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Mental health
Anxiety disorders
Assessment and management in
general practice
Michael Kyrios Richard Moulding Maja Nedeljkovic
Background
Anxiety is a normal physiological response to a threat. Anxiety disorders occur when this normal physiological response is associated with high levels of autonomic arousal, erroneous cognitions and dysfunctional coping strategies. Anxiety disorders are highly prevalent and present commonly to general practice. Anxiety disorders are often comorbid with other psychiatric and medical disorders and may be associated with significant morbidity.
Objective
This article describes the diagnosis, assessment and management of anxiety disorders in the general practice setting.
Discussion
Assessment in patients presenting with anxiety symptoms involves excluding a medical cause, identifying features of specific anxiety disorders as well as other coexisting psychiatric disorders, and assessing the degree of distress. Management options include psychoeducation, psychological treatments (particularly cognitive behaviour therapy) and pharmacological treatments. Patients with a diagnosis of an anxiety disorder can access Medicare funded psychological care under a number of Australian government initiatives. Selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors are the first line pharmacological agents used to treat anxiety disorders. Regular review is vital to monitor for clinical improvement and more complex presentations may require specialist psychological or psychiatric referral.
Keywords: anxiety disorders; mental health; treatment
Anxiety is a normal human physiological mechanism designed to help the body respond to a threat. The autonomic changes that occur in anxiety are essential to avoid danger and moderate anxiety can actually improve performance. However, when anxiety is associated with very high levels of autonomic arousal, erroneous cognitions including exaggerated threat perceptions and dysfunctional coping strategies, it can result in significant distress and impairment in work, school, family, relationships, and/or activities of daily living. Patients presenting with anxiety symptoms in the general practice setting do not always fit the criteria for a specific anxiety disorder. However, it is important for the general practitioner to know how to assess patients for specific anxiety disorders and the basic principles of management of these disorders. Equally, GPs need strategies to manage patients with distressing anxiety symptoms who do not fulfil the criteria for the diagnosis of a specific anxiety disorder and/or where the anxiety coexists with another mental health disorder (such as depression), substance abuse or medical condition.^1
Twelve month prevalence rates in Australia indicate that anxiety disorders are the most common mental health problem, affecting 14.4% of the population (although some people experienced more than one type of anxiety disorder). Post-traumatic stress disorder (PTSD) is the most widespread affecting 6.4% of the population, followed by social phobia (4.7%), agoraphobia (2.8%), generalised anxiety disorder (GAD, 2.7%), panic disorder (2.6%), and obsessive compulsive disorder (OCD, 1.9%).^2 Women experienced higher rates than men (18% and 11% respectively), and the highest rate of anxiety disorders was in the 35–44 years age group (18%). One in 5 women and one in 10 men report a specific phobia.^3 General practice is often the first port-of-call for patients with anxiety disorders; one in 10 people experiencing an anxiety disorder within the past 12 months visited a GP for their mental health problems but did not receive care from any other provider.^4 The Bettering the Evaluation and Care of Health program showed that GPs treat psychological problems at a
rate of 11.5 per 100 encounters and anxiety is the second commonest psychological problem managed after depression.^5
Assessment
initial assessment should begin with a focused history. Allow the patient to describe the symptoms they find most concerning and enquire about substance use as well as symptoms that may be suggestive of a medical condition. Physical examination and investigations should concentrate on excluding an underlying medical cause. medical conditions that can be associated with anxiety include: 6
- hypoglycaemia
- hyper- or hypo-thyroidism
- cardiac disorders
- chronic respiratory disease
- vitamin B deficiency
- inner ear conditions
- acute reactions to aspartame
- withdrawal from benzodiazepines. if there is no evidence of a medical cause for the patient’s symptoms, assessment should move on to looking for features of specific anxiety disorders as well as other coexisting psychiatric disorders, and assessing the degree of distress.
Symptoms of specific anxiety disorders
Diagnosis of specific anxiety disorders involves identification of a specific focus for the anxiety. For instance, if a patient has panic attacks and catastrophises about these as indicating an imminent heart attack/suffocation, a diagnosis of panic disorder may be warranted. However, if anxiety or the panic attacks occur only on exposure to social situations, then social phobia may be the diagnosis ( Figure 1 ). Full diagnostic criteria are available in the Diagnostic and Statistical manual of mental Disorders (4th edn, text revision) (DSm- iV-TR).^6 Of course, in the general practice setting, many patients do not fit neatly into this framework and have symptoms of multiple disorders without fulfilling the criteria for a specific disorder.
Coexisting psychiatric disorders
Anxiety may be a symptom of, or coexist with, another underlying psychiatric
disorder such as depression, bipolar disorder or a psychotic disorder. it is important to screen for these diagnoses at the initial assessment. For example, the ruminative thoughts seen in depression can be similar to worry, but they usually are more concerned with past events, self criticism and guilt, rather than future events. if a specific anxiety disorder is diagnosed, there is a high risk that the patient will also have a psychiatric comorbidity or significant substance use. For example, the presence of GAD increases the likelihood of having depression by an odds ratio of 28.9.^7 Anxiety disorders themselves tend to co-occur and the greater the comorbidity, the greater the likelihood of help seeking.^8 Hypochondriasis is another important diagnosis to consider in the
Figure 1. Differential diagnosis of anxiety disorders
Exaggerated autonomic arousal as a reaction to perceived danger/s
Avoidance of open or crowded spaces with accompanying worry about panic
Chronic, exaggerated, excessive, unwarranted worries and preoccupation about future or everyday issues with associated tension
Excessive preoccupation about perceived criticisms or being judged negatively by others with associated social avoidance or anxiety
Preoccupation and recurrent re-experiencing of traumatic event/s, persistent hyperarousal and avoidance
Unwanted intrusive recurrent thoughts, images or urges leading to distress or discomfort and/or excessive, ritualised compulsive responses
Consider simple phobia
Consider panic disorder
Consider social phobia
Consider post-traumatic stress disorder
Consider obsessive compulsive disorder
Consider generalised anxiety disorder
Consider agoraphobia
Does the patient have a medical condition or substance related problem?
What signs or symptoms does the patient report?
Specific triggers causing anxiety and avoidance
Recurrent panic attacks, catastrophising about anxiety and panic symptoms
Yes Yes
Are there possible co-occurring anxiety problems?
No
Anxiety disorders – assessment and management in general practice FOCUS
management to motivate her, an exposure program to challenge her avoidance, and a cognitive therapy program to help Simone with control of her worry. Within two lots of six individual sessions, Simone’s anxiety and avoidance have ameliorated, although her chronic worrying is still a problem. The psychologist suggests the GP refer Simone to a 10 session group therapy program run at a local university psychology clinic. Subsequently, Simone’s quality of life improves significantly.
Case study 2
Jack, aged 46 years, presents with severe dermatitis on his hands. He reports constantly washing his hands and has always been concerned about ‘catching germs and diseases’. More recently, following an overseas trip where he caught a severe flu, he has become hypervigilant about ‘avoiding germs’ and can hardly think about anything else. He complains of symptoms of depression, which are severe enough for a diagnosis of a major depressive episode, and feels unable to cope with life. He refuses to leave the house except under enormous duress and cannot take public transport to go to work in the abattoir where he is a manager. He has a large mortgage and is at risk of losing his job. Jack’s GP assesses Jack and assesses that the primary diagnoses are major depression and OCD, with a secondary dermatitis caused by abrasions from overwashing of hands. He completes a Mental Health Plan and refers Jack to a clinical psychologist who specialises in the treatment of OCD. The psychologist suggests a CBT program focusing on activity management to motivate Jack, a program of exposure with response prevention for the OCD, as well as a cognitive therapy program. Unfortunately, Jack’s depression makes it difficult for him to undertake any of the psychological strategies. Jack is started on a SSRI following consultation between the psychologist and GP. Jack responds very positively to the combined intervention, and within 10 weeks has a moderate severity rating on an OCD measure. The psychologist further suggests that Jack undertake an online treatment for OCD before seeing him for a further two sessions to discuss relapse prevention strategies. The additional treatment produces further amelioration in OCD and depressive symptoms. Jack is able to return to work and function satisfactorily. Jack’s GP continues to monitor him for another 12 months before commencing a process to cease the SSRI.
Summary of important points
- Anxiety disorders occur when the normal physiological response to a threat is associated with high levels of autonomic arousal, erroneous cognitions and dysfunctional coping strategies.
- Anxiety disorders are highly prevalent, present commonly to general practice and are associated with significant morbidity.
- Anxiety disorders are often comorbid with other psychiatric and medical disorders.
term efficacy of benzodiazepines, however, they have clear short term efficacy, quick onset of action and generally good tolerance.^20 ideally, benzodiazepines should be restricted to short term use (eg. up to 4 weeks) and at the lowest possible doses.^22 Azapirones, a group of drugs that work at the 5-HT1A receptor, are also used to treat GAD, but findings for their efficacy are conflicting.^23 Tricyclic antidepressants and monoamine oxidase inhibitors as well as adjunctive treatment with anticonvulsants and atypical antipsychotics may be considered in treatment resistant cases.^19
Pharmacological, nonpharmalogical or both
it is important to note that the management of anxiety disorders with concurrent CBT and pharmacotherapy has not been found to be superior in the longer term to either treatment alone, despite its continued use in practice.24,25^ Some researchers consider the concurrent use of CBT and anxiolytic medications to be detrimental to the extinction phase of exposure based therapies, which is dependent on the effects that glucocorticoid activity has on learning of emotional material.^26 Patients value both CBT and pharmacotherapy, but tend to prefer CBT to medication for the treatment of anxiety disorders, and see CBT as more likely to be effective in the long term.27,28^ A commonly used rule of thumb is to start with CBT and, if patients do not respond or if significant depression levels are present, to consider pharmacotherapy. For more severe forms of presentation, starting off with an evidence based medication is considered prudent before commencing CBT. Either way, patient preferences and characteristics must be considered in clinical decision making. Regular review is vital to monitor for clinical improvement. more complex presentations (eg. severe, comorbid) or disorders requiring more specialised psychological interventions (eg. OCD, PTSD, GAD) may necessitate referral to a psychologist or psychiatrist with a special interest in these areas.
Case study 1
Simone, aged 35 years, reports generally being a ‘worry wart’ and details a range of chronic symptoms including feeling nervous and jumpy, palpitations, hyperventilating and nausea. More recently, she was caught up in an armed robbery at the local supermarket. Since this event, Simone reports insomnia and intrusive worries that it might happen again. She has avoided going to the supermarket since the robbery and is reticent to leave the house at all, even for work. She is slowly becoming more isolated and depressed. Simone’s GP suspects that she is suffering from PTSD with depression following the armed robbery, on the background of underlying generalised anxiety symptoms. After a full history and examination, the GP completes a Mental Health Plan and refers Simone to a clinical psychologist who specialises in the treatment of PTSD. The psychologist undertakes a thorough diagnostic interview and also diagnoses a pre-existing GAD. The psychologist suggests a CBT program focusing on anxiety management training to decrease Simone’s arousal, activity
FOCUS Anxiety disorders – assessment and management in general practice
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- Kyrios m, Hegarty K. Self-monitoring and psychometric tools. in: Blashki G, Judd F, Piterman l, editors. General practice psychiatry. north Ryde, nSW: mcGraw-Hill, 2007;356–72.
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- Assessment in patients presenting with anxiety symptoms involves excluding a medical condition, identifying features of specific anxiety disorders, as well as other coexisting psychiatric disorders and assessing the degree of distress.
- Management options in anxiety disorders include psychoeducation, psychological treatments (particularly CBT) and pharmacological treatments.
- Patients with a diagnosis of an anxiety disorder can access medicare funded psychological care under a number of Australian government initiatives.
- SSRIs and SNRIs are the first line pharmacological agents used to treat anxiety disorders.
- Regular review is vital to monitor for clinical improvement and more complex presentations may require specialist psychological or psychiatric referral.
Resources
- The Depression Anxiety Stress Scales-21 is available from the university of new South Wales School of Psychology: www2.psy. unsw.edu.au/groups/dass
- The K-10 questionnaire is available from the Black Dog Institute: www.blackdoginstitute.org.au/docs/5.K10withinstructions.pdf
- Information about GP Mental Health Care Medicare Items: www. health.gov.au/internet/main/publishing.nsf/content/health-pcd-gp- mental-health-care-medicare.
Authors
michael Kyrios BA(Psych, Phil), DipEd(Psych), mPsych(Clin Psych), PhD(Clin Psych), FAPS, is Professor of Psychology and Director of the Brain and Psychological Sciences Research Centre, Faculty of life and Social Sciences, Swinburne university of Technology, melbourne, Victoria. mkyrios@swin.edu.au Richard moulding BSc(Hons), mPsych(Clin Psych), PhD, mAPS, is a lecturer, Brain and Psychological Sciences Centre, Faculty of life and Social Sciences, Swinburne university of Technology, melbourne, Victoria. maja nedeljkovic BSc(Hons), mPsych(Clin Psych), PhD, mAPS, is a lecturer, Brain and Psychological Sciences Centre, Faculty of life and Social Sciences, Swinburne university of Technology, melbourne, Victoria.
Conflict of interest: none declared.
References
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- Australian Bureau of Statistics. Survey of mental Health and Wellbeing: summary of results. Publication 4326.0, 2007.
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- Burgess Pm, Pirkis JE, Slade Tn, Johnston AK, meadows Gn, Gunn Jm. Service use for mental health problems: findings from the 2007 national Survey of mental Health and Wellbeing. Aust n Z J Psychiatry 2009;43:615–23.
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