Pearls about anxiety disorders

Anxiety disorders, which include generalized anxiety disorder, social anxiety, phobias, and PTSD, cause great personal distress, missed work, and overuse of medical services. They are also associated with neuro-hormonal changes that might predispose patients to other medical conditions such as COPD, diabetes, hypertension, and osteoarthritis. However, it’s important not to become fatalistic since recovery happens for many people–40% within 2 years.

It can be hard to decide if a patient truly has an anxiety disorder: do they have something else, like an MI, a PE, hyperthyroidism, or drug-induced feelings of anxiety? Do they have somatization and complain of symptoms that can’t be explained by diagnostic workups? Do they have obsessive tendencies? Do they live in a dangerous neighborhood and have a “normal” reaction to their surroundings? Are they being abused?

Are they depressed? Just as there is a PHQ-9 for depression, there is a GAD-7 for anxiety that patients can fill out in the office to help figure out if they have treatable anxiety. Most people would say that a score of 10 qualifies a patient for treatment.

Speaking of depression, the DSM-V states that a patient who has been diagnosed with depression can only be diagnosed with anxiety AFTER their depression has gone into remission. There’s controversy surrounding this, but suffice to say in a patient with depression and anxiety, depression should be treated first.

Generalized anxiety disorder in particular carries an independent risk for suicidality. It’s always important to ask patients with anxiety if they have suicidal ideation!

As far as treatment goes, meta-analyses have found no difference between medications and therapies like cognitive-behavioral therapy. Plenty of patients cope through activities like yoga and meditation.

If prescribing medication, SSRIs and SNRIs should be your first choice. Because they take 2-4 weeks to see an effect, you can use benzos in the meantime to provide relief for acute anxiety. Try to avoid using benzos long-term, obviously–and pause before prescribing for elderly patients, patients with seizure disorders, hepatic impairment, or respiratory issues. Pregabalin (Lyrica) may be helpful for anxiety attacks, and buspirone (Buspar) for generalized anxiety. Re-evaluate the treatment in 6 months.


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