cognitive symptoms. Isolated attacks are common, affecting as many as 1 in 10 people in a given year, and may not require treatment. Panic disorder is characterised by repeated panic attacks, typically accompanied by fears about future attacks or behavioural changes aimed at avoiding future attacks. Panic disorder is much less common than isolated panic attacks and affects women 2-3 times more often than men.

Phobic disorders consist of persistent, unreasonable, intense fears of situations, circumstances, or objects. The fears provoke anxiety and avoidance. Phobic disorders may be general, such as social phobia or agoraphobia (fear of experiencing an embarrassing situation) or specific, such as zoophobia (fear of animals) or acrophobia (fear of heights). Like other anxiety disorders, the cause is unknown. Phobic disorders are diagnosed based on the patient inventory and history.

If there appear to be no other causes and the anxiety is very distressing, interferes with daily functioning, and does not resolve on its own within a few days, an anxiety disorder is present and should be treated, says Peterson.

Treating Anxiety Disorders

Anxiety disorders tend to respond to the same first-line treatments as depressive disorders: selective serotonin reuptake inhibitors (SSRIs). The choice of medication depends on the type and severity of disorder and the patient's history.

The most commonly used psychotherapy for anxiety disorders is cognitive-behavioural therapy (CBT), in which a psychologist teaches the patient to restructure his or her thought patterns, replacing distorted thoughts with more realistic substitute ideas, changing behaviours.

"The main challenge with CBT is having access to trained providers," says Peterson. Some studies indicate that SSRIs and CBT are more effective when used together than either is alone. But other studies contradict these findings. "For the most part, whether to use medication or CBT alone or in combination depends on the patient," Peterson says. "Based on an extensive review of the literature, the general rule of thumb is that the more severe the symptoms are, the more likely we are to recommend both forms of therapy."

Exposure therapy, in which the patient confronts what he or she fears, helps to lessen the fear and diminish avoidance behaviours. This form of therapy is most commonly used in treating phobias and is often the only treatment needed for specific phobias.

As for whether to prescribe medication or psychotherapy, Peterson advises deferring to the patient's preference. "We know in psychiatry that there is a large placebo effect to many of our treatments," he explains. "If we are working against our patients' wishes we probably won't be successful," he says. He adds that the same holds true for psychotherapy.

Other factors that influence which method of treatment to choose include the patient's history of treatment - for example, whether the patient has been treated before and if so, what the patient has or has not responded to. Another factor is any medical illnesses that might influence the medication. "We don't want to pick treatments that will exacerbate any comorbid illness," Peterson cautions.

Relaxation techniques, such as yoga and meditation, and biofeedback may be of some help with anxiety disorders, but few studies have documented their efficacy. Still, Peterson says, these therapies are being actively studied, which is promising. Guidelines for anxiety and depression have been issued by the American Psychiatric Association and the Agency for Healthcare Policy Research and Quality. Both provide evidence-based treatment guidelines that can be accessed via the Web.

InformationDr. Peterson will discuss cultural issues in managing anxiety disorders as part of a continuing medical education (CME) course, "Mental Health for Primary Care Physicians and Other Healthcare Professionals" taking place in Dubai November 8 - 9, 2007.

For more information, please email info-hmsdc@hms.harvard.edu

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