Now, don't be nervous,
but we’re going to be talking
about anxiety disorders now.
And let's start with a case to help illustrate
this common condition that we see in primary care.
Now, remember back when I gave
the introduction of family medicine,
the way we approach the patient
and I mentioned that you have
to respond to patient's cues.
And they’re telling you something
verbally or non-verbally,
you want to make sure
that you pay attention to it.
This is one of those cues.
So, if I come –
walk in the room
and I see a patient has taken off her
clothes and is bent in this position,
I know something is
pretty wrong right away.
This has never happened before.
But let's see what her story is.
She looks in distress.
You’re seeing a 22-year-old woman,
eight months history of anxiety symptoms
which bother her on most days of the week
and they have led to
So, sounds like a case of anxiety.
Let’s get a little bit more history.
She worked with a therapist already
and she's tried relaxation therapy,
but she now presents with –
and she is desiring medical treatment.
She has never taken any chronic
medications for anxiety in the past.
So, right away,
let's think about what we
want to do for treatment.
What will be the best choice for initial
pharmacotherapy for this patient.
Is it, A, a benzodiazepine;
B, tricyclic antidepressant;
C, an SSRI;
or D, bupropion?
The answer to me is C.
SSRIs have a strong track record of efficacy
in patients with generalized anxiety disorder
and they are generally better tolerated
than some of the other agents listed there
and don't have the risk for misuse
and addiction that benzodiazepines have.
So, we’ll go over therapy,
but that's after we get through
our usual discussion of epidemiology,
symptomatology and diagnosis first.
So, anxiety is very, very prevalent.
So, the lifetime prevalence
of an anxiety disorder,
you can see it's well higher among women versus men.
Women have up to a 7, 7.5% risk whereas men have an average
risk of 4% overall for generalized anxiety and panic disorder.
So, what are the risk factors for anxiety disorders?
As I just mentioned, female sex is one.
It is hereditary.
Family history is important.
Comorbid mental health disorders.
And so, this could be –
the most common one being depression,
but also bipolar disorder,
post-traumatic stress disorder can also be
associated with significant anxiety and anxiety disorders.
And then, other physical diagnoses.
Pain is one that's frequently
related to anxiety disorders.
particularly irritable bowel syndrome is one I think
is commonly reflected in anxiety disorders as well.
And then a history of abuse.
So, that could be physical abuse or sexual abuse
associated with a higher risk of anxiety as well.
What about the diagnostic criteria
for generalized anxiety disorder.
First of all, the symptoms should be
present for at least six months.
This is a chronic disorder.
They include anxiety and then they have to
have at least three of the following symptoms –
restlessness, fatigability, difficulty concentrating,
irritability, muscle tension or sleep disturbance.
So, anxiety present for at least six months
with three of those other symptoms,
which shows when you’re
talking about fatigability,
difficulty concentrating, sleep disturbance,
all those are related to function too
and they really can have a
significant impact on one's life.
Panic disorder, I actually think the criteria
here are a little bit more lenient.
So, the definition of panic is a severe
anxiety that peaks within minutes.
So, it really feels –
we call them panic attacks
because it feels like an attack.
It comes on.
Sometimes it's cued by certain things,
maybe being in an enclosed space or some
other memory that's triggered that produces panic.
A lot of times, it arises out of nowhere.
And then it goes away spontaneously
within minutes as well.
Now, it has to be associated with
at least four other symptoms.
And I’m just going to highlight a few of them because these describe
some of the symptoms that are common in panic disorder.
Palpitations being one.
Getting chest pain.
Getting tremulous, shaky.
But there are seven more.
That shows you how panic disorder can be very
serious and promotes this grand total of symptoms.
So, many patients will have all of these
symptoms in single episodes of panic.
And so, it's the panic episode itself and then
worrying about the panic and what’s called agoraphobia,
avoiding situations which cause the panic.
It’s literally –
fear of the marketplace.
That's what takes such a
toll in panic disorder.
So, one thing with anxiety disorders,
pay very close attention to
How is the job going?
Relationships, romantic and also within
family or close friends, those you care about.
How is the financial situation?
What else could be promoting anxiety?
A lot of times, there is a trigger.
And that can be a good
target for talk therapy
or at least talking it out
with you as their physician.
Even that's helpful.
The other thing as a clinical pearl I would offer is that
many times these patients are younger, healthier adults
and don't have the chronic disease
that I see among my older patients.
These labs, hemoglobin, thyroid
stimulating hormone, basic metabolic panel,
they are a good idea to do in
patients with anxiety disorders,
but I wouldn't repeat them
on a routine basis
just because the symptoms are continuing.
Get them one time.
And if everything remains
you shouldn’t get them for years afterwards
because it's rare that I see evolving hyperthyroidism
in somebody with generalized anxiety disorder.
Usually, it’s just the continuing anxiety
disorder that gives them symptoms.
So, in terms of treatment
for anxiety disorders,
start with non-pharmacologic therapy first.
That includes limiting caffeine.
That's fairly obvious.
There's no treatment that's quite as
good for generalized anxiety as exercise.
It really does work to reduce anxiety levels.
And it also has the side
benefits of better sleep.
I think it's really empowering because patients
can use it to help control their own illness.
So, it's empowering that way.
It leads to more satisfaction.
And, of course, it helps create a
healthy weight, more muscle mass,
less risk of diabetes and hypertension.
All of those, good things.
When it comes to pharmacotherapy,
first-line therapy really is
a serotonin reuptake inhibitor.
There is evidence of fair efficacy and the
drugs are generally safe and well tolerated.
Tricyclic antidepressants can
also be used for panic disorder,
but there's a problem with tolerability
due to anticholinergic side effects.
Buspirone is another option,
but it’s just less effective.
So, it’s a second line agent.
I don't recommend them generally
for most patients for long-term use
because of the potential
for misuse and abuse,
but they can be helpful
for short-term situations.
And where I use benzodiazepines is particularly
for patients with severe psychosocial stressors.
So, they just lost a loved one or they just
went through an eviction this week.
Benzodiazepines may take the edge off
that anxiety for another five or seven days,
but usually that's the
limitation I had put on it,
is a week of treatment or so.
In terms of the clinical course,
patients can feel heartened that,
while it usually comes on
while they’re in early adulthood,
there are a number that
Whereas most developed,
more chronic disease,
40% recover fully within 12 years.
Even among those who recover, though,
there is a risk for dysthymic
disorders and depression.
That may be as high as 50%.
So, that’s something to
watch even among patients
who have experienced a
regression of their anxiety.
And when you diagnose a patient with
both depression and anxiety at the same time,
that predicts a longer clinical course.
Unfortunately, also greater
So, what we learned today was that
anxiety disorders are very, very common.
And not to go overboard with
your laboratory diagnosis.
Definitely pay attention to
SSRIs in terms of pharmacotherapy are a great option,
but don't forget about the basics,
limiting caffeine and increasing
exercise very important.
And also, consider talk therapy.
That can really work well for some patients
and is a nice adjunctive treatment for
patients with anxiety disorders.
Thank you very much.