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

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Differential Diagnosis

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

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

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

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

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

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Best Tests

• 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)

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• 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

• 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

• 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

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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.

 

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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

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