Anxiety and Anxiety Disorders

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[edit] Anxiety and Anxiety Disorders

David M. Benedek

Charles C. EngelJr.

Anxiety may be defined as a diffuse and unpleasant sense of apprehension and restlessness. Often the main symptoms of anxiety are physical, such as headache, tremor, chest tightness, palpitations, stomach discomfort, or perspiration (Table 49-1). When overlooked, minimized, misdiagnosed, or mismanaged, these symptoms can become enigmatic, frustrating, costly, and disabling. Normal anxiety is a universal experience, an adaptive response to new or threatening situations that allows a person to take appropriate preventive measures. Less often, anxiety becomes pathologic, interfering with social, occupational, or interpersonal functioning because of its timing, intensity, or duration. If anxiety assumes certain disabling patterns for an individual, it may be diagnosed as a disorder. Disabling anxiety may also be a manifestation of other problems, such as another psychiatric disorder, a general medical condition mimicking a psychiatric disorder (see Table 49-3), or the undesired effects of a medication or drug of abuse.✢✢The views expressed in this article are those of the authors and do not reflect the offical policy or position of Walter Reed Army Medical Center, the Department of the Army, Uniformed Services University, the Department of Defense, or the U.S. Government.

Table 49-1 Physical Manifestations of Anxiety and Anxiety Disorders

Table 49-3 Common Medical Conditions Associated with Anxiety

Disabling anxiety, although less common than normal anxiety, is surprisingly prevalent among people seeking health care. A basic understanding of its natural history, differential diagnosis, clinical features, and primary care management can improve the physician's effectiveness when addressing anxiety-related complaints or determining the need for specialist collaboration or referral.

[edit] EPIDEMIOLOGY

Anxiety disorders are among the most common psychiatric disorders in the general population (Box 49-1). The National Comorbidity Study reported that one in four people meets diagnostic criteria for at least one anxiety disorder during their lifetime and that the 12-month prevalence of anxiety disorder is 17.7%. The PRIME-MD 1000 study found that 18% of patients presenting to primary care physicians meet criteria for at least one anxiety disorder. In general, women are twice as likely to experience anxiety disorders as men. Anxiety disorders, particularly panic disorder, are strongly associated with frightening physical symptoms and heightened patient concerns regarding physical illness. Despite physician reassurances, patients with anxiety frequently attribute autonomic symptoms to catastrophic medical problems and make multiple visits to emergency or ambulatory care settings. Anxiety disorders frequently go unrecognized, and patients may see numerous physicians and receive many unnecessary diagnostic tests before the correct diagnosis is made. Physicians must actively poll patients for prototypical anxiety symptoms to make the appropriate diagnosis (Box 49-2). When an anxiety disorder is present, treatment is usually best initiated empirically and without delay, since it can be easily discontinued if another medical problem is uncovered.

[edit] PATHOPHYSIOLOGY

Regardless of diagnostic category or classification, the etiology of anxiety symptoms is complex and stems from multiple factors. Contributors include biologic abnormalities and genetic predisposition, behaviorally conditioned or learned responses, and both conscious and unconscious psychosocial stressors.

[edit] Psychologic Theories

Freud originally posited that anxiety stemmed from unconscious sexual tension. Later he viewed anxiety as a “signal” communicating the presence of danger in the unconscious. This is similar to current behavioral or social-learning theories that view anxiety as a conditioned response to environmental stimuli. For example, a passenger may escape from a serious automobile accident with minor injuries but experience tremendous fear, anxiety, and autonomic hyperactivity during the event. Consequently, this person may develop mistrust for the driving of others or suffer panic attacks when riding in a car. Cognitive psychology might view this as an example of cognitive distortion. Because of the recent and traumatic nature of the accident, the victim overestimates (distorts) the likelihood of another accident occurring and consequently overreacts to the possibility with disabling anxiety symptoms when driving.

[edit] Biologic Theories

The observation that anxiety is frequently accompanied by observable signs of autonomic nervous system (ANS) hyperactivity (e.g., tremor, diaphoresis) has led to theories relating ANS dysregulation to the pathogenesis of anxiety disorders. Subsequent studies have demonstrated that ablation of the locus ceruleus (a brainstem site where noradrenergic cell bodies are localized) inhibits the ability of primates to form a fear response. Studies also show that β-adrenergic and α₂-adrenergic antagonists increase firing rates of neurons in the locus ceruleus and provoke panic attacks in some individuals, providing further support for such theories. Infusions of sodium lactate may also precipitate panic attacks, leading to the hypothesis that panic involves an excessive centrally mediated respiratory response to hypoxia. Observations that serotonergic and noradrenergic neurons project to similar locations within the limbic system and cerebral cortex and that serotonergic antidepressant medications help in anxiety disorders have prompted investigation into the role of serotonin in the genesis of anxiety. Studies using brain scans suggest abnormalities in regional cerebral blood flow among people with anxiety disorders. Finally, the role of the inhibitory neurotransmitter γ-aminobutyric acid (GABA) in anxiety disorders is strongly supported by the anxiolytic effects of benzodiazepines. These drugs probably decrease anxiety by increasing the activity of the GABA-A receptor.

Studies indicate that heredity contributes to the onset of anxiety disorders by both genetic and environmental mechanisms. Although only about 1% of the general population suffers from panic disorder, approximately half of all patients with panic disorder have at least one affected relative. Other anxiety disorders show similar but less dramatic familial associations.

[edit] SPECIFIC DISORDERS

[edit] Substance-induced Anxiety Disorder

After phobias, substance use disorders are the most common mental disorders. Virtually all substances of abuse, as well as many prescription medications and over-the-counter preparations, may result in clinically significant anxiety as a result of cumulative effect, intoxication, or withdrawal (Table 49-2). Substance-induced anxiety may take the form of generalized anxiety, panic attacks, obsessive-compulsive symptoms, or phobias. Many patients with anxiety disorders “self- medicate” with drugs of abuse in misguided attempts to feel better. Obtaining a longitudinal history in patients with substance misuse and anxiety can offer clinical evidence regarding which problem is primary.

Table 49-2 Substances and Medications Associated with Anxiety

[edit] Anxiety Disorder Due to General Medical Condition

A variety of medical conditions can present with symptoms of anxiety (Table 49-3). Hypothyroidism, hyperthyroidism, hypoglycemia, and vitamin B₁₂ deficiencies are among the most common conditions associated with anxiety. Cardiac dysrhythmia or endocrine tumors (e.g., pheochromocytoma) less frequently produce episodic anxiety symptoms. Careful attention to patient history, physical examination, and focused diagnostic testing directed by clinical suspicion is imperative for anxious patients, especially those with disease risk factors. Treatment of anxiety may proceed as the diagnostic evaluation is undertaken.

[edit] Panic Disorder

Panic disorder is diagnosed when a patient experiences one or more panic attacks that occur without environmental provocation (i.e., are “uncued”) and are accompanied by at least a month of fear about further attacks or worry about the implications of the attack (e.g., worry about having a heart attack or “going crazy”). One of the most debilitating aspects of panic disorder is the impact of subsequent worry that another panic attack will occur in a public or open space. This fear is called agoraphobia and occurs in varying degrees for most people with panic disorder. In extreme cases, patients are so fearful of having an attack they refuse to leave their own homes.

[edit] Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is often chronic; 25% of patients relapse within 1 month of discontinuing a 6-to 12-month course of treatment, and 60% to 80% of patients relapse within a year. Excessive worry or anxiety about several events or activities (e.g., school or work) characterizes GAD. Symptoms occur most days over 6 months or longer and result in significantly impaired functioning. Three of the following six symptoms are necessary: (1) restlessness or feeling “keyed up” or on edge, (2) easy fatigability, (3) difficulty concentrating or mind going “blank,” (4) irritability, (5) muscle tension or a feeling of weakness, and (6) sleep disturbance (difficulty falling or staying asleep, restless sleep).

[edit] Adjustment Disorder with Anxious Mood

Disabling anxiety within 3 months of an identifiable stressful event suggests an adjustment disorder with anxious mood. If symptoms persist for 6 months or longer after resolution of the stressor, another disorder should be considered. A careful patient history often elicits one or more recent stressful events (e.g., newly diagnosed chronic or terminal illness, job change, divorce, relocation). The temporal association between an event and symptoms as well as the patient's sense that the event contributed to distress help confirm the diagnosis.

[edit] Acute Stress Disorder and Posttraumatic Stress Disorder

When a person is involved in an extremely traumatic or catastrophic event (e.g., natural disaster, motor vehicle accident, sexual assault), flashbacks, nightmares, hypervigilance, heightened startle response, and other signs of autonomic arousal may accompany anxiety symptoms. When these symptoms occur within a month of the event and symptoms are not yet persistent beyond 4 weeks, acute stress disorder is diagnosed. When symptoms start more than 4 weeks after the stressful event or persist for more than a month, posttraumatic stress disorder (PTSD) is diagnosed. Chronically poor coping, poor functioning, and substance misuse are often present, frequently predate the traumatic event, and may complicate the diagnosis and management of PTSD.

[edit] Obsessive-Compulsive Disorder

Recurrent intrusive thoughts, feelings, or ideas are obsessions. Repetitive rituals such as checking, handwashing, or counting are termed compulsions. When obsessions and compulsions are extensive and cause marked distress, consume large amounts of time, or create other disability, obsessive-compulsive disorder (OCD) is diagnosed. In persons with OCD, obsessions result in increased anxiety, whereas compulsions are maladaptive attempts to reduce anxiety. Most OCD patients recognize at some point that their obsessions and compulsions are unreasonable or irrational. Because obsessions often manifest violent or sexual themes, and because the compulsions that reduce them have social consequences (e.g., fighting, masturbation), patients may be reluctant to share these symptoms with their physicians. In patients with undiagnosed anxiety symptoms, screening questions regarding obsessions or compulsions may provide the patient “permission” to disclose these symptoms (see Box 49-2).

[edit] The Phobias (Social Phobia, Specific Phobia, Agoraphobia)

A phobia is an irrational fear that causes the person to avoid the feared object or situation or that produces marked anxiety or panic attacks when the feared object or situation cannot be avoided. Persons with social phobias have excessive fears of humiliation or embarrassment in social settings (e.g., speaking in public, attending a party). Small animals or insects, heights, needles, dentists, and airplane flights are among the more common foci for specific phobias. Persons with panic disorder often develop agoraphobia, the fear of open spaces or public places, as a result of worry that an uncontrollable panic attack will occur in such a location. Agoraphobia may also occur in the absence of panic disorder. Epidemiologic studies have demonstrated that phobias are the most common mental disorder in the U.S. population, 15% of whom acknowledge having one or more phobias during their lifetime. Although phobias are extremely common, on average they are the least disabling of the anxiety disorders. Most persons with phobias either choose to live with them or overcome them without medical attention. For some, however, social or specific phobias may have severe occupational or social consequences.

[edit] Mixed Mild Anxiety and Depression

Perhaps the most common primary care presentation associated with anxiety does not meet the formal criteria for any psychiatric disorder. Anxiety occurs along a spectrum of severity and disability, and much recent attention has focused on subsyndromal forms of anxiety and depression. The level of disability associated with subsyndromal anxiety is usually less than that associated with the more characteristic anxiety syndromes just described. Because most anxiety encountered in primary care is not associated with a psychiatric disorder, however, the prevalence of subsyndromal anxiety is high, accounts for a large portion of the primary care physician's clinical time, and is associated with the largest proportion of population disability due to anxiety. Similarly, consistently effective management of subsyndromal symptoms and associated psychosocial stressors can have a substantial impact on the average health of the physician's patient panel. The treatment of subsyndromal anxiety and depression is currently the focus of intense, primary care–oriented clinical research.

[edit] DIFFERENTIAL DIAGNOSIS

As described, anxiety symptoms often occur normally or as a manifestation of one of the anxiety disorders. In addition, anxiety symptoms may be caused by other psychiatric disorders (e.g., substance use, mood, psychotic personality) or medical illnesses. Fig. 49-1 diagrams a differential diagnostic approach to anxiety. The first step is to determine whether anxiety symptoms are caused by illicit or prescription substance use. The following questions help discriminate a causal from a coincidental relationship:

• Is there an association between the substance of concern and anxiety symptoms? Is the association consistent over time? Is it consistent across methods of estimating the severity of substance use (e.g., laboratory vs. reported use)? The more consistent and striking the association between symptoms and substance use, the more likely a causal link exists.
  
• Is there a dose-response relationship between the substance of concern and anxiety symptoms? Does the history suggest that periods of more extensive substance use are marked by more severe anxiety symptoms? If so, a substance-induced disorder is more likely.
  
• Which comes first, the anxiety symptoms or use of the substance of concern? If anxiety typically precedes substance use, a substance-induced disorder is less likely.
  
• Is a causal relationship between the substance and anxiety biologically plausible? For example, stimulant intoxication and alcohol withdrawal are more plausible causes of anxiety than is alcohol intoxication.
  

Figure 49-1 Anxiety disorder diagnostic algorithm. Modified from Levinson W, Engel CC, Jr: Anxiety. In Feldman MD, Christensen JF, editors: Behavioral medicine in primary care, Norwalk, Conn, 1997, Appleton & Lange.

The only clinically reliable method of diagnosing a substance-induced anxiety disorder is to observe reduced anxiety after an extended period without the substance of concern. Often, however, significant anxiety symptoms persist despite discontinuation of the suspected substance, or discontinuation of the suspected substance is not possible or feasible.

Next the physician should consider the physiologic relationship between anxiety symptoms and any coexisting medical illness. The same clinical clues used to determine the relationship between substances and anxiety (plausibility, timing, consistency and strength of association, dose- response relationship) are useful for determining whether a given medical condition is causally related to anxiety symptoms. As with substance-induced anxiety, anxiety due to a general medical condition is confirmed if improving the status of the condition consistently reduces anxiety. If no comorbid medical problems exist, if significant anxiety symptoms persist despite the improved status of coexisting conditions, or if improvement of the medical condition is not possible or feasible, the physician should manage the anxiety as a symptom of a primary psychiatric disorder.

Before considering an anxiety disorder as the primary cause of symptoms, the physician should consider other psychiatric disorders that can cause anxiety symptoms. For example, psychosis typically causes anxiety symptoms because patients who are psychotic experience frightening hallucinations or delusions. Depressive disorders are more common and subtle causes of anxiety symptoms than psychosis, especially in primary care settings.

Determining whether a patient's anxiety occurs in discrete episodes, is environmentally or behaviorally cued or relieved, or persists in a “free-floating” manner is a quick and practical way to focus the differential diagnosis (see Fig. 49-1). The physician first determines whether the patient has panic attacks. Panic attacks are sudden, discrete episodes of anxiety that last from minutes to hours. If panic attacks are present, can the patient identify any environmental triggers or “cues”? If panic attacks occur without specific cues, panic disorder is likely. If cues are present, the nature of the cue may suggest the diagnosis. If the cue is a specific event, object, place, person, or situation, one or more of the phobias may be present (social phobia, specific phobia, or agoraphobia). If the cue is a chronic stressor or an event or situation resembling a past traumatic event, adjustment disorder with anxious mood or acute stress disorder or PTSD may be present. If the cue is the interruption of a compulsive ritual or the exacerbation of an obsessive fear (e.g., contamination), OCD is the most likely diagnosis. If panic attacks are not present, panic disorder and the phobias are unlikely. Persistent, free-floating anxiety characterized by worry over several life concerns suggests GAD but may be a prominent feature of any of the anxiety disorders. For example, panic disorder sometimes generalizes from episodic attacks to persistent anxiety.

[edit] MANAGEMENT

The management of anxiety parallels its differential diagnosis. Principal treatment of substance-induced anxiety is discontinuation of the offending substance. This may require a gradual taper (e.g., benzodiazepine-induced anxiety) or cross-treatment with other pharmacologic agents (e.g., alcohol withdrawal) to reduce anxiety symptoms and prevent other complications. Similarly, the primary treatment for anxiety due to a general medical condition is treatment of the underlying condition. If there are no medical or substance-related treatment considerations, or if anxiety symptoms persist even after substance and medical factors are fully addressed, pharmacologic and psychosocial options should be considered.

[edit] Psychopharmacologic Approaches

Medications used for the treatment of anxiety disorders are becoming increasingly safe, tolerable, and effective (Table 49-4; see Chapter 48 ). Primary care physicians should develop skill and experience with one or two agents within each drug class. This section discusses general approaches pertaining only to the treatment of anxiety and anxiety disorders.

Table 49-4 Medications Indicated for Anxiety Disorder Treatment

✢Approved by U.S. Food and Drug Administration for obsessive-compulsive disorder only.

Short-term use of benzodiazepines (8 weeks or less) to reduce incapacitating anxiety and treat insomnia often bolsters coping, improves functioning, and enhances the therapeutic alliance when patients have an adjustment disorder or acute stress disorder. No single medication is highly effective for PTSD, so medication management is usually determined by the presence or absence of various associated disorders, such as major depressive disorder, dysthymic disorder, panic disorder, or a substance use disorder.

Psychopharmacologic treatment of panic disorder generally relies on antidepressants, typically the selective serotonin reuptake inhibitors (SSRIs) or tricyclic agents, with or without benzodiazepine therapy. The different antidepressants are equally efficacious and should be chosen by side effect profile, past patient experience, and current patient preference. The favorable side effect profile of the SSRIs and their ease of administration have increasingly made them the medications of first choice in primary care. Antidepressant therapy, however, is typically not effective until several weeks after therapeutic doses are achieved. The benzodiazepines are rapidly effective and may be used early in a panic attack to abort it. Benzodiazepines may also help to reduce panic attacks in the first weeks of antidepressant therapy and then can be discontinued later to avoid the adverse effects of chronic benzodiazepine use. Unfortunately, tolerance, rebound anxiety symptoms, and potential for misuse often limit the long-term usefulness of benzodiazepines. A few patients with panic disorder require long-term administration of benzodiazepines, however, and collaboration with a psychiatrist may help the primary care physician intermittently reassess the appropriateness of this approach.

Duration of therapy for panic disorder is based on several considerations. Panic disorder is frequently chronic, and duration of therapy is usually 6 to 12 months even when the disorder is mild, uncomplicated, and of recent onset. If symptoms are chronic or seriously disabling, or if previous exacerbation was associated with suicidal ideation or suicide attempts, pharmacologic treatment may be required indefinitely.

Buspirone is effective for GAD but is not effective for other anxiety disorders. Buspirone therapy requires a 3-to 4-week latent period before onset of effectiveness, and it is relatively less effective among patients who have been previously treated with benzodiazepines. Antidepressants do not reduce anxiety for patients with GAD but may reduce the depression that frequently complicates GAD.

OCD is responsive to relatively high doses of SSRIs or clomipramine (a predominantly serotonergic tricyclic agent). As with panic disorder, OCD tends to be chronic, and relapse is frequent even after extended (6 months or more) trials of medication.

Low doses of β-blocking agents such as atenolol or propranolol are often helpful for phobias when exposure to the focus of fear can be anticipated and medication administered in advance. These agents block many of the autonomic manifestations of anxiety but do not reduce the subjective sense of fear or worry. Care must be taken to avoid the adverse effects of these agents (e.g., hypotension, lethargy). These agents are not effective for anxiety symptoms unrelated to a phobic stimulus.

Antipsychotic (neuroleptic) agents are seldom if ever indicated as maintenance therapy for anxiety in the absence of psychosis. These agents are not habit forming and will reduce anxiety, but they are associated with an unacceptably high risk of tardive dyskinesia, an iatrogenic and treatment-resistant movement disorder that can be extremely disabling.

[edit] Psychosocial Approaches

Primary care physicians vary in the amount of time, skill, and motivation they bring to the care of patients with anxiety. Physicians should maximize, however, their awareness and level of comfort with using a number of primary care–based strategies for ameliorating anxiety symptoms and related disability. These strategies include patient education, reassurance, behavioral modification, problem solving, physical reactivation, relapse prevention, support groups, and self-help tools.

[edit] Patient Education.

All patients benefit from a clear understanding of their problems. Primary care physicians should equip their waiting rooms with take-home literature on the basic anxiety disorders. The stigma associated with psychiatric disorders may prevent many patients from asking for literature unless it is readily accessible. Clinics should equip their patient libraries with more intensive education materials, such as self-help books, videotapes, and fact sheets, that can be made available to patients as indicated.

Physicians should develop, practice, and memorize a few simple and direct explanations for patients with various anxiety disorders. This eases stigma, increases patient trust and hope, and enhances patient adherence to treatment. It is essential to emphasize the biologic nature of anxiety disorders and the availability of effective therapies. For example, patients with panic disorder may be told the disorder is caused by a malfunctioning “fight-or-flight” switch in the brain that causes it to switch “on” without warning at inappropriate times, and medicines can help “recalibrate” the switch. Explaining the biologic nature of symptoms reduces the guilt, shame, and self-doubt that many people with panic disorder experience.

[edit] Reassurance.

Reassurance is critical for patients with anxiety, especially those with prominent physical health concerns. Panic disorder involves the rapid and unexpected onset of protean physical symptoms. Consequently, many patients with panic disorder seek urgent medical care and not psychiatric care. Before the patient can be reassured, it is typically necessary to evaluate worrisome physical symptoms (e.g., chest tightness, shortness of breath). Once an appropriate evaluation is completed, the physician should avoid repeating diagnostic tests unless new objective findings are present, since unnecessary testing is costly, increases the likelihood of false-positive results, and leads patients to think they have an undiagnosed illness.

Reassurance is also important for patients who have suffered stressors or traumatic life events that are driving anxiety symptoms. Patients with acute stress disorder should be reassured that nightmares, flashbacks, and autonomic arousal in the immediate posttraumatic period do not necessarily indicate a chronic mental illness. Empathic comments help patients feel understood (e.g., “The symptoms you describe are common and normal when people go through an awful experience like the one you had.”).

[edit] Problem Solving and Physical Reactivation.

Physicians often underestimate the value of offering their anxious patients brief assistance with problem-solving strategies during the visit. Anxious patients, especially those with adjustment disorder or subsyndromal anxiety, will benefit from efforts to help them identify and troubleshoot their problems. Anxiety can prevent normally high-functioning people from thinking clearly and coping effectively with a life circumstance. Often patients find they have overlooked simple strategies, such as writing out a problem and listing some initial steps to address it. Other patients may not connect their symptoms to a clearly stressful life event, and direct, nonjudgmental questioning may help them connect transient physical symptoms such as fatigue to important stressors.

Simple suggestions to promote physical reactivation, including instructions on light exercise or encouragement to consider leisure activities, can help patients refocus their attention and energy. Patients can track the time they spend in these activities using charts or a diary and review these during follow-up visits.

[edit] Behavioral Modification.

Phobic anxiety symptoms can be blocked with medications, but avoidance of past phobic foci will persist until extinguished using behavioral modification. For example, in panic disorder, medication will reduce the intensity and frequency of panic symptoms, but agoraphobia-related avoidance behavior (e.g., reluctance to go shopping) will continue even in the absence of panic attacks until behavioral strategies are employed. Primary care physicians can help (alone or in collaboration with a nonphysician provider) phobic patients develop and implement a plan for behavioral modification using systematic desensitization. For example, a person with social phobia might be taught to rehearse social speaking in a series of progressively more threatening situations. The patient might first learn and practice relaxation and visual imaging to rehearse speaking before a series of progressively larger and more frightening imaginary audiences. The patient can then practice speaking before a few real but familiar people in a comfortable setting about a safe topic. Later the setting, topic, and size and composition of the audience may be altered gradually to become more threatening as the patient masters the tendency to avoid frightening situations. Desensitization continues as a series of homework assignments until avoidance is overcome and confidence is regained. The key to this approach is gradual and controlled exposure to whatever was previously avoided.

Similar behavioral approaches are also useful for patients with OCD. For example, a patient with compulsive handwashing might be instructed to count the times handwashing occurs each day and eliminate one episode of handwashing every few days. The patient can graph this progress and bring graphs to follow-up appointments. The physician can offer encouragement and reassurance until handwashing occurs normally.

[edit] Relapse Prevention.

Prevention of relapse is especially important for patients with an established history of anxiety problems. Patients with GAD, panic disorder, or PTSD must be reminded of the cyclic nature of their anxiety symptoms. They can be taught to attend to the early physical and social manifestations of anxiety (e.g., increased muscle tension, increased sleep latency, avoidance of certain situations or people) and encouraged to seek early assistance rather than wait until symptoms are severe, disabling, or treatment resistant. Relapse prevention strategies are particularly important to emphasize for people with substance-induced anxiety when the substance is a drug of abuse.

[edit] Support and Self-help.

Often, community support groups are available for people experiencing common situational stressors (e.g., cancer, single parenting, sexual assault, family member with a chronic disease) that give rise to anxiety or exacerbate a chronic anxiety disorder. Support groups help ill patients to realize they are not alone with their problems and to obtain satisfaction helping others encountering similar challenges. For patients with complicating substance problems, Alcoholics Anonymous, Narcotics Anonymous, or similar 12-step support programs have become an important standard of care. The local veterans affairs medical center lists service organizations that offer support groups and resources for military veterans with PTSD. Assistance in finding these and similar groups may be obtained through the clinic's social worker.

Primary care physicians should be able to refer anxious patients to appropriate self-help literature. These books can help patients implement their own self-therapy programs, including cognitive therapies, self-hypnosis, and relaxation techniques for panic disorder, OCD, and coping with stressful situations. A brief bibliography of such books should be maintained and updated in the patient library.

[edit] SPECIALIST COLLABORATION, CONSULTATION, AND REFERRAL

Primary care physicians can effectively treat most patients with anxiety disorders, who may prefer one modality to another. Unfortunately, some disabled patients will reject all treatment unless the physician speaks directly, hopefully, and candidly about the anxiety disorders and the available treatment options. Collaboration, consultation, or referral may be necessary when a patient expresses a preference for a psychosocial treatment the primary care physician is uncomfortable with or unskilled at performing.

Epidemiologic studies have shown that panic disorder is associated with an increased risk of suicide. Patients with suicidal thoughts or a history of suicidal or other forms of risk-taking behavior (e.g., violence) should prompt the primary care physician to consider specialist collaboration or consultation. Erratic behavior (e.g., frequent missed appointments, unstable interpersonal relationships, impulsive actions, criminal charges, aggressive acts) or poor adherence with recommended treatment suggests a personality or substance use disorder. Specialist consultation may help clarify factors complicating effective treatment and may result in recommendations for augmenting strategies or adjunctive treatments.

Incomplete symptom response to feasible primary care intervention in an appropriate time frame should prompt additional referral, particularly with complicating issues such as coexisting medical or psychiatric illnesses. Consultation or collaboration is also suggested for patients with an apparent adjustment disorder if symptoms or related disabilities persist beyond the stressor.

[edit] ADDITIONAL READINGS

• EH Cassem: Depression and anxiety secondary to medical illness. Psychiatr Clin North Am 1990; 13:597.
• GO Gabbard: Psychodynamic psychiatry in clinical practice: the DSM-IV edition. Washington, DC: American Psychiatric Press; 1994:
• R Hales, S Yudofskyeditors: Anxiety disorders. Textbook of psychiatry Washington, DC: American Psychiatric Press; 1995:
• HI Kaplan, BJ Sadockeditors: Anxiety disorders. Synopsis of psychiatry ed 8. Baltimore: Williams & Wilkins; 1998:
• RC Kessler,et al.: Lifetime and 12-month prevalence of DSM-III-R psychiatric disorder in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51:8.
• RL Spitzer,et al.: Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA 1994; 272:22.

[edit] Self-Help Literature

• EJ Bourne: Anxiety and phobia workbook. New York: Fine Communications; 1997:
• RZ Peurifoy: Anxiety, phobias, and panic: a step-by-step program for regaining control of your life. New York: Warner Books; 1995: