Anxiety is a common, normal and useful response to life’s challenges and dangers, and is therefore part of the human experience. It is usually experienced as a vague sense of uneasi-ness. When we are confronted with a danger, anxiety causes us to get out of the way of the danger. When we are faced with a test, either in an educational setting, or a test of our skills in the workplace, anxiety may be the driving force behind our preparation to meet this challenge; without the anxiety we might not prepare and therefore might fail the test! Anxiety can become overwhelming and cause problems with our ability to function. When this happens in a transient situation, we are often able to deal with the situation and then move on to other issues in our lives. When the feeling of being overwhelmed continues for more than a brief period of time, it can become problematic. Fear is different than anxiety. Fear is generally thought of as a response to a known, external, definite threat, while anxiety is a response to an unknown or internal threat.
Anxiety in a Complex World
Most adults have experienced anxiety. Things such as intense worry or fear, difficulty con-centrating, a “keyed up” feeling, accompanied by physical symptoms such as sweating, palpitations, dry mouth, hot flashes or chills, dizziness, trembling, restlessness, shaking and muscle tension are common when one is anxious. Anxiety has an effect on the general health of an individual. Anxiety can also affect thinking, perception and learning. It can result in confusion and distortion of perceptions, which can affect learning.
Many people talk about stress rather than using the term anxiety. There are physiological responses that occur when the body is under stress detailed by Hans Selye (1956) in the General Adaptation Syndrome (GAS) including the alarm stage (fight or flight), the
• Anxiety in a Complex World
• Prevalence and Description of the Problem
• Anxiety in Primary Care Settings and Differential Diagnosis
• Presentation of Anxiety Disorders
• Co-morbid Psychiatric Problems and Anxiety
• Assessment Issues
• Treatment: Psychotherapeutic and Pharmacologic
• Self-management Strategies
• References
resistance/recovery stage, and the exhaustion stage. Psychological defense mechanisms such as denial, projection, rationalization, and intellectualization are the psychological system’s response to anxiety that threatens our physical, mental, and social selves. An individual’s perception of an event as well as the person’s coping mechanisms is what determines how stressful an event is to that person and how much anxiety the person may experience.
Anxiety in American society was dramatically changed on September 11, 2001. As people worldwide witnessed the attacks in New York, Pennsylvania, and Washington, D.C. and sat glued to their television sets, we entered a new age of anxiety. Prior to these events, anxiety was primarily a personal issue related to the stressors of everyday living. Current difficulties related to the financial state of one’s country bring anxiety to the forefront as people become anxious about their ability to provide for food and shelter for their families. Anxiety about diverse issues is common across cultures.
It is important for primary care providers to differentiate between anxiety about a common life situation, and anxiety as a symptom of a psychiatric illness. Additional information about the person, one’s family, and life circumstances will assist the primary care provider to develop an understanding of the problems and appropriate questions to pursue in assessment of the individual (see Chapter 3, Crisis Care Basics). Severity of the anxiety, as well as duration of the symptoms and effect on how the person functions in daily activities, can help determine the need for treatment and follow-up care.
Prevalence and Description of the Problem
Anxiety disorders are the most common mental health problem in the U.S., affecting an estimated 40 million adults. Anxiety problems are highly treatable, yet only one-third of those suffering with anxiety receive any treatment (ADAA, 2008). The National Co-morbidity Study (National Institute of Mental Health, 2009) reported that one in four people in the U.S.
met the diagnostic criteria for at least one anxiety disorder, and that the prevalence rate for anxiety disorders was 18 % in a six-month period. Women have a higher level of anxiety than men and the prevalence of anxiety decreases with higher socioeconomic status.
Anxiety problems cost the U.S. more than $42 billion a year, accounting for almost one-third of the country’s mental health bill of $148 million (ADAA, 2008). Over half of this amount is associated with the use of healthcare services. People with anxiety problems most often seek care from primary care providers first for symptoms that mimic physical illnesses.
People with anxiety are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than those without anxiety (ADAA, 2008).
Common somatic signs of anxiety are listed in Box 6.1.
Anxiety in Primary Care Settings and Differential Diagnosis
Anxiety is common in any primary care practice. Who among us has not gone to a medical appointment as the result of some symptoms and feared for the worst outcome? When people feel that their physical well-being is in a state of change, perhaps putting them at risk for some unknown disease, it can strike fear in their hearts and cause great anxiety. In primary care settings more than half of the medical visits are for somatic complaints, which are most often associated with anxiety or depression.
There is some evidence that chronic anxiety can lead to long-term health problems. The Framingham Heart Study found connections between anxiety and hypertension in men aged 45–59 (Kubzansky, 2009). Other studies have examined the association of anxiety to heart attacks. In a 2005 study, women aged 65 and older with anxiety were found to have more difficulty with activities of daily living (Sareen, Cox, Clara, & Asmundson, 2005).
Box 6.1 lists the most common somatic signs and symptoms of anxiety. Many people come into a primary care setting presenting with these symptoms and never endorse problems with anxiety or worry unless asked about these problems. Questions related to life events and changes in everyday functioning may assist in determining anxiety as a problem. Often, laboratory tests will be needed to rule out any medical cause of the anxiety.
Additionally, several medical conditions (Box 6.2), intoxication or withdrawal from cer-tain drugs and/or alcohol, as well as side effects of several medications (Box 6.3) may cause symptoms related to anxiety. Complete physical work-up of these conditions should take place, based on presenting symptoms, physical examination, and thorough history before arriving at a diagnosis of anxiety (see Assessment and Screening Tools).
BOX 6.1 Somatic Signs and Symptoms of Anxiety
• Anorexia • Fatigue
• Backache • Flushing
• Butterflies in the stomach • Headache
• Chest discomfort • Hyperventilation
• Diaphoresis • Light-headedness
• Diarrhea • Muscle tension
• Dizziness • Nausea
• Dyspnea • Urinary frequency
• Palpitations • Paresthesia
• Vomiting • Sexual dysfunction
• Faintness • Shortness of breath
• Pallor • Sweating
• Dry Mouth • Tremulousness
• Tachycardia
BOX 6.2 Medical Illnesses that Mimic Symptoms of Anxiety
• Respiratory Illnesses • Cardiovascular Disorders – Asthma – Angina
– COPD – Arrhythmias – Hypoxia from any cause – Atrial tachycardia – Pulmonary embolism – Mitral valve prolapse
– Myocardial infarction
• Endocrine Disorders • Orthostatic hypotension – Acute intermittent porphyria – Congestive heart failure – Carcinoid syndrome – Coronary artery disease – Cushing’s syndrome
– Hyperthryroidism • Neurological Disorders
– Hypoglycemia – Aura of migraine
– Insulinoma – Cerebral neoplasia
– Hypothyroidism – Delirium
– Pheochromocytoma – Demyelinating disease
– Menopause – Early dementia
• Metabolic Disorders • Partial complex seizures
– Acidosis • Vestibular disturbance
– Electrolyte abnormalities – Brain tumor
– Substance Abuse/Dependence – Cerebral syphillis
– Hyperthermia – CVA
– Pernicious anemia – Huntington’s chorea
– Wilson’s disease – Multiple Sclerosis
– Pain
Source: Adapted from Pollock, Otto, Bernstein & Rosenbaum, 2004; Saddock & Saddock, 2003
BOX 6.3 Medication Side Effects that Mimic Symptoms of Anxiety
• Analgesics • Intoxication and/or withdrawal from:
• Antibiotics – Analgesics/narcotics
• Digitalis – Alcohol
• Anabolic steroids – Sedative/hypnotics
• Anticholinergic agents – Benzodiazepines
• Antidepressants – Nicotine
• Antihypertensives – Opiates
• Antiparkinson agents – Methamphetamine
• Anticonvulsants – Phencyclidine (PCP)
• Antihistamines – Ecstacy (MDMA)
• Anti-inflammatory agents
• Aspirin
• Caffeine
• Coritcosteroids
• Neuroleptics
• Indomethacin
• Ephedra
• Theophyllin
• Chemotherapy agents
• Sympathomimetics
• Thyroid supplements
• Bronchodilators and decongestants
• Cocaine
• Epinephrine
• Cannabis
• Oral contraceptives
• Anesthetics
• Toxins
CASE EXAMPLE: ANXIETY IN THE FAMILY
Maria Rodriguez is a 23-year-old single woman from Puerto Rico. She comes to see her primary care provider (PCP) only to find out that the provider, a nurse practitioner (NP) who cared for her for the last year and a half, has moved out of state, and she has been assigned to a new NP. She is very quiet in her presentation, has no eye contact and is looking sus-piciously around the room as if thinking about running out of the room. She is very hesitant in her responses to medical questions; when asked about her mood, substance abuse, or any family history of mental illness she gets up and starts pacing in the room. The main reason for the visit is that she has been experiencing abdominal pain for about a week and a half. The nurse practitioner is beginning to think that there may be a mental health problem and is not sure at all how to proceed since Maria is not being very cooperative with the history.
The nurse practitioner finally says to Maria that she seems very nervous and that she wonders if there is something she is worried about. At this point, Maria bursts into tears and says that her beloved aunt Tina had bad abdominal pain just like she is experiencing and that when she went to the doctors to find out about the pain she was diagnosed with liver cancer and died within three months of that visit. Maria is terrified that she also has liver cancer.
This scenario is more common than most professionals would predict and is rarely the kind of information that patients offer freely. The necessity of paying attention to the mood of each individual patient and asking clearly about the mood can often elicit information that would not be revealed otherwise. The intervention may be very brief, as it was in this case, allowing the PCP to move on to other parts of the assessment. Reassurance that the similar symp-toms would make anyone frightened and the fact that making the appointment quickly after the appearance of symptoms was the right thing to do, may be all that is necessary to do at this point. Following a physical exam and other tests, the nurse practitioner was able to rule out the liver cancer.
Presentation of Anxiety Disorders
Anxiety Disorders are classified in the DSM-IV-TR (APA, 2000) as: Acute Stress Disorder, Generalized Anxiety Disorder, Panic Disorder, Social Phobia, Specific Phobia, Obsessive-Compulsive Disorder, and Post-traumatic Stress Disorder. There are also anxiety problems associated with medical conditions and their treatments and anxiety problems associated with medications and substance use and withdrawal (Boxes 6.2 and 6.3).
Acute Stress Disorder Acute stress disorder is characterized by the development of anxiety and other symptoms, within one month of exposure to a traumatic stressor. This includes personal experience of an event involving a threat (actual or perceived) of death or personal injury, witnessing such an event, or learning about an unexpected or violent death, serious harm or threat of death experienced by someone close to you such as a family member or close associate. The response to the stressor must include intense fear, helplessness, or horror.
The individual will also show signs of re-experiencing the event, such as recurrent images, thoughts, dreams, illusions, or flashbacks. The person will also avoid any stimuli associated with the event and experience numbing and symptoms of arousal such as difficulty sleeping, irritability, poor concentration, hypervigilance, motor restlessness or exaggerated startle response (APA, 2000). The DSM-IV-TR criteria requires that there must be significant distress or impairment of functioning over at least two days and less than four weeks, occurring within four weeks of the event to be classified as an acute stress disorder (APA, 2000).
Generalized Anxiety Disorder (GAD) Generalized anxiety disorder presents with excessive uncontrollable worry and anxiety over everyday issues. People with this problem can agonize over job responsibilities, finances, health issues, personal appearance, and family well-being and relationships. This excessive worry can affect daily functioning and can cause multiple physical symptoms. The focus of the worry and anxiety may shift from day to day. The inten-sity, duration, and frequency of the worry is disproportionate to the real situation; the person is often aware that the fears are out of proportion to the situation; yet is not able to control the anxiety. People who have this problem may be very irritable, restless, and complain that they feel on edge, are easily tired and have trouble sleeping. Normal daily activities may become impossible to maintain. GAD affects 2–3% of the U.S. population (Swartz, 2006).
GAD commonly occurs with other anxiety disorders, depression, and substance abuse. It can be difficult to diagnose since it lacks the dramatic presentation seen with a panic attack.
Panic Disorder Panic disorder is twice as common in women as in men. It affects approx-imately 2.7% of the U.S. population or six million people. Attacks usually begin in the late teens or early twenties and often are not diagnosed. Only about one in four people with panic attacks receive adequate treatment.
Many otherwise healthy people may experience an isolated panic attack and never expe-rience one again; this does not signify a diagnosis of panic disorder. A panic attack is an abrupt onset of an episode of intense fear or discomfort that peaks in about ten minutes and lasts only about 20–30 minutes. People experience a feeling of imminent danger and the need to escape, as well as physical symptoms such as: palpitations, sweating, trembling, shortness of breath, a choking feeling, chest pain or discomfort, dizziness, lightheadedness, a sense of things being unreal or feeling detached, a fear of losing control or “going crazy,” a fear of dying, tingling sensations, and/or chills or hot flashes. The intensity of these physical symp-toms frequently brings patients to an emergency setting. In the popular movie Something’s Gotta Give Jack Nicholson portrays a man who presents to the ER with chest pain that is a panic attack.
Panic disorder is diagnosed when the person has recurrent and unexpected panic attacks accompanied by persistent concerns about having more attacks, continued worry about the meaning or implications of the attack, and a change in the person’s behavior due to the attack.
A complication of panic is agoraphobia—the fear of being in public places. This fear may have developed as a result of trying to avoid situations and places that have triggered panic attacks. Panic disorder with agoraphobia can severely restrict a person’s life. Panic disorder occurs co-morbidly with depression, substance abuse, and suicidal thinking.
Social Phobia Social phobia is also called social anxiety disorder and describes people who have extreme and persistent anxiety in social situations. This can include performance anx-iety and fear of public speaking. The main problem is the fear of embarrassment or ridicule that accompanies the anxiety. The person is able to recognize that the fear is not reasonable or is out of proportion to the situation, but the anxiety persists and the person will either avoid or tolerate the situation with great discomfort. Anticipatory anxiety is often a problem with the person experiencing significant anxiety for days or weeks prior to the event.
Social phobia is more common in women, typically beginning in childhood or adolescence and associated with shyness and social inhibition. Approximately 15 million people (in the U.S., or 6.8% of the population) are affected by social phobia (ADAA, 2008). A stressful public experience may intensify the problem (Swartz, 2006).
Specific Phobia Up to 8% of the adult U.S. population may suffer from one or more specific phobias. Usually phobias develop during childhood and may persist for years or decades.
Specific phobias do not generally develop as the result of a single traumatic event. Instead there is often evidence of a phobia in another family member and/or social or vicarious learn-ing of phobias (Swartz, 2006). Panic attacks may also be involved in the development of specific phobias.
The DSM-IV-TR describes specific phobia as a marked and persistent fear of the presence or anticipation of a specific object or situation; the fear is excessive or unreasonable and is often recognized as unreasonable by the person (APA, 2000). The avoidance of the specific object or situation causes significant distress and interferes with the person’s functioning.
Obsessive-Compulsive Disorder (OCD) Obsessive-compulsive disorder is characterized by recurrent, repetitive thoughts (obsessions), or behaviors (compulsions), or both. The person recognizes these thoughts or behaviors as unreasonable and intrusive, and that they interfere with ability to function in job, school, and/or relationships. The obsessions and compulsions must take at least up to an hour a day, every day, and interfere with normal social and occu-pational functioning to meet DSM criteria for diagnosis (APA, 2000).
“Obsessions are defined as recurring and persistent thoughts, ideas, images, or impulses, sometimes of an aggressive nature, that seem to invade a person’s consciousness” (Swartz, 2006, p. 51). The thoughts are experienced as intrusive and inappropriate and cause anxiety or distress. Some of the more common examples of obsessions include fear of contamination from germs, thoughts of aggressive or violent behavior or fear of harming oneself, and a fear of making a mistake.
Compulsions are repetitive and ritualistic behaviors that are performed following a specific set of rules or patterns. The behaviors are aimed at reducing distress or preventing some dreaded event or situation. The behavior temporarily relieves whatever tension is brought about by obsessive thoughts. Some of the more common types of compulsive behavior include checking and rechecking to make sure that doors are locked, windows closed, appli-ances are turned off, repetitive hand washing accompanied by an obsession with germs and dirt and excessive neatness, cleanliness and organization, and hoarding behavior.
OCD occurs in about 1–2 % of the population, up to 2.2 million adults in the U.S. One-third of people with OCD first experience symptoms as children. OCD occurs equally among men and women, and accounts for 6 % of the $148 billion yearly mental health bill (ADAA, 2008). Mild OCD may allow people to function with only minimal interference with their daily activities, while severe OCD may be incapacitating. Common comorbid psychiatric problems that occur with OCD include depression and substance abuse.
Post-Traumatic Stress Disorder (PTSD) Post-traumatic stress disorder is a chronic problem that follows an exposure to a traumatic event such as a natural disaster, rape or another violent crime, an accident, war, or terrorism. The event must have involved actual or threatened death or serious injury, and the response of the person was intense fear, helplessness, or horror.
Witnessing such events is known to be as stressful as being personally affected by the event.
The symptoms associated with PTSD include:
• recurrent, intrusive, distressing dreams and memories of the event;
• flashbacks and a sense that the event is recurring;
• extreme distress when stimuli that symbolize or elicit memories of the event are encountered;
• avoidance of thoughts, feelings, and activities associated with the event;
• inability to remember parts of the event;
• markedly diminished interest in normal activities;
• feeling of detachment or unreality; dissociation;
• hyperarousal, hypervigilance, exaggerated startle response;
• low expectations of the future;
• insomnia, nightmares, and excessive fatigue;
• extreme irritability;
• inability to concentrate;
• significant distress and impairment in functioning (APA, 2000; Swartz, 2006).
If these symptoms persist for over a month after the event and are associated with severe distress or functional impairment, a diagnosis of PTSD is made. Symptoms usually occur within three months of the event but there may be a delayed onset of symptoms that occurs six months after the event. The chronic nature of this problem adds to the difficulties that a person faces such as low self-esteem, a sense of hopelessness and being permanently dam-aged, difficulties in relationships, difficulties with work and abuse of substances, including alcohol and illicit or legal drugs.
In the general population the prevalence of PTSD in one year is 3.6% with women being twice as likely as men to have this problem. Among those exposed to extreme trauma, about 9% develop PTSD (Satcher, 2008). Hoge and colleagues (2004) studied members of the armed services deployed in Iraq and Afghanistan either before combat or three to four months after their tour of duty. They found major depression, generalized anxiety, and post-traumatic stress disorder (PTSD) among these troups, based on standardized screening, with the highest rates in the group following duty in Iraq. The largest difference was in the screening for PTSD. It is anticipated that as the war goes on, more veterans will be diagnosed with PTSD.
Hoge also found that only 23–40% of the participants sought mental healthcare.
Co-morbid Psychiatric Problems and Anxiety
Nearly one half of people diagnosed with a depressive disorder are also diagnosed with an anxiety disorder (ADAA, 2008). These illnesses can occur at the same time or one may precede the other. One diagnosis may be the primary diagnosis and the other secondary. For example, someone with social anxiety disorder may become anxious about not being able to attend family gatherings and therefore may become depressed. The combination of the two problems may result in greater disability and decreased functioning than either alone.
Additionally, anxiety and substance misuse or abuse are also common co-morbid problems. The desire to self-medicate anxiety may lead to a long-term problem with substances, and the effect of the substances and/or detoxification from the substances may contribute to ongoing symptoms of anxiety. In a study of primary care patients 58% of the patients with a substance use disorder met the criteria for another mental disorder. The most common co-morbid disorders with alcohol misuse were depression and agoraphobia, and with other drug use disorders the most common disorders were specific phobia and agoraphobia (Olfson, et al., 1997). Other research has indicated that social anxiety disorder and PTSD are common co-morbid problems with alcoholism (ADAA, 2008). Having both an anxiety disorder and substance abuse problem may result in a vicious circle effect causing the person to use a substance to deal with the anxiety, and then experiencing more anxiety as a side effect of the substance use, leading to further use of the substance. The implications for treatment are that both problems must be addressed simultaneously for treatment to be effective, and to break the vicious circle.
The National Epidemiological Survey on Alcohol and Related Conditions conducted by the National Institute on Alcohol Abuse and Alcoholism (NIAAA, 2006) reported that about 20% of those with an anxiety or mood disorder have a current alcohol or substance abuse problem. Additionally, this study found that the vast majority of people with both alcohol