Separating anxiety disorders from mimics and masks
From the May ACP Observer, copyright © 2007 by the American College of Physicians.
By Deborah Gesensway
It's a familiar scenario in primary care: as you're preparing to leave the exam room at the end of a 20-minute visit—during which you've reviewed symptoms, signed prescriptions and recommended preventive measures—the patient casually mentions the real reason for her visit.
"Just as your hand is on the door to leave the room," said Pittsburgh, Pa., general internist Francis Solano, FACP, "the patient says, 'Doc. I haven't been sleeping lately, and I've been having trouble focusing at work.'"
Then you recall that your medical assistant remarked that this particular patient has been calling the office lately with all sorts of questions about disparate aches and pains. Up shoots a red flag. Is this a possible anxiety disorder?
Diagnosing an anxiety disorder is akin to detective work, say many primary care physicians. The clues are often there but physicians lack an efficient screening tool, and there is disagreement about the best ways to approach treatment.
That's especially problematic considering that, after substance abuse, anxiety disorders are the most common psychiatric conditions in the U.S. According to the National Institute of Mental Health (NIMH), as many as 18% of American adults—about 40 million people—suffer from an anxiety disorder every year. The most common types are general anxiety disorder, panic disorder, post-traumatic stress disorder, obsessive-compulsive disorder and social anxiety disorder, also known as social phobia.
"We would love to have a screening tool," Dr. Solano said—something to make more efficient the time-consuming and notoriously flawed job of teasing out whether that patient is just transiently worried, stressed and anxious or whether she is suffering from a persistent and damaging anxiety disorder—quite possibly alongside depression—that warrants treatment.
"We are about 20 years behind when studying anxiety as compared to depression."
—Kurt Kroenke, MACP
"We are about 20 years behind when studying anxiety as compared to depression," explained Kurt Kroenke, MACP, professor of medicine at Indiana University School of Medicine and research scientist at the Regenstrief Institute for Health Care in Indianapolis.
Screening for hidden symptoms
A new study published in the March 6 issue of Annals of Internal Medicine may provide physicians with a much-needed anxiety screening tool. (See sidebar.) The new tool, called the GAD-7 (The Generalized Anxiety Disorder Scale), includes several questions that easily can be incorporated into a busy primary care visit.
Authors of the study, led by Dr. Kroenke, found that even asking only the first two questions in the GAD-7 can provide some answers. The patient is asked, "Over the last two weeks, how often have you been bothered by the following problems: Feeling nervous, anxious or on edge? Not being able to stop or control worrying?"
Using a standard tool takes some of the guesswork out of diagnosis, which is made more difficult with a condition that many sufferers deliberately mask.
"Anxiety doesn't always present as anxiety," explained Peter P. Roy-Byrne, MD, professor of psychiatry and behavioral science at the University of Washington Medical School in Seattle and a principal investigator of a large, NIH-funded multicenter study of a primary care intervention strategy for anxiety disorders. "People who are anxious don't look like they are nervous and jittery," he said. "An individual with social anxiety disorder who goes to their doctor may just appear to be haughty and unfriendly, because they are avoidant."
It is also common that people suffering from anxiety disorders complain of physical symptoms. The most common are gastrointestinal distress, such as irritable bowel, sleep disorders, fatigue, headaches, palpitations and panic attacks. Studies have found that people with anxiety disorders are three to five times more likely than non-sufferers to go to the doctor or to be hospitalized. They undergo many more tests and procedures and report poorer quality of life and more disability than people who have the same physical symptoms but not anxiety.
"We spend a fair amount of time looking and fishing for answers when the answer turns out to be under our nose the whole time—anxiety or depression or both," Dr. Solano said. "You do have to make sure there is not a medical illness, or that they don't have some kind of bipolar disorder or substance abuse, and sometimes women have atypical chest pain. So, you can't ignore the symptoms," but it still would be nice to have a way to screen for anxiety at the same time to save time—let alone potentially unnecessary medical tests and procedures.
Moreover, unlike depression, which has lost much of its stigma over the last couple decades, the label of anxiety still carries shame for many patients. Anxious people tend to differ from depressed ones in that they are "much less likely to think they have a problem and that they need treatment," said Dr. Roy-Byrne. Studies, he said, have found that people with anxiety disorders look more like people with substance abuse problems than those with depression in this regard. "That makes it that much harder for primary care docs to effectively recognize it."
Dennis Stull, ACP Member, a general internist in Pittsburgh, Pa., whose patient base includes many university and graduate students and other young adults, often deals with the opposite problem. For him, he said, the challenge often is figuring out how worried is worried. This group tends not to feel any stigma about the diagnosis, and everyone seems to know somebody on medication.
"People come to me all the time and tell me they think they need to be on [paroxetine] or have a prescription for [alprazolam]," he said. "People have self-diagnosed a lot of times, and then I have to figure out if this person is just stressed out or if they have an anxiety disorder Do they really have an anxiety disorder, or are they just nervous about what's going on in their lives?"
Dr. Stull has come up with his own strategy to deal with these patients—mostly aimed at "buying time"—so that he can work up whatever physical complaints need to be checked out, raise the ideas of anxiety and depression with people, talk about diet, exercise and sleep hygiene, give them a prescription for 10 or 20 low-dose benzodiazepine tablets "to get them through their test or problem" and schedule a follow-up appointment two or three weeks hence.
During that period, he said, usually two things happen: He gets back any blood work or other testing results, occasionally picking up a previously undetected physical problem like thyroid disease or anemia, and the patient has had time to think more about how persistent or intrusive his anxiety is.
"I'm usually reassured on that second visit that either that person doesn't really have anxiety or depression or that, yes, they really do," Dr. Stull said. Now in his sixth year of primary care practice, Dr. Stull said he also has come to believe that the working up physical complaints can be therapeutic in and of itself. EKGs, for example, ordered if patients are complaining about palpitations, "have a very powerful therapeutic effect. You can show it to them, and they are reassured. And if you don't do a work-up, you are going to miss things. It has happened to me."
Familiar treatments aren't enough
A number of new NIH-funded studies, some still underway, are offering clues and tips for physicians struggling with this extremely prevalent but understudied set of mental health disorders.
These long-lasting mental illnesses that share symptoms of "excessive, irrational fear and dread," according to NIMH, can get worse if they are not treated and commonly occur alongside other mental or physical illnesses, including depression and alcohol or substance abuse. Study after study has suggested that only about half the people with anxiety disorders are receiving treatment, many because of detection problems, others because of rejection by patients of the diagnosis and medical treatment for it.
Although most of the SSRI and SNRI antidepressants have been approved by the FDA for treatment of anxiety disorders, curing anxiety is not as simple as writing a prescription. Anxiety experts say that people with these mental health problems—even more than with depression—often need the kind of hand-holding, intensive follow-up and concomitant psychotherapy that is difficult to deliver in busy primary care offices. Collaboration is needed, but given many insurance companies' mental health carveouts and lack of integrated health care, providing and paying for that remains an enormous obstacle for most patients.
While most of the antidepressants that primary care physicians are familiar with are helpful in treating both anxiety and depression, they should not always be used in the same way, say experts. Although antidepressants are helpful for many anxiety disorders, they are not always sufficient.
Anxiety sufferers often need additional medications—particularly benzodiazepines—during the first weeks and sometimes months of treatment. Psychotherapy, particularly cognitive-behavioral therapy (CBT)—is also helpful in teaching coping skills.
The "legacy of valium" overuse, however, means that internists generally have been wary about prescribing benzodiazepines, Dr. Kroenke said. "Specialists believe there is a role," he said. "It's like opiod use for chronic pain; there is a role, but you don't want to overuse it."
In terms of antidepressants, anxiety experts generally recommend that patients with anxiety be started on much lower doses of antidepressants—usually half the usual dose typically prescribed for depression.
"They (anxiety sufferers) are much more sensitive to side effects, and they are much more worried about their body being under the sway of some foreign substance."
—Peter P. Roy-Byrne, MD
"They (anxiety sufferers) are much more sensitive to side effects, and they are much more worried about their body being under the sway of some foreign substance," Dr. Roy-Byrne said. At the same time, the biggest problem psychiatrists see, he noted, is that patients referred from primary care are taking insufficient dosages.
Another frustrating stumbling block that primary care physicians regularly run up against is that even when a patient they diagnose with an anxiety disorder agrees to begin treatment, they often stop their antidepressants before they have time to work, if they even fill the prescription in the first place.
"It's like the 'Princess and the Pea' story," said Bruce L. Rollman, ACP Member, an associate professor of medicine and psychiatry at the University of Pittsburgh and an author of several articles on treatment of anxiety in primary care. "Anxious people are more sensitive to side effects."
Moreover, anxious people actively avoid putting themselves in anxiety-provoking situations, Dr. Roy-Byrne said, and facing up to their illness can be extremely anxiety-provoking.
This paradox is another of the most frustrating common scenarios in primary care: Dr. Solano in Pittsburgh describes what he calls the vicious cycle that can exasperate both patients and doctors. "The minute you talk to them [about starting treatment], they get extremely anxious just about the thought of it. They don't want to admit they are anxious because they are anxious about getting treated."
Initiating treatment in the primary care setting, therefore, can be helpful. Anxious people are more likely to accept the diagnosis and treatment if it is coming from someone they trust and with whom they have a long relationship—namely their primary care physician, Dr. Roy-Byrne said.
Dr. Solano agrees: "If I have an anxious person and I say, 'I think you have an anxiety disorder. Why don't you go see a psychologist or psychiatrist?' that ends the conversation. They are too anxious to act."
One major problem with trying to treat anxiety in the primary care setting, however, is that most insurance plans, including Medicare, will not pay for it. And problems are bigger that just figuring out how to get paid—research on the topic shows that patients with anxiety need more than a prescription; they need frequent follow-up and behavioral counseling.
"It's often more than primary care doctors can do by themselves," said Risa Weisberg, PhD, assistant professor of psychiatry and human behavior and family medicine at Brown University Medical School and the author of a recent study published in February in the American Journal of Psychiatry, which found that nearly half of primary care patients with at least one anxiety disorder go untreated. Anxiety disorders don't "tend to go away on their own."
While primary care physicians have had an effective and easy way to screen for depression among their patients since the much circulated and widely adopted PHQ-9 (Primary Care Evaluation of Mental Disorders Patient Health Questionnaire) made its way into practice, they have not had a similar simple anxiety screening tool at their fingertips. And although the two common mental health problems often go hand-in-hand, the depression-screening tool is not sensitive for anxiety.
"At the front line, you want to be able to recognize anxiety, and if you use only depression measures, you may miss them," said PHQ co-developer Kurt Kroenke, MACP, professor of medicine at Indiana University School of Medicine. "And secondly, you want to be able to recognize it because if you are treating them for depression and they aren't getting better, they may also be having co-existing anxiety, and they may require specialized treatment."
In fact, when a patient's depression doesn't seem to be responding to antidepressants, the problem very likely could be co-morbid anxiety. Studies have consistently found that about half the patients with depression have anxiety too and vice versa: about half the people diagnosed with anxiety disorders also have depression.
The new anxiety screening tool—called the GAD-7 (The Generalized Anxiety Disorder Scale)—is similar to the PHQ in that the answers patients provide to its several questions can easily be incorporated into a busy primary care office as a quick valid screening tool. (Articles by Dr. Kroenke and his colleagues describing the tool and its questions are online here and here.)
The authors also found that simply asking the first two questions can work as a valid anxiety screening tool too: "Over the last two weeks, how often have you been bothered by the following problems? 1-Feeling nervous, anxious or on edge? 2-Not being able to stop or control worrying?"
Dr. Kroenke said he is now testing a four-question anxiety and depression primary care screening tool that incorporates the first two depression screening questions from the PHQ-9 (about depressed mood and anhedonia) plus the first two GAD anxiety screening questions to be able to screen for patients who are suffering from both depression and anxiety.
Testing the GAD questionnaire, he said, also showed that the four most common major anxiety disorders (generalized anxiety, panic disorder, social anxiety and PTSD) perhaps share more in common than they differ. Primary care physicians, they concluded, mayd start treatment before determining which specific anxiety disorder exists; only if first-line treatment doesn't work, do specialists need to drill down further to make a specific diagnosis and order psychotherapy tailored to that disorder.
- Prescribe an SSRI or SNRI-type antidepressant approved by the FDA for anxiety. These include paroxetine, citalopram, fluoxetine, fluvoxamine, sertraline and venlafaxine; consider avoiding the most activating ones, including fluoxetine. Start with half the usual starting dose and titrate up slowly to a full dose.
- Consider in select cases of very anxious patients prescribing a benzodiazepine concurrently for the first few weeks before the antidepressant's effects can be felt. Do not prescribe it on as "as needed" basis, but instead advise patients to take it every day. Ensure that patients do not suddenly stop taking the antidepressant, but rather, taper them down and discontinue their use after the antidepressants start working.
- Follow-up with weekly or biweekly phone calls to make sure patients are taking their medication. Empower your practice's nurses or other workers to do that, or find other ways to provide collaborative care.
- Have a high suspicion that the patient also suffers from alcohol or substance abuse.
- Rule out a diagnosis of bipolar disease before prescribing antidepressants.
- Recommend cognitive-behavioral therapy.
- Advise patients to become active and avoid fewer activities, along with taking their medication.
- Refer to psychiatry in cases of suicidality, manic depressive illness or psychosis.
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