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Don’t be anxious about psychiatric diagnoses

From the June ACP Internist, copyright 2013 by the American College of Physicians

By Stacey Butterfield

It doesn’t usually take intensive questioning to identify a patient with a common psychiatric problem such as anxiety disorder, according to Heidi Combs, MD, assistant professor of psychiatry at the University of Washington and Harborview Medical Center in Seattle.

Just ask the patient how much time he or she spends worrying in a day, she advised attendees of the “Psychiatry: Beyond Depression” session at Internal Medicine 2013, held in San Francisco in April. “People with generalized anxiety disorder will often say, ‘Uh, all the hours I’m conscious?’” Dr. Combs said.

During the session, she provided tips on screening and treatment of several mental disorders likely to be seen by internists, including somatoform, bipolar and anxiety disorders. “You see these patients all the time. Anxiety disorders in primary care are very, very common,” Dr. Combs said.

These disorders also cause more problems for patients than physicians may realize. “Patients with anxiety disorder really struggle,” she said. “Because they don’t get hospitalized, it doesn’t translate in our heads as impairing function.”

A series of questions brief enough for a busy internist to fit into a short visit can identify many of these patients, including “Have you ever experienced a panic attack?” to identify panic problems or “Have you ever had anything happen that still haunts you?” for post-traumatic stress disorder (PTSD).

Social anxiety disorder, which often starts as early as high school, Dr. Combs noted, can be diagnosed with a question like “When you are in a situation where people can observe you, do you feel nervous and worry that they will judge you?” Asking “Do you get thoughts stuck in your head that really bother you or need to do things over and over like washing your hands, checking things or counting?” can uncover obsessive-compulsive disorder.

With any of these quick screens, “if you get a positive hit, it will take longer to go down the path” of complete diagnosis and treatment, Dr. Combs acknowledged. But it’s also reasonable to take note of the positive answer and return to the issue when you have time, she said. Follow-up can include administering the Hospital Anxiety and Depression Scale (a 14-question self-rating), the Generalized Anxiety Disorder 7-item scale, or the panic module of the Patient Health Questionnaire.

Bipolar disorder is a bit trickier to diagnose than the other conditions and often goes unrecognized by primary care physicians, Dr. Combs said. Studies have shown that 25% to 50% of patients diagnosed with major depression actually have bipolar disorder, she reported. “There are really good reasons why that’s the case. Do patients come in to see you when they’re manic or hypomanic? Heck no, they see you when they’re depressed.”

Alcohol abuse and family history of bipolar disorder (both of which are more common in bipolar patients than depressed ones) can be diagnostic clues. Other clinical features include a history of postpartum depression, antidepressant-induced mania or a hyperthermic personality (“people who are a notch or two above positive all the time,” described Dr. Combs).

If you suspect bipolar disorder, there are several screens you could give a patient, all of which have some evidence to support their effectiveness. The Structured Clinical Interview for DSM-IV is the gold standard for diagnosis, but it doesn’t fit well into primary care, Dr. Combs acknowledged. “I imagine a lot of you don’t have time for any of that stuff,” she said.

There are also several questionnaires that patients can complete themselves, including the Mood Disorder Questionnaire 1, the Bipolar Spectrum Diagnostic Scale, and the Hypomania Checklist 32.

“They aren’t perfect, so you’re going to have to use your clinical acumen,” Dr. Combs said. When questioning a patient with suspected bipolar disorder, Dr. Combs usually starts by asking about depressive symptoms (which most people are more comfortable talking about) and then asks if the patient has ever experienced “the opposite.”

With somatoform disorder, Dr. Combs views it “as physical manifestations of people’s psychic distress,” she said. “[If] a patient has a pan-positive [review of systems], you need to stop looking at medical problems and start looking at psychiatric problems.”

Physical symptoms are the cause of more than half of patients’ clinic visits, and one-third of the symptoms are medically unexplained, Dr. Combs said. She noted that many medical specialties have their own diagnoses to describe this problem, including irritable bowel syndrome, atypical/noncardiac chest pain, postviral fatigue syndrome, conversion disorder, multiple chemical sensitivities and pelvic pain.

These patients are frustrating to treat, Dr. Combs acknowledged. “They come to see you a lot, and they’re not happy that you can’t fix them, and you aren’t happy that you can’t fix them,” she said.

After diagnosis of any of these psychiatric conditions, “Now you’ve got to do something about it,” said Dr. Combs. If a patient has an anxiety disorder, he or she should be screened for possible comorbid psychiatric conditions, such as other anxiety disorders and depression.

“It is the exception that they have an anxiety disorder and nothing else,” said Dr. Combs, citing research that 90% of patients with generalized anxiety disorder have another Axis I disorder in their lifetimes and 66% have one concurrently.

“The nice thing about anxiety disorders is that they’re pretty treatable,” said Dr. Combs. The primary treatments for anxiety are cognitive behavioral therapy (CBT) and pharmacotherapy. “For mild to moderate anxiety disorder, CBT is as effective as medication” with the additional advantage that you don’t have to take it forever, she said.

Among the medication options, antidepressants to increase serotonin are the first line of treatment and should be started at low doses, since they tend to increase anxiety at first. “Which one you use, I don’t care,” given that the efficacies are similar, said Dr. Combs. “Start tiny and warn them it’s going to get worse before it gets better ... You have to ride through it.”

She starts patients at half or even a quarter of the usual dose and has them titrate up as they feel ready. Benzodiazepines can also be used to get patients through this initial bumpy ride, but consider the risks of dependence and tolerance. Patients who have a history of substance abuse or dependence shouldn’t take benzodiazepines, and “Don’t use alprazolam!” warned Dr. Combs. The drug peaks early and leaves the blood quickly, causing patients to take another pill soon afterward.

Other options for anxiety treatment include hydroxyzine, buspirone or anticonvulsants. “Gabapentin is one I actually use quite a bit. The patients can’t get toxic on this,” Dr. Combs said.

She also offered a drug treatment pearl for PTSD. Dr. Combs asked how many in the audience prescribe prazosin for nightmares, and some hands went up. “That’s awesome,” she said. “It’s a nice ace in the hole to have for patients with PTSD.” Start the drug at 1 mg at bedtime for three nights, and then increase it by 1 mg every three nights until nightmares improve or the patient develops postural hypotension, she advised. Some patients might require as much as 10 mg.

Other drug treatment choices for PTSD include selective serotonin reuptake inhibitors and venlafaxine, mood stabilizers, beta-blockers and clonidine.

As with anxiety, CBT can be good for PTSD patients, but don’t force them to recount their traumatic experiences, Dr. Combs said.

“People have this idea that they have to get this off their chest. For some patients, it’s absolutely true. For other patients, it’s countertherapeutic,” said Dr. Combs. Let the patient decide what he or she wants to reveal, and remember that therapy can be effective long after the traumatic event. “Even women who have had PTSD for more than 30 years can lose the diagnosis when they get CBT,” said Dr. Combs.

Treating somatoform disorder requires empathy and good communication. “First, acknowledge their suffering. It is no less painful, no less distressing for them than for someone who has an organic cause” of their symptoms, said Dr. Combs.

Then, warn patients that while you will thoroughly investigate their symptoms, you might not find a physical cause of their problem. “Bring up this idea early, early, early,” she said. “Once you feel you have turned over the rocks, stop testing.”

It can be hard to avoid overtesting, she acknowledged, because somatoform patients will usually develop new symptoms and visit multiple physicians. “These problems tend to morph from one symptom to another over time,” Dr. Combs said. “It’s like the shell game.”

Try to focus the conversation on the patients’ suffering, rather than symptoms, and train them to use CBT strategies to deal with their problems. “You teach people that they can have control of the situation that they’re experiencing and how their symptoms manifest,” said Dr. Combs.

Using relaxation techniques and engaging in pleasurable physical activities, even for as little as 10 minutes, can be a helpful distraction. Increasing patients’ awareness of the link between their emotions and the severity of their symptoms can also improve the condition.

See these patients regularly, not just when they’re in crisis or presenting a new symptom. Otherwise, “It reinforces that they have to be ill to get care,” she said.

You should also screen somatoform patients for comorbid psychiatric conditions and try to get them off any opioid medications they’re taking. Antidepressants are the most commonly used medication for somatoform disorder, although there have been relatively little data to support this. “There’s really a paucity of information about treatments for this patient population,” Dr. Combs said.

The analgesic effects of antidepressants may be responsible for their beneficial effects, or they may work because somatic symptoms are the result of undiagnosed anxiety or depression. “For some patients, it’s like they have a magnifying glass on their entire body. Some antidepressants can help to make them experience these things less intensely,” Dr. Combs said. Among other drug treatment options, levosulpiride and topiramate also each have one study supporting their effectiveness in somatoform disorder, she reported.

If you do use medication to treat somatoform disorder, be prepared for patients to have lots of drug side effects, and make sure that they don’t expect a pill to eliminate all their problems. “You want them not to have an unrealistic expectation of what the medication is going to do,” she said. “If you give them the idea that this pill is going to fix them, and it doesn’t, they’ll be disappointed.” Compare it to diabetes or hypertension, conditions that are managed rather than cured, Dr. Combs suggested.

And remember to dig deep into your “empathy well,” she recommended. “They are not trying to make you miserable, and they are not trying to make themselves miserable,” she said. “This is the best coping strategy that they have.”

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