Anxiety

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Chapter 13 Anxiety

INTRODUCTION

Description: Anxiety is a common acute or chronic emotion associated with physical symptoms, and it is two to three times more common in women. Subtypes include situational anxiety, adjustment disorders, panic disorders, phobias, and post-traumatic stress disorder. Obsessive-compulsive disorders are often classified in this group as well.

Prevalence: Eighteen percent of women, 40 million Americans.

Predominant Age: 20 to 45.

Genetics: Increased risk of panic disorders within monozygotic twins. Panic disorder, social phobia, and obsessive-compulsive disorders have a genetic base.

ETIOLOGY AND PATHOGENESIS

Causes: Psychosocial stressors, abnormality of the neurotransmitter system (serotonin, norepinephrine, γ-aminobutyric acid) involving the amygdala and hippocampus.

Risk Factors: Social, family or financial stress, medical illness, family history, and a lack of social support network.

DIAGNOSTIC APPROACH

Workup and Evaluation

Laboratory: No specific evaluation indicated. Tests should be based on the diagnoses being considered (e.g., thyroid function studies).

Imaging: No imaging indicated.

Special Tests: None indicated.

Diagnostic Procedures: History and psychological testing.

Pathologic Findings

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation and assessment of cause and subtype, screening for substance abuse, counseling, establishing ties to support systems, beginning exercise program, and maintaining frequent follow-up.

Specific Measures: Psychotherapy (cognitive–behavioral therapy), medications.

Diet: No specific dietary changes indicated.

Activity: No restriction.

Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP068 (Alcohol and Women), AP083 (The Abused Woman).

Drug(s) of Choice

Acute anxiety or adjustment disorders—short-term benzodiazepines (alprazolam, 0.25 mg two to three times daily, increase in 0.25-mg increments if needed).

Generalized anxiety—azaperones (buspirone [BuSpar] 5 mg PO two to three times daily, increased every 2 to 3 days to a maximum of 60 mg/day).

Panic disorders and phobias—selective serotonin reuptake inhibitors (SSRIs; fluoxetine [Prozac] 4 mg PO, increased by 4 mg every 5 days to maximum of 40 mg, sertraline [Zoloft] 25 mg PO, increased by 25 mg every 5 days, paroxetine [Paxil]) 10 mg PO increased by 10 mg every 5 days).

Obsessive-compulsive disorders—selective serotonin reuptake inhibitors or clomipramine (Anafranil) 25 mg PO two times daily, increased to 250 mg/day.

Contraindications: Benzodiazepines are contraindicated in the first trimester of pregnancy, in patients with acute alcohol intoxication, and in patients with sleep apnea or open-angle glaucoma.

Precautions: Agents with short half-lives (e.g., alprazolam) have a high potential for dependency and withdrawal symptoms; acute withdrawal may precipitate panic attacks or seizures. Hepatic and renal function should be monitored in patients using benzodiazepines or buspirone. Breastfeeding should be discouraged in women taking chronic or high-dose benzodiazepines.

Interactions: Buspirone should not be used with monomine oxidase inhibitors (MAOIs).

Alternative Drugs

Panic disorders and phobias—imipramine (Tofranil) 10 to 25 mg PO every night, increased by 10 to 25 mg/day every 2 weeks to a maximum of 300 mg/day in adults and 100 mg/day in adolescents and elderly patients.

FOLLOW-UP

Patient Monitoring: Frequent follow-up, identification and treatment of associated depression, periodic assessment of renal and hepatic function (based on medical therapy chosen).

Prevention/Avoidance: Stress management, relaxation training.

Possible Complications: Social withdrawal or isolation, drug dependence or side effects.

Expected Outcome: Generally good outcome. (Obsessive-compulsive disorders and post-traumatic stress disorders are more difficult to treat.)

MISCELLANEOUS

Pregnancy Considerations: Medical therapy must be adjusted based on risk and need.

ICD-9-CM Codes: 300.00 (others based on cause).

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