Day # 61: Clinical Pearls for Anxiety Disorders

Welcome back to our current theme of anxiety disorders. Today we are going to have a discussion on clinical pearls for anxiety disorders which will include tips on the clinical interview, validated questionnaires, and differential diagnosis. Let's get started.

Today's Content Level: Beginner; Intermediate

CLINICAL CRITERIA REFRESHER

•Before we start our discussion it will be helpful to review the symptom criteria for generalized anxiety disorder (GAD) and panic disorder (PD) in order to help inform the clinical interview and the type of symptoms to screen for.

Generalized Anxiety Disorder = Worried WWARTS

• Worried

• Wound up = irritability

• Worn out = fatigue

• Absent-minded = impaired concentration

• Restless

• Tense = muscle tension

• Sleepless = insomnia

Panic Disorder

• Recurrent, unexpected panic attacks.

• Panic attack is described as an abrupt surge of intense anxiety and include both physical and cognitive symptoms. 4 or more of the following symptoms:

• Physical -> palpitations, sweating, trembling/shaking, shortness of breath, feeling of choking, chest pain/discomfort, nausea or abdominal distress, dizziness or lightheadedness, chills or heat sensations, and numbness or tingling.

• Cognitive -> feelings of unreality or being detached from oneself, fear of "going crazy", and fear of dying.

CLINICAL INTERVIEW

Screen for current or past anxiety from a variety of anxiety disorders. Example questions could include:

• How often have you been bothered by feeling nervous, anxious or on edge? (GAD-7 # 1)

• How often have you been unable to stop or control worrying? (GAD-7 # 2)

• How often have you felt afraid as if something awful might happen? (GAD-7 # 7)

• Do you have feelings of tension, fatiguability, startle response, moved to tears easily, trembling, feelings of restlessness, inability to relax? (HAM-A # 2)

• Repeated or unexpected “attacks” during which you suddenly are overcome by intense fear or discomfort for no apparent reason?

• Are symptoms predominantly fear of embarrassment or scrutiny or humiliation?

• Does the anxiety involve specific triggers (animals/spiders, heights, needles, airplanes, etc...)?

Keep in mind that some patients experience anxiety as mostly somatic. They may have difficulty describing worries or the cognitive aspects of anxiety, but they will present with headaches, muscle tension, sleep complaints, GI distress, fatigue, difficulty concentrating, or irritability. The following can all be seen as somatic signs and symptoms of anxiety.

• Constitutional: fatigue, sweating, shivering.

• Cardiac: chest pain, palpitations, tachycardia, hypertension.

• Pulmonary: shortness of breath, hyperventilation.

• Neuro/MSK: dizziness, lightheadedness, numbness/tingling (paresthesias), tremors, insomnia, muscle tension.

• GI: abdominal discomfort, anorexia, nausea or vomiting, diarrhea, constipation.

Other tips on the clinical interview include:

• Clarify onset/duration of symptoms with patient and family. Were they always anxious even from childhood or did it start more recently after a known trigger/event?

• Carefully document when the patient experiences symptoms. Generalized worry vs social anxiety vs separation anxiety vs phobias vs panic attacks vs trauma-related disorder.

• Screen for how their symptoms are affecting their function to include school/work/social difficulties, poor self care, etc.

• Comprehensive psychiatric review of symptoms. Ensure to evaluate for mood, OCD, psychotic, and trauma-related disorders as all can have prominent symptoms of anxiety.

• Substance use - determine if this is substance/medication induced. Critical for all mental disorders but particularly so for anxiety disorders. Very high comorbid substance use particularly alcohol. This will be discussed in more detail later but a variety of substances can cause anxiety whether during intoxication, withdrawal, or chronic use.

• Thorough review of medical conditions and physical exam. This will be discussed in more detail later, but many medical conditions can cause anxiety to include epilepsy, neurocognitive disease (Huntington's, Alzheimers), hyperthyroidism, pheochromocytoma, asthma, pulmonary embolism, arrhythmia, and much more.

• Medical and family history of anxiety and other mental health disorders.

• Risk assessment for suicide and aggression - will cover risk/safety assessments in significant detail in later lessons. Among individuals reporting a lifetime history of suicide attempt, over 70% had an anxiety disorder. 1

• Optional rating scales: Generalized Anxiety Scale 7 (GAD-7); Hamilton Anxiety Scale (HAM-A); Beck Anxiety Inventory (BAI).

DIFFERENTIAL DIAGNOSIS

•Before making any psychiatric diagnosis it is important to consider other related disorders and appropriately determine the best fit according to the patients symptoms, biological, psychological, and social factors.

Psychiatric differential diagnosis:

• Other Anxiety Disorders: Whenever you are considering the diagnosis of an anxiety disorder it is important to remember that multiple anxiety disorders can be comorbid and overlap. Screen all patients specifically for panic disorder, generalized anxiety disorder, social anxiety disorder, and other phobias as these are most common. Also remember that panic attacks can be present in many different disorders.

• Mood and Psychotic disorders: Generalized anxiety and worry is a common associated feature of depressive disorders, bipolar disorder, and psychotic disorders. There are also other overlapping features to include sleep difficulties, difficulty concentrating, fatigue, tension, irritability, etc... Anxiety disorders are frequently comorbid with these disorders but shouldn't be diagnosed separately IF the excessive worry has occurred only during the course of these conditions.

• Obsessive Compulsive Disorder (OCD): There is overlap between OCD and GAD in the sense that both involve excessive and consuming worry. GAD involves generalized worry and the focus is about future problems and events. OCD is characterized by intrusive obsessive thoughts are often described as unwanted urges, thoughts, or images and anxiety is relived with mental or physical rituals.

• PTSD: Significant anxiety is experienced in those with PTSD or other trauma-related disorders. A comorbid anxiety disorder is not diagnosed if the anxiety/worry is better explained by the symptoms of the trauma disorder.

• Adjustment disorder: Anxiety can also obviously be seen in response to an identifiable stressor. Adjustment disorder "with anxiety" is used in these cases when the onset of anxiety occurs within 3 months of the stressors, doesn't persist for ≥ 6 months after termination of stressor/consequence, and doesn't meet full criteria for an anxiety disorder.

• Substance/Drug Induced: Known substance causes include alcohol (intoxication/withdrawal/chronic use), anxiolytics (withdrawal), cannabis, hallucinogens, stimulants, caffeine, tobacco, and opioids (withdrawal). Screen specifically for alcohol and other substance use, as this may cloud accurate diagnosis and there is high comorbidity. We will also discuss other prescription medications when we discuss medical causes.

• Medical causes: anxiety symptoms can frequently occur directly due to medical causes. See day # 64 for the differential diagnosis for medical causes and the suggested medical workup for anxiety.

CONCLUSION

I hope you enjoyed these clinical pearls. Today's lesson was geared towards a beginner/intermediate audience, but I hope all of the readers got something out of today's topic. Next we are going to cover mental status exam elements that are relevant to anxiety disorders to improve your evaluation of patients as well as your documentation.

Resources for today's post include: Kaplan and Sadock's Synopsis of Psychiatry, DSMV, and Pocket Psychiatry.

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