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How to better diagnose and treat anxiety disorders

From the May 1995 ACP Observer, copyright 1995 by the American College of Physicians.

By Bob Keaton

Learning to correctly diagnose and treat patients with panic and anxiety disorders can improve the quality of their lives and, in some cases, even save lives, according to Mark H. Pollack, MD, director of the anxiety disorders program at Massachusetts General Hospital and associate professor of psychiatry at Harvard Medical School.

"You can make a big difference by medicalizing panic and anxiety disorders," he said, "since 11% of primary care office visits are from patients complaining chiefly of 'anxiety/nervousness.' "

Studies show that 60% of patients with panic and anxiety disorders are treated by primary care physicians. "That means you have a tremendous opportunity to help these patients and make a major difference in their lives," Dr. Pollack said during a workshop on pharmacologic treatment of panic and anxiety disorders.

Ninety percent of patients with panic and anxiety disorders are initially misdiagnosed, Dr. Pollack said. These patients are often in and out of primary care physicians' offices with chest pain or palpitations, epigastric pain, irritable bowel syndrome, headaches, dizziness, syncope and shortness of breath or feelings of choking.

Drug and cognitive-behavioral therapy are available to treat all of the panic and anxiety disorders. But to correctly diagnose patients with these problems, physicians should first ensure that the condition is not caused by a cardiac, neurologic, gastrointestinal or respiratory problem. They should also check for alcohol or drug withdrawal and possible side effects from other medications patients may be taking.

Panic and anxiety disorders usually have an early onset--late teens or 20s--and there is often a personal or family history of anxiety. Psychosocial influences may also play a role. Dr. Pollack emphasized that it is important to find out if the patient is also experiencing depression, because that can influence treatment. "And the only way to find out is to ask if they have any of the symptoms associated with depression," he said.

Dr. Pollack described the symptoms and diagnostic criteria for the following disorder and phobias:

  • Panic disorder. Patients with panic disorder have recurrent, unexpected panic attacks. The criteria for panic disorder diagnosis state that at least one of the attacks is followed by more than a month of persistent concern about additional attacks or worry about the implications of the attack or its consequences. There may also be a significant change in behavior related to the attack. Patients with panic disorder may also have agoraphobia--anxiety about being in places or situations from which they feel that escape might be difficult or embarrassing. Untreated panic patients may die young from cardiovascular disorders or suicide.
  • Social phobias. There are two types of social phobias--generalized, which happen in most social situations, and performance, which occur only in specific situations, such as when a person has to give a speech. Since there is some selectivity in treatment, it is important to recognize this condition. Patients with generalized social phobia respond to the newer serotonin selective reuptake inhibitors, the monoamine oxidase inhibitors and the high-potency benzodiazepines, such as alprazolam or clonazepam. They do not do as well on tricyclic antidepressants. Patients with performance anxiety respond well to beta blockers.
  • Post-traumatic stress disorder. This has been highly publicized as a disorder of veterans, especially Vietnam veterans, but also occurs in the general population in people who have experienced a horrifying trauma. Treatment usually involves psychotherapy and treating the symptoms, such as depression, with medication. One study shows fluoxetine to be effective.
  • Generalized anxiety disorder (GAD). The criteria for diagnosing GAD are excessive anxiety and worry (about several events or activities) occurring more days than not for at least six months. The patient finds it difficult to control the worry and has three of these six symptoms: restlessness, fatigue, concentration difficulty, irritability, muscle tension and sleep disturbance. Up to three-fourths of patients with GAD also have depression. These patients should receive antidepressants in addition to (or in lieu of) benzodiazepines.
  • Specific phobia. Patients with specific phobias are afraid of one or two situations, such as flying. Most people with specific phobias don't seek medical help; they just avoid the situations. The age of onset varies by the type of phobia.
  • Obsessive-compulsive disorders (OCD). As much as 3% of the population experiences obsessive-compulsive disorders. OCD is typified by recurrent, intrusive thoughts that seem senseless or frightening, and/or repetitious, purposeful, intentional behavior, performed in a stereotyped fashion in response to an obsession. OCD can cause marked distress and interfere with normal functioning.

Drugs to treat these conditions differ somewhat in their specific indications and side-effect profile. Three major classes of antidepressants are used to treat patients with anxiety and depression: serotonin selective reuptake inhibitors, tricyclic antidepressants and monoamine oxidase inhibitors. To optimize therapy, Dr. Pollack said, physicians should be aware of such critical issues as dose, duration, compliance and strategies for discontinuation. In most cases, he added, treatment for these disorders requires ongoing maintenance.

Serotonin selective reuptake inhibitors are broad-spectrum antidepressants for panic, anxiety, depression. They can increase anxiety initially, noted Dr. Pollack, "so it's critical to start patients on low dosages." In general these drugs are better tolerated and have fewer side effects than older antidepressants. They can cause gastrointestinal distress, so patients should take them after eating. They can also cause jitteriness, sleep disturbances and like all antidepressants, sexual disturbances.

Dr. Pollack recommends telling patients up front about the possible side effects, since studies show that compliance is greater if patients are informed initially. These medications take two to six weeks to be effective. Since all serotonin selective reuptake inhibitors can interact with other drugs, physicians should be aware of other medications their patients may be taking.

Tricyclic antidepressants, which have been around for about 30 years, are effective in panic disorders with or without depression. They are less expensive than the serotonin selective reuptake inhibitors but have more side effects, including anticholinergic effects, orthostatic hypotension, cardiac conduction disturbance, weight gain and sexual disfunction.

Venlafaxine, a relatively new antidepressant, is generally well-tolerated and though not extensively studied yet, likely effective for anxiety disorders. It must be taken twice daily.

Monoamine oxidase inhibitors are effective for all types of depression, but Dr. Pollack said, "I would generally use them only if other agents failed because of the diet restrictions and concerns about hypertensive reactions." People taking monoamine oxidase inhibitors should avoid foods containing tyramine, such as aged or smoked meats, cheeses and red wine, since they do not metabolize tyramine or other sympathomimetic agents, which may cause dramatic and dangerous increases in blood pressure.

Bob Keaton is an Atlanta-based freelance writer specializing in medical issues.

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