Anxiety

  1. For a patient with multiple unexplained symptoms or behaviours, look for anxiety as a primary or contributing cause.

  2. When a patient presents with symptoms of anxiety, clearly distinguish between distress (e.g. fear, nervousness, worry) and an anxiety disorder

  3. In a patient presenting with acute symptoms of panic (e.g., shortness of breath, palpitations, hyperventilation), do not attribute the symptoms to anxiety without first excluding serious medical pathology (e.g., pulmonary embolism, myocardial infarction) from the differential diagnosis, especially in patients with established anxiety disorder.

  4. When working up a patient with symptoms of anxiety, and before making the diagnosis of an anxiety disorder:

    1. Exclude serious medical pathology.

    2. Identify:

      • other co-morbid psychiatric conditions

      • abuse

      • substance use

    3. Assess the risk of suicide.

    4. Discuss functional impact with the patient

  5. When an anxiety disorder is suspected, assess and classify according to established diagnostic criteria, as treatment will vary according to the classification.

  6. In patients with known anxiety disorders, do not assume all new symptoms are attributable to the anxiety disorder.

  7. When planning management of anxiety, offer appropriate treatment, which may include one or a combination of the following:

    • Self-management techniques

    • Regular office follow-up

    • Community resources

    • Structured therapies (Cognitive Behavioral Therapy, psychotherapy)

    • Judicious use of pharmacotherapy

    • Referral to other health professionals with ongoing shared care

  1. When managing anxiety or an anxiety disorder do not use medication as a sole treatment

  2. When assessing and managing anxiety, discuss the use of alcohol and substances as harmful self-medication

Risk Factors

  • Family history of anxiety

  • Personal history of anxiety/mood disorder

  • Childhood stressful life events or trauma

  • Female

  • Chronic medical illness

  • Behavioral inhibition

Screen

Generalized Anxiety Disorder - GAD-2 or GAD-7

  • During the past 2 weeks, have you been bothered by

    • Feeling worried, tense, or anxious most of the time?

    • Not being able to stop or control worrying

Panic Disorder

  • In the past month, have you on more than one occasion, had spells or attacks when you suddenly felt anxious, frightened, uncomfortable or uneasy even in situations where most people would not feel that way?

  • Did the spells peak within 10 minutes?

  • Have you spent more than a month in fear of having another attack or about the consequences of the attack?

Agoraphobia

  • In the past month, have you felt anxious or uneasy in places or situation where you might have a panic attack or panic-like symptoms, or where help might not be available or escape might be difficult (e.g., being in a crowd, standing in a queue, when you are away from home or alone at home, or when crossing a bridge, travelling in a bus or train or car)?

Social Phobia (Mini-SPIN) - Social Phobia Inventory (SPIN)

  • Does fear of embarrassment cause you to avoid doing things or speaking to people?

  • Do you avoid activities in which you are the center of attention?

  • Is being embarrassed or looking stupid among your worst fears?

Obsessions:

  • Are you bothered by repeated and unwanted thoughts of any of the following types:

    • Thoughts of hurting someone else

    • Sexual thoughts

    • Excessive concern about contamination/germs/disease

    • Preoccupation with doubts (“what if” questions) or an inability to make decisions

    • Mental rituals (e.g., counting, praying, repeating)

    • Other unwanted intrusive thoughts

  • If you answered “YES” to any of the above… Do you have trouble resisting these thoughts, images, or impulses when they come into your mind?

Compulsions:

  • Do you feel driven to perform certain actions or habits over and over again, or in a certain way, or until it feels just right (eg. Washing, cleaning, checking doors/locks/appliances, repeatedly counting/touching/praying, hoarding/collecting)?

    • Do you have trouble resisting the urge to do these things?

PTSD - PC-PTSD:

  • Have you experienced or seen a life-threatening or traumatic event such as a rape, accident, someone badly hurt or killed, assault, natural or man-made disaster, war, or torture?

    • Do you re-experience the event?

Child Anxiety Related Disorders - SCARED (Child, Parent)

DDx

  • Medical

    • Cardiovascular: Myocardial Infarction, Arrhythmia, CHF, valvulopathy

    • Respiratory: Pulmonary Embolism, Asthma/COPD

    • Endocrine: Hyperthyroidism, hypoglycemia

    • Metabolic: Vitamin B12, porphyria

    • Neurologic: TBI

  • Psychiatric

  • Medication-induced

  • Substance-induced: Intoxication (caffeine, stimulants) or withdrawal (benzodiazepines, alcohol)

Investigations

  • Consider

    • CBC

    • Electrolytes, Fasting glucose

    • TSH, LFTs

    • Lipid profile

    • UA, urine toxicology for substance abuse

    • EKG for arrhythmia

Treatment

  • Assess suicide risk

  • Address substance use

  • Self-management techniques

    • Relaxation and breathing control skills

    • Physical activity

    • Self-help books

    • Internet-based CBT

  • Regular office follow-up

  • Community resources

  • Structured therapies

    • Cognitive Behavioral Therapy,

    • Psychotherapy

  • Pharmacotherapy

    • Long-term antidepressants

      • Panic

        • CBT

        • Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, paroxetine CR, sertraline, venlafaxine XR

      • Specific Phobia

        • Exposure-based techniques (eg. virtual exposure)

        • Pharmacotherapy unproven

      • SAD

        • CBT, Exposure therapy

        • Escitalopram, fluvoxamine, fluvoxamine CR, paroxetine, pregabalin, sertraline, venlafaxine XR

      • GAD

        • CBT

        • Agomelatine, duloxetine, escitalopram, paroxetine, paroxetine CR, pregabalin, sertraline, venlafaxine XR

          • Usually at least 12 months to prevent relapse (9.8% relapse vs 53.7% if only treated for 6 months)

      • OCD (Note: not considered part of anxiet disorders in DSM 5)

        • CBT (Exposure with response prevention - ERP)

        • Escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline

    • Short-term adjunctive treatment

      • Can consider low-dose benzodiazepine dosed regularly if no history of substance-use disorder

        • eg. Clonazepam 0.25-0.5mg PO daily (titrate up to 1mg TID based on response)

DSM-V

Panic disorder

  • Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

    1. Palpitations, pounding heart, or accelerated heart rate.

    2. Sweating.

    3. Trembling or shaking.

    4. Sensations of shortness of breath or smothering.

    5. Feelings of choking.

    6. Chest pain or discomfort.

    7. Nausea or abdominal distress.

    8. Feeling dizzy, unsteady, light-headed, or faint.

    9. Chills or heat sensations.

    10. Paresthesias (numbness or tingling sensations).

    11. Derealization (feelings of unreality) or depersonalization (being detached from oneself).

    12. Fear of losing control or “going crazy.”

    13. Fear of dying

  • At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

    1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).

    2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).

  • The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).

  • The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).

Agoraphobia

  • Marked fear or anxiety about two (or more) of the following five situations:

    1. Using public transportation (e.g., automobiles, buses, trains, ships, planes).

    2. Being in open spaces (e.g., parking lots, marketplaces, bridges).

    3. Being in enclosed places (e.g., shops, theaters, cinemas).

    4. Standing in line or being in a crowd.

    5. Being outside of the home alone.

  • The individual fears or avoids these situations because of thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear of incontinence).

  • The agoraphobic situations almost always provoke fear or anxiety.

  • The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.

  • The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.

  • The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

  • The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • If another medical condition (e.g., inflammatory bowel disease, Parkinson’s disease) is present, the fear, anxiety, or avoidance is clearly excessive.

  • The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder—for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations (as in social anxiety disorder); and are not related exclusively to obsessions (as in obsessive-compulsive disorder), perceived defects or flaws in physical appearance (as in body dysmorphic disorder), reminders of traumatic events (as in posttraumatic stress disorder), or fear of separation (as in separation anxiety disorder).

  • Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.

Specific Phobia

  • Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood).

    • Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging.

  • The phobic object or situation almost always provokes immediate fear or anxiety.

  • The phobic object or situation is actively avoided or endured with intense fear or anxiety.

  • The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.

  • The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

  • The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • The disturbance is not better explained by the symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms (as in agoraphobia); objects or situations related to obsessions (as in obsessive-compulsive disorder); reminders of traumatic events (as in posttraumatic stress disorder); separation from home or attachment figures (as in separation anxiety disorder); or social situations (as in social anxiety disorder).

Social Anxiety Disorder (Social Phobia)

  • Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech).

    • Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.

  • The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).

  • The social situations almost always provoke fear or anxiety.

    • Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

  • The social situations are avoided or endured with intense fear or anxiety.

  • The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

  • The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

  • The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

  • The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

  • If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

  • Specify if: Performance only: If the fear is restricted to speaking or performing in public.

Generalized Anxiety Disorder (GAD)

  • Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

  • The individual finds it difficult to control the worry.

  • The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months), Note: Only one item is required in children:

    1. Restlessness or feeling keyed up or on edge.

    2. Being easily fatigued.

    3. Difficulty concentrating or mind going blank.

    4. Irritability.

    5. Muscle tension.

    6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

  • The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

  • The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

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