Best Dx/Best Rx: Anxiety Disorders

Anxiety Disorders

M. Katherine Shear, M.D.
Columbia University

Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References

Definition/Key Clinical Features

Most common community mental disorders
Shared features

Prominent somatic symptoms
Panic attacks
Anticipatory worrying or fear
Avoidance or compulsive rituals

Frequently occur together with depression

Presages poorer medical outcome

Differential Diagnosis

Panic Disorder

Heart palpitations
Mitral valve prolapse
Cardiac arrhythmias
Hyperthyroidism
Irritable bowel syndrome
Migraine headaches

Posttraumatic Stress Disorder (PTSD)

Insomnia
Substance use disorders
Unexplained fears of medical procedures
Unexplained worsening of medical illness

Generalized Anxiety Disorder

Insomnia
Migraine or tension headaches
Hypertension
Peptic ulcer disease
Irritable bowel syndrome

Social Phobia

Unexplained urinary retention
Academic or occupational underachievement
Mood disorders
Substance use disorders

Obsessive-Compulsive Disorder

Tourette syndrome
Other tic disorders
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS)
Excoriative dermatitis
Unexplained fears of illness

Best Tests

Panic Disorder

Recurrent unexpected panic attacks

Fear of panic or its consequences
Occurs with or without agoraphobia (fear and avoidance of places where it may be difficult to get help or easily leave)

Diagnostic criteria for panic attacks

Development and abrupt peak within 10 min of at least four of the following:

Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sensations of shortness of breath or smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, light-headed, or faint
Derealization (feelings of unreality) or depersonalization (feelings of being detached from oneself)
Fear of losing control or going crazy
Fear of dying
Paresthesias
Chills or hot flushes

Common clinical presentations

Physical symptoms (e.g., palpitations, chest pain)
Anxiety and tension
Hypochondriacal concerns
Certain diagnosed medical conditions (e.g., asthma, migraine, COPD, labile hypertension)

Acute and Posttraumatic Stress Disorders

Exposure to a life-threatening or physically threatening event, followed by symptom clusters in three categories:

Disturbing images, flashbacks, nightmares
Avoidance of trauma reminders
Hyperarousal (e.g., easy startling, irritability, difficulty concentrating, insomnia)

Acute stress disorder (ASD) diagnosed up to 4 wk after traumatic episode
PTSD not apparent until > 1 mo after trauma exposure

Generalized Anxiety Disorder

Persistent, excessive, uncontrollable worries about everyday things

Fatigue, muscle tension, insomnia
Restlessness, irritability, difficulty concentrating

Diagnosis based on ≥ 6 mo persistent worry accompanied by at least three associated clinical features
Most common anxiety disorder seen in primary care

Social Phobia

Fear and avoidance of specific social situations (e.g., fear of urinating in public bathrooms, fear of public speaking) or social situations in general
Tendency toward negative interpretation of social events, self-focused attention, negative-outcome-based cognitive processes
Occasional specific medical presentations (e.g., urinary retention)
Risk of suicide or suicide attempt similar to that in major depressive disorder

Obsessive-Compulsive Disorder

Repeated intrusive thoughts, impulses, or images, recognized as irrational
Compulsive ritualistic behaviors such as cleaning or checking

May present with skin excoriation or excessive picking and scratching

Diagnosed when obsessions, compulsions, or both are present for ≥ 1 hr/day or are present at a level that interferes with functioning

Specific Phobias

Fear and avoidance of a specific place, activity, or situation
Medically relevant phobias

Blood and injection phobias

Vasovagal reactions common (unlike other anxiety/phobic reactions)

Dental phobias
Phobia of childbirth

Best Therapy

Drug Therapy

Selective Serotonin Reuptake Inhibitors (SSRIs)

Any SSRI can be used to treat any anxiety disorder
Selection based on side effect profile (e.g., activating versus sedating), potential for interactions with other drugs the patient is taking, and cost
Patients who do not respond to one SSRI may respond to another
Elevated risk of increased suicidal ideation or behavior during the initial period after starting SSRIs

Patients should be seen more frequently during the first 3 months of SSRI use
Patients and family members should be advised to immediately report any suicidal symptoms

Citalopram

Relatively more sedating
Dose: 20 mg q.d. (starting dose); 20–60 mg q.d. (target dose)
Cost/mo: $120

Escitalopram

Relatively more sedating
Dose: 10 mg q.d. (starting dose); 10–20 mg q.d. (target dose)
Cost/mo: $76

Fluoxetine

Relatively more activating
Dose: 5-10 mg q.d. (starting dose); 20–80 mg q.d. (target dose)
Cost/mo: $83

Fluvoxamine

Relatively more sedating
Dose: 50 mg h.s. (starting dose); 100–300 mg in two divided doses (target dose)
Cost/mo: $234

Paroxetine

Relatively more sedating
Dose: 10 mg q.d. (starting dose); 10–60 mg q.d. (target dose)
Cost/mo: $74

Sertraline

Relatively more activating
Dose: 25–50 mg q.d. (starting dose); 50–200 mg q.d. (target dose)
Cost/mo: $152

Drug Treatment for Panic Disorder

Imipramine

Dose: 10–25 mg q.d. (starting dose); 150–200 mg q.d. (target dose)
Cost/mo: $47

SSRI
Alprazolam

Dose: 0.25–0.50 mg b.i.d. or t.i.d. (starting dose); 0.5–2.0 mg b.i.d. or t.i.d. (target dose)
Cost/mo: $18

Drug Treatment for PTSD

SSRI

Drug Treatment for Generalized Anxiety Disorder

SSRI
Venlafaxine

Dose: 75 mg q.d. in two or three divided doses (starting dose); 150-300 mg q.d. in two or three divided doses (target dose)

Cost/mo: $170

Drug Treatment for Social Anxiety Disorder

SSRI

Drug Treatment for Obsessive-Compulsive Disorder

Clomipramine

Dose: 25–50 mg q.d. (starting dose); 150–300 mg q.d. (target dose)
Cost/mo: $78

Psychological Treatment for Anxiety Disorders

Cognitive-behavioral psychotherapy

As effective as medication in treating panic disorder
Highly effective in some cases of rape-related PTSD
May prevent PTSD in some patients with ASD
Effective in treatment of social phobias
Highly effective in treatment of obsessive-compulsive disorder
Beneficial in treatment of specific phobias

The author has received grants for clinical research from Pfizer, Inc., and Forest Pharmaceuticals, Inc., and has served as a consultant for and member of the speakers' bureaus of Pfizer, Inc., and GlaxoSmithKline.

Best References

Ballenger JC: Biol Psychiatry 46:1579, 1999 PMID 10599485

Hidalgo RB, et al: Med Clin North Am 85:691, 2001 PMID 11349480

Stein MB, et al: J Fam Pract 48:514, 1999 PMID 10428248

Zaubler TS, et al: J Psychosom Res 44:25, 1998 PMID 9483462

November 2006