Anxiety Disorders inPrimary Care

Heidi Combs, MD, MS*, Jesse Markman, MD, MBA

KEYWORDS

� Anxiety disorders � Primary care � Generalized anxiety disorder � Panic disorder� Social anxiety disorder � Posttraumatic stress disorder� Obsessive-compulsive disorder

KEY POINTS

� Anxiety disorders are the most common psychiatric condition presenting to primary carepractitioners.

� Patients with anxiety disorders present significant costs in terms of healthcare use, loss ofworkforce productivity, disability, and quality of life.

� Detection of anxiety disorders in primary care is poor and can be improved with use ofavailable screening tools.

� Effective management for each of the anxiety disorders is available, but currently under-used, leaving patients in a less-than-optimally treated state.

INTRODUCTION

Anxiety disorders, the most common psychiatric diagnosis in the United States, havean estimated prevalence of 13.3%.1 Even though potentially and significantly debili-tating, these conditions often command less attention than higher-profile affectiveand psychotic illnesses. Supporting the serious nature of these conditions is the studyby Kroenke and coworkers2 of 965 randomly selected patients in primary care clinics.The study found 19.5% had at least one anxiety disorder. As the number of anxietydiagnoses rose, accompanying impairment correspondingly increased. These condi-tions are also associated with elevated divorce rates, greater unemployment, a dimin-ished sense of well-being, and increased reliance on public assistance.3 Significantly,suicide risk elevates with acute and chronic anxiety disorders.4

Patients with anxiety disorders often seek treatment from primary care providers(PCP).5 They may present with medically unexplained symptoms, making identifica-tion of the correct diagnosis a challenge. The patient may be oblivious to recognizing

Department of Psychiatry and Behavioral Sciences, Harborview Medical Center, University ofWashington, 325 9th Avenue Box 359911, Seattle, WA 98103, USA* Corresponding author.E-mail address: hcombs@uw.edu

Med Clin N Am 98 (2014) 1007–1023http://dx.doi.org/10.1016/j.mcna.2014.06.003 medical.theclinics.com0025-7125/14/$ – see front matter � 2014 Elsevier Inc. All rights reserved.

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their symptom as anxiety and the correct diagnosis becomes easier to miss. Giventhat 25% to 50% of primary care clinic patients present with medically unexplainedsymptoms, it is important for the PCP to screen for psychiatric illnesses, including anx-iety disorders.6

Adequate treatment is necessary. Effective management for each of the anxiety dis-orders is available, but currently underused, leaving patients in a less-than-optimallytreated state. For example, in Kroenke’s sample of 965 patients, 41%with anxiety dis-orders went untreated.2

This article reviews epidemiology, screening tools, impact on patients, costs, andtreatment of each of the major anxiety disorders.

METHODS

A PubMed literature search was conducted in September and October of 2013using the following terms: “Anxiety Disorders and Primary Care,” “Generalized Anx-iety Disorder and Primary Care,” “Social Anxiety Disorder and Primary Care,” “PostTraumatic Stress Disorder and Primary Care,” and “Obsessive-Compulsive Disor-der and Primary Care.” Abstracts from articles on adults, written in English andpublished within the past 5 years, were reviewed for relevance. Additional articlesand texts were identified from references found in the bibliographies of appropriatemanuscripts.

DIAGNOSTIC CHALLENGES

PCPs often miss the accurate diagnosis of anxiety disorders. In a study of 840 primarycare patients, rates of misdiagnosis were 85.8% for panic disorder (PD), 71% forgeneralized anxiety disorder (GAD), and 97.8% for social anxiety disorder (SAD).7

The first step in making an accurate diagnosis is to understand the disorder.Table 1 contains a brief description of the key features of the major anxiety disorders.Unfortunately, patient descriptions of their symptoms can mislead even the mostastute physician. Patients may report physical or psychological distress, including so-matic complaints, pain, sleep disturbance, and depression,8 but are unaware that theyare actually experiencing anxiety. Wittchen and colleagues9 noted that only 13.3% ofpatients with GAD presented with anxiety symptoms as a chief complaint, whereassomatic concerns were described 47.8% of the time. Table 2 contains a case illus-trating a common presentation for a person with GAD. Screening for key symptomsassociated with the disorder can help identify the diagnosis. Patients with anxiety dis-orders also have high rates of coexisting additional mental illnesses, further compli-cating the diagnostic process.

CO-OCCURRING MENTAL DISORDERS

Co-occurring mental conditions are commonly found in patients with anxiety disor-ders. These can be disorders of mood, substance use, psychosis, or another anx-iety disorder. It is estimated that up to 90% of persons with GAD experience one ormore comorbid psychiatric diagnoses.11 Stein and coworkers12 found that in pa-tients with posttraumatic stress disorder (PTSD), major depression is seen in61% of patients, GAD in 39%, social phobia in 17%, PD in 6%, and substanceuse disorders in 22% of patients. Additionally, the presence of comorbid psychiat-ric conditions worsens prognosis. Patients with multiple psychiatric diagnosesexperience lower remission rates, increased rate of suicide, and higher use ofhealth care.8,11

Table 1Key diagnostic features of various anxiety disorders

Diagnosis Key Features Including Signs/Symptoms10

Generalized anxietydisorder

Excessive, uncontrolled anxiety/worry about several things thatinterfere with ability to function. In addition, worry accompaniedby other symptoms, such as fatigue, muscle tension, irritability,restlessness, and sleep disturbance.

Social anxietydisorder

Marked anxiety or fear in social settings where there is risk of scrutinyor judgment. Results in avoidance of situation or enduringsituation with marked distress.

Panic disorder Recurrent panic attacks described as unexpected waves of anxietyassociated with multiple physical and cognitive symptoms.Common symptoms include elevated heart rate, shortness ofbreath, trembling, abdominal distress, dizziness, and fear of deathor losing control.

Posttraumatic stressdisorder

After trauma exposure person experiences symptoms that can includeintrusive thoughts of trauma, negative mood, dissociation,avoiding thinking about the trauma or external reminders of it, andhyperarousal.

Obsessive-compulsivedisorder

Presence of unwanted recurrent intrusive thoughts or images and/orrepetitive behaviors or mental acts, such as counting or checkingperformed to reduce anxiety. These thoughts/acts impair functionor are significantly time-consuming.

Data from American Psychiatric Association, DSM-5 Task Force. Diagnostic and statistical manual ofmental disorders: DSM-5. Arlington (VA): American Psychiatric Association; 2013.

Table 2Case and key diagnostic features

Case Key Diagnostic Features

A 36-year-old woman comes in with a chiefcomplaint of insomnia. She feelsconstantly on edge and finds it hard to fallasleep because of concern about herparents. She also experiences musclestiffness and shoulder and back pain. Onquestioning, she describes unremittingworry that something terrible will happento her elderly parents. The patient lives in astate distant from her parents. There is afamily history of cardiovascular disease andshe worries they will die of heart attacks.The patient calls her parents multiple timesa day to check in with them and feelsextremely anxious if she cannot reachthem. She also worries about how her kidsare doing in school even though they aregetting good grades, and about herfinances even though she is in goodstanding financially. She has beenexperiencing the worry for 5 y. She hasmissed multiple days of work because ofher incapacitating worry.

She experiences multiple symptomsassociated with the worry includingfeeling on edge, sleep disturbance, musclestiffness, shoulder pain

The worry is uncontrolledThe worry is about multiple things5-y history indicating chronic problemIt is impairing function as evidenced by

missing multiple days of work

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HUMAN AND FINANCIAL COST

Patients with anxiety disorders present significant costs in terms of health care use,loss of workforce productivity, disability, and quality of life. The estimated directand indirect cost of PD per 1 million persons in 2005 was between $241.7 and$287.6 billion US dollars.13 The estimated health costs for persons with GAD are64% higher than those without GAD, and patients with obsessive-compulsive disorder(OCD) are estimated to lose 3 years of wages because of their illness over their life-time.14,15 Moitra and colleagues16 found patients with SAD had significantly impairedworkplace function compared with individuals with other anxiety disorders and unem-ployment was twice as likely. Those who suffer from anxiety also experience disabilityoutside of work resulting in poor quality of life and diminished life satisfaction.

IMPACT OF SUBTHRESHOLD SYMPTOMS

Multiple studies describe that persons suffering from anxiety symptoms that are sub-diagnostic threshold have significantly more impairment than those who report nosymptoms.17–20 Problems these patients encounter include poor perceived health,psychological distress, and increased use of medical services.17–20 Predictably,data indicate that there are far more patients with subthreshold anxiety symptomsthan there are patients with diagnosed, threshold disorders; yet it is questionable ifthis group is identified or treated.17,19,20 Data do not yet exist for criteria for treatmentin subthreshold cases.

INCREASED RISK OF SUICIDE

Practitioners associate increased risk of suicide with depression; however, many donot realize anxiety disorders also increase risk. Suicidal ideation, rates of self-injury,and suicide attempts are elevated in persons with anxiety disorders.21–23 Bomyeaand colleagues24 found approximately 26% of patients with anxiety disordersendorsed passive suicidal ideation and 16% endorsed suicidal thoughts in the previ-ous month. Both current and lifetime anxiety disorders confer increased suicide risk.Kahn and colleagues4 found suicide risk among patients with anxiety disorders wasincreased by a factor of 10 or more compared with the general population, regardlessof the type of anxiety disorder. The association between suicide and anxiety disordersunderscores the importance of detection and treatment.

SCREENING TOOLS

Effective screening tools are available to detect anxiety disorders (Table 3). Finding timeto use these adjuncts can be challenging in a busy primary care practice. Screeningtools designed to address the full spectrum of co-occurring affective and anxiety disor-ders are especially useful. The Hospital Anxiety and Depression Scale distinguishes be-tween depression and anxiety if both are present.25 Other broad-based instruments,such as the PRIME-MD-PHQ, can identify anxiety and mood disorders.26 For the caseshown in Table 2, either of the screening tools for GAD listed in Table 3 are appropriate.

CHANGES FROM DIAGNOSTIC AND STATISTICAL MANUAL OF PSYCHIATRICDISORDERS-IV TO DIAGNOSTIC AND STATISTICAL MANUAL OF PSYCHIATRICDISORDERS-V

The newest version of the Diagnostic and Statistical Manual of Psychiatric Disorders(DSM), the DSM-V, is now available.10 Some highlights are relevant. Agoraphobia is

Table 3Screening tools

Diagnosis Screening Tools Screening Question

GAD GAD-727

GAD-228Do you consider yourself a worrier?

SAD SPIN29

Mini-SPIN30

When you are in a situation where people can observe you,do you feel nervous and worry that they will judge you?

PD PHQ panicdisorder scale31

Do you have waves of nervousness that come out of theblue and you notice things in your body like your heartgoes fast or it is hard to breathe?

PTSD PC-PTSD32

PCL-C33

M-334

Have you experienced a trauma that still haunts you?

OCD MINI35

Y-BOC35

PRIME-MD35

Do you have thoughts that occur over and over that reallybother you? Are there things you have to do over andover, such as washing your hands, checking, or counting?

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now in a category of its own rather than a qualifier for PD. The diagnosis of PTSD is nolonger found in the anxiety disorder section but is now described in the section on,“Trauma and Stress-Related Disorders.” In addition, the trauma can have occurredto a close family member or friend, or the trauma could be first-hand repeated orextreme exposures to details, such as those experienced by police officers. The latercriteria mean that such persons as first responders could develop PTSD. OCD is nowfound under the classification, “Obsessive-Compulsive and Related Disorders.”Although PTSD and OCD are no longer officially classified in the category of “anxietydisorders” in the DSM-V, they share the same issues of underdiagnosis andapproaches to treatment so they are therefore included in this review.

EPIDEMIOLOGY, COURSE OF ILLNESS, AND PROGNOSISGAD

The prevalence rates for GAD in primary care settings range from 3.7% to 14.8%.17,36

GAD accounts for 50% of anxiety disorders seen in this setting.37 Only depression is amore commonly identified psychiatric diagnosis. GAD tends to be a chronic illnesswith fluctuating symptom severity. A 12-year longitudinal study found 60% of patientsrecovered; however, approximately half of these patients relapsed during that time.38

Disability caused by GAD is comparable with that of major depressive disorder.39

SAD

The 1-month prevalence of SAD in primary care is 7%.40 This condition is a chronicillness marked by long duration and has a rate of recovery of only 38%.41,42 One studydescribed the probability of recovery from SAD in 12-year follow-up as 37%; this num-ber was lower than for GAD and PD.38 SAD is associated with marked impairment inwork productivity and decreased income.43

PD

The median prevalence of PD in primary care is 4% to 6%, whereas the median prev-alence in the general population is 2.7%.1,44 The course of PD is similar to other anx-iety disorders in that it is chronic and relapsing. In the Harvard/Brown AnxietyResearch Study, nearly one-third of patients with PD were likely to experience a

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recurrence within a year after recovery and another study by Simon and coworkersfound that nearly half had recurrence in 2 years.38,45,46

PTSD

The prevalence for PTSD in primary care settings is estimated to be 11.8%.12 This ishigher than the 1-year prevalence rate of 3.5% to 6% for the general US population.47

In Stein’s study of 368 patients in a primary care clinic, 65% reported a history of expo-sure to a severe, potentially traumatic event. Similar to other anxiety disorders,patients with PTSD are more likely to reach out to their primary care physiciansthan to a mental health specialist. PTSD is a chronic condition with only one-thirdrecovering at 1 year and one-third still experiencing symptoms 10 years after traumaexposure.48

OCD

OCD has an estimated lifetime prevalence of 1.6%.1 The onset of the condition can bein adolescence; however, patients may be sufficiently embarrassed or ashamed pre-venting them from revealing their symptoms. Consequently, the average time to diag-nosis is 11 years.49 An estimated 70% of patients with OCD experience a chroniccourse, whereas only 23% experience a waxing and waning course.49 Data vary forremission rates with treatment. In the largest trial of 213 patients, 22.1% had partialremission, 16.9% had full remission, and 59% of patients who remitted subsequentlyrelapsed.50

TREATMENT

Treatment of anxiety disorders can be difficult and intimidating for the PCP. There arespecific recommendations for interventions that can be accomplished without thesupport of psychiatrist or psychotherapist. Many options address multiple anxiety dis-orders. Table 4 provides an overview of treatment options for each anxiety disorder.

PHARMACOTHERAPY

Pharmacotherapy for anxiety disorders is separated into two categories of medica-tions each having a different purpose. The first consists of agents that aim to preventfuture anxiety, whereas the second treat acute anxiety, but do not decrease futureoccurrences.First-line pharmacologic treatment of anxiety disorders aims to prevent future

symptoms. This is best accomplished with single-agent treatment with a selective se-rotonin reuptake inhibitor (SSRI) or serotonin noradrenergic reuptake inhibitor(SNRI).51–54 These medications have been shown to be effective in reducing anxietysymptoms in multiple placebo-controlled trials, but no single agent has proved consis-tently more effective than others.51–55 The choice of SSRIs and SNRIs over tricyclicantidepressants (TCAs) as first-line therapy is due largely to their lack of anticholin-ergic side effects and toxicity in overdose.51 Increased tolerability does not translateto increased efficacy, however, and some experienced PCPs may be more comfort-able with use of TCAs because they have been in use for more than 40 years. The an-tidepressant mirtazapine is an effective agent either as single agent or combined withSSRIs for augmentation.55 Unfortunately, these medicines can require 4 to 8 weeks toshow efficacy. Treatment of anxiety disorders typically requires higher doses andlonger duration than indicated for unipolar depression.56 Brief medication trials cangive the false perception of failure and treatment resistance. The ability to wait forresponse is therefore required on the part of provider and patient.

Table 4Treatment options

GAD PD OCD SAD PTSD

Medication-basedtreatmentrecommendations

Daily SSRI/SNRIAnxiolytics may be

needed as a bridge forsevere symptoms untilantidepressantsprovide relief

Daily SSRI/SNRIUse long-acting

anxiolytics becauseshort-acting agents areunlikely to actuallyabort panic attacks

Daily SSRI/SNRIAnxiolytics may beneeded as a bridge forsevere symptoms untilantidepressantsprovide relief

Daily SSRI/SNRIPropranolol is useful

for public speaking

Daily SSRI/SNRIUse prazosin for

nightmaresAnxiolytics may be

needed as a bridge forsevere symptoms untilantidepressantsprovide relief

Benzodiazepines aregenerally notrecommended

Psychotherapyrecommendations

Cognitive behavioraltherapy

Cognitive behavioraltherapy

Exposure and responseprevention

Cognitive behavioraltherapy

Prolonged exposureCognitive processing

therapy

Anxie

tyDiso

rders

inPrim

ary

Care

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Anxiolytic medications compose the second set of pharmacologic agents for treat-ment of acute anxiety. These medicines abort current symptoms of anxiety and do lit-tle to prevent symptom recurrence. Anxiolytics can be divided into benzodiazepinesand nonbenzodiazepines.Benzodiazepines are frequently thought of as the classic anxiolytic. This class ofmedi-

cationprovides awide rangeof choices in termsof onset of action, half-life, and the pres-ence of an activemetabolite.57 There are no specific recommendations in terms of use ofone benzodiazepine over another in the treatment of anxiety disorders. In general terms,benzodiazepines with shorter half-lives andmore rapid onset of action are more likely tolead to rebound anxiety when effects of the medication wane, leading to a need to takemore of the medication.58 If possible, longer-acting benzodiazepines (ie, clonazepam)should be used in conjunction with antidepressants, when the provider needs todecrease anxiety acutely, to allow for treatment engagement, and/or treat symptomsthat are threatening patient safety. If possible, treatment should be limited in durationand stopped once antidepressants lower overall anxiety levels and patients are able toengage in other forms of treatment. Although benzodiazepines are effective, physiologicdependence develops in all users somisuse poses potential problems. Tapering benzo-diazepines must be gradual and can be dangerous if completed too abruptly. The with-drawal syndrome that accompanies benzodiazepine cessation closely parallels that ofalcohol withdrawal. The mildest form is rebound anxiety that can be seen with reducingor missing doses and is most common with short-acting benzodiazepines (ie, alprazo-lam).58 In rare cases, severe withdrawal symptoms can be seen, which can lead toseizure, coma, and death. Although exact rates of risk are unknown, severe withdrawalis rare and more likely in patients taking higher doses, for prolonged periods, and forwhom the medication is discontinued abruptly.58 Co-occurring substance use disorderis common and in such situations treatment with benzodiazepines is contraindicated.When anxiety needs to be controlled acutely, but benzodiazepines are not indi-

cated, there are other alternatives. The anticholinergic agent hydroxyzine, b-blockerpropranolol, and gabapentin are effective alternatives as anxiolytics without abusepotential.

PSYCHOTHERAPY

Several psychotherapy modalities are effective in the treatment of anxiety disorders.The modality that has the most robust data is cognitive behavioral therapy (CBT).59

CBT is designed to identify the maladaptive automatic thoughts and behaviors, andthen restructure them through therapeutic exercises. CBT has been shown sufficientlyeffective for several anxiety disorders,with very limited side effects, so it is often consid-ered first-line treatment. Disorder-specific and general protocols are created to addressall major anxiety disorders.59 Major drawbacks to therapy include difficulty in engagingthe patient (a significant barrier with anxiety disorders) and limited or variable availabilityof well-trained therapists. With the advent of manualized therapy and computer-basedtherapy, treatment can now be delivered without therapists. This provides an excitingresource for rural areas or for isolated primary care physicians with limited support. So-cial workers, nurses, and medical assistants can be trained to provide therapy and pri-mary care physicians can guide the patient through the protocol in a few office visits.

COMBINATION TREATMENT

Although psychotherapy and pharmacotherapy have been shown to be individuallyeffective, studies consistently demonstrate that combination treatment gives superiorresults compared with either treatment alone.51,59,60

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ADJUNCTIVE TREATMENTS

Although recognized as components of behavioral therapies, breathing exercises,muscle relaxation, and mindfulness-based meditation techniques are effective aloneor in conjunction with other therapies.61 Exercise as adjunctive therapy producesmixed results. Randomized controlled trials of exercise as treatment of anxiety disor-ders compared with waitlist control do show a benefit for exercise therapy. Trials thatcompare exercise therapy with pharmacotherapy or CBT, however, show no benefitfor exercise over these traditional treatments. Although it may seem, then, that exer-cise may be better than no intervention, yet not superior to pharmacotherapy or psy-chotherapy, one cannot yet draw that conclusion. There is significant variabilitybetween the discussed studies in terms of type of exercise intervention, population,and control groups, making it difficult to draw any firm conclusions when looking atthe collection of studies as a whole.62

COMPLEMENTARY AND ALTERNATIVE MEDICINE

A robust review of the use of complementary and alternative medicine (CAM) isoutside the scope of this article, although CAM is commonly used in patients with anx-iety disorders. The Coordinated Anxiety Learning andManagement study reports 43%of patients relied on CAM when they believed that their symptoms were inadequatelytreated.63 CAM includes such remedies as St. John’s wort and kava, substances withpotential negative side effects so their use should be identified by the practitioner.St. John’s wort frequently interacts with medications through the P-450 system. Addi-tionally, providers often do not recognize that combining St. John’s wort with otherserotonergic agents can precipitate serotonin syndrome. Kava is potentially hepato-toxic.63 PCPs should identify patients using alternative agents so they can monitorfor side effects and drug-drug interactions.

USE OF RATING SCALES IN TREATMENT

Rating scales are very useful in terms of diagnosis and following treatment response,but providers should not mistake changes in rating scales as a replacement for thesubjective experience of the patient. Treatment choices (ie, dose changes, medicationinitiation, or discontinuation) should be driven by patient choice and subjective expe-rience of improvement or lack thereof.

SPECIFIC TREATMENTS AND RECOMMENDATIONSGAD

The generalized nature of symptoms in GAD requires the use of pharmacotherapy ori-ented toward prevention. SSRIs and SNRIs are considered the mainstay of therapy.51

Anxiolytics, although effective for a short time, have limited overall utility given thatthey need frequent repeat dosing as a result of accompanying rebound anxiety.Longer-acting benzodiazepines, such as clonazepam, offer some benefit, but stillfail to inhibit future anxiety once the medication has worn off.57 Severe cases ofGAD may require that serotonergic medications be pushed to maximum dosageand response to medication may not appear until 12 weeks or more have elapsed.55

Augmentation with agents, such as mirtazapine, buspirone, and even atypical anti-psychotics, has been effective but this strategy is best done with psychiatricconsultation.51,55

Psychotherapy for GAD is very effective. CBT for GAD focuses on psycho-education and identifying and restructuring common automatic thoughts, such as

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catastrophizing. Several different manualized protocols have been developed andcan be used in a primary care setting.59 For patients who are particularly emotion-ally sophisticated and motivated, some of these protocols can be completed withvery limited practitioner support or even without supervision.64,65 Although manyprotocols exist, we recommend “Mastery of your anxiety and worry” as part ofthe “Treatments That Work” series, published by Oxford University Press, becausethis manual is practical, effective, and well validated. Although treatment manualsfor providers are not free of charge, a single therapist’s guide can be reused forhundreds of patients. A sample case of combination treatment is presented inTable 5.

Table 5Generalized anxiety disorder case and treatments

Case: Treatment Generalized Anxiety Disorder

A 36-year-old woman comes in with a chiefcomplaint of insomnia. She feelsconstantly on edge and finds it hard to fallasleep because of concern about herparents. She also experiences musclestiffness and shoulder and back pain. Onquestioning, she describes unremittingworry that something terrible will happento her elderly parents. The patient lives in astate distant from her parents. There is afamily history of cardiovascular disease andshe worries they will die of heart attacks.The patient calls her parents multiple timesa day to check in with them and feelsextremely anxious if she cannot reachthem. She also worries about how her kidsare doing in school even though they aregetting good grades, and about herfinances even though she is in goodstanding financially. She has beenexperiencing the worry for 5 y. She hasmissed multiple days of work because ofher incapacitating worry.

Initial Treatment:� Start SSRI or SNRI medication

� Sertraline, 25 mg PO Q day � 7 d, thenincrease to 50 mg PO Q day

� Refer patient to therapist for CBT� Therapy focused on psychoeducation

and understanding safety behaviors(calling parents). Therapy also chal-lenges automatic, catastrophic thoughts(ie, “my parents will die”)

Return visit in 6 wk:Patient has mild symptom improvement,

but still feels anxious

Continued treatment:� Increase sertraline to 100 mg PO Q day

because symptoms have improved some-what, but further improvement may beseen with a higher dose

� May need future dose increase to 200 mg� Continued CBT protocol

Return in 12 wk:Patient completed CBT; feels appreciably

improved. Worry decreased, she makesfewer calls to her parents, and chronicpain has significantly subsided. Sleep isimproved and she no longer misseswork.

Patient would like to continue her currentmedication regimen as it is.

Continued treatment� Maintain sertraline at 100 mg per day for

now because the patient is pleased withher improvements and would like tocontinue her current treatment

� Return in 6 mo to assess progress

Anxiety Disorders in Primary Care 1017

PD

Treatment of PD centers on the prevention of panic attacks and reducing anxietyabout impending attacks. Treatment with SSRIs and SNRIs is effective in preventingattacks and reducing overall anxiety.53 These agents do nothing to treat an acuteattack, however, and reducing symptoms typically takes 4 to 8 weeks or longer. Se-vere cases of PD may require high dosing of SSRIs and prolonged treatment, butimprovement can be tracked by frequency of attacks.Providers may find that patients benefit from an agent to abort an impending attack

at its onset. Benzodiazepines are the agent of choice66; however, these medicationsmust be prescribed with caution. If a patient has attacks that last less than 20 minutes,limited efficacy is seen from a short-acting benzodiazepine because the agent’s onsetoccurs after the attack has resolved. There is also evidence that use of benzodiaze-pines worsens the response or outcome of psychotherapy, an important treatmentmodality in PD.59 Some providers find that using longer-acting benzodiazepines,such as clonazepam, may reduce overall anxiety that can contribute to or trigger at-tacks, but use of these agents should be reserved for cases when patients are unableto function without them or cannot otherwise tolerate the use of serotonergicmedications.Psychotherapy for PD is at least as effective a treatment as pharmacotherapy and at

times superior to medication.59 CBT for PD is the most studied and validated.59

Although more experienced therapists have been shown to provide better outcomesfor their patients, novice therapists can also be effective.59 Online and manualizedCBT protocols for PD are well-validated and can be used with limited supervisionor, with certain versions, by the patient alone.64,65 “Mastery of your anxiety and panic”is another manualized favorite from the “Treatments That Work” series, published byOxford University Press.67

SAD

Medication for true SAD requires serotonergic agents. SSRIs and SNRIs are first-linechoices. Positive results may not be evident for up to 8 weeks.52 There is limited usefor anxiolytic agents except for specific anxiety-provoking events (ie, public speaking)that acutely worsen symptoms. In these cases, propranolol can be used at low dosesand side effects are minimal. There have been no studies, however, that demonstrateefficacy for b-blockers for the treatment of overall symptoms of SAD.52 Benzodiaze-pines can be tried, but used with caution, as previously described.52

CBT for social phobia centers on exposure to anxiety-provoking situations todemonstrate that resulting anxiety is tolerable and not dangerous. Over time, repeatedexposure leads to an overall symptom reduction and patients are able to tolerate whatthey could not before. This modality can be combined with cognitive restructuringtechniques that examine and challenge assumptions that patients make about them-selves (ie, “I will embarrass myself”). A combination of exposure and cognitive restruc-turing may be the most effective psychotherapy available.59 Although effective,patients are frequently unable to engage in it on their own or with only limited providerguidance. Therapists require more extensive treatment experience than merely famil-iarizing themselves with a treatment manual; therefore, we recommend patient referralto a trained therapist.59

OCD

Pharmacologic treatment of OCD also centers on the use of serotonergic agents.SSRIs and SNRIs are first choice and treatment of adults often requires prescribing

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maximum dosage. Time to efficacy can be as long as 12 weeks at this dose.55

Treatment-resistant cases of OCD may respond to higher-potency serotonergic med-ications, such as clomipramine, a TCA with significant serotonergic activity, or to theaddition of augmentation agents, such as atypical antipsychotics.55 These strategiesshould be managed by a psychiatrist. Little benefit is seen from short-acting anxiolyticmedication other than in extreme cases when they are needed to reduce anxiety suf-ficiently severe so as the patient is inhibited from travel to a provider’s office.Exposure and response prevention therapy is the gold standard of treatment of

patients with OCD.59 This therapy consists of exposing the patient to an anxiety-provoking stimulus (ie, germs from a dirty sink) and then preventing typical responsebehavior (ie, hand washing). Through experience of anxiety, the patient learns that it istolerable and response behaviors are unnecessary. Taking a patient through this typeof therapy requires a highly trained therapist and a committed patient. PCPs shouldrefer patients with OCD, willing to engage in psychotherapy, to experienced therapistswhenever possible.

PTSD

Pharmacotherapy for PTSD spans several different agents because there are oftenmultiple symptom domains that require treatment. Overall mood and anxiety symp-toms associated with PTSD are well-treated by SSRIs and SNRIs.54 These agentscan also help reduce the acute hypervigilance and explosive anger outbursts thatmanifest with this disorder. Efficacy after starting medication is usually evident in 4to 8 weeks.56 Patients may require acute anxiolytics for management of immediatesymptoms while serotonergic agents take effect. Benzodiazepines can be used,but have no long-term effect on PTSD and might possibly be harmful by prolongingrecovery time.54 Many patients with PTSD experience trauma-related nightmares.Treatment with prazosin is considered the first-line agent of choice, but providersshould counsel patients about the risk of dizziness and orthostatic hypotensionwith use.54 Treatment-resistant or complex cases of PTSD (those with severe symp-toms, extreme mood variability, and psychosis) can be treated with the addition ofantipsychotic agents and/or mood stabilizers, and should also be referred to apsychiatrist.The standard of care for PTSD uses psychotherapy and medication management.54

Multiple therapies have been developed. Two forms of therapy shown to have thebest efficacy are prolonged exposure and cognitive processing therapy.54 Prolongedexposure focuses on exposing the patient (in a real or imaginative way) to the traumathey experienced and progressively habituating the patient to the resultant anxiety.Cognitive processing therapy seeks to restructure assumptions and thoughts raisedby exposure to trauma. Both therapeutic modalities require trained, experienced ther-apists for successful treatment.

DISCUSSION AND CONCLUSION

Anxiety disorders are prevalent and debilitating. They are often underdiagnosed andundertreated in the primary care setting. Because of their propensity to cause gener-alized and poorly differentiated symptoms, detection can prove difficult. Multiple,effective screening tools exist to aid the PCP in this challenge. Once identified, how-ever, treatments are predictably effective. Protocols for managing GAD, PD, SAD,OCD, and PTSD have much in common. Even if delineation of the specific disorderis unclear, the PCP will rarely go wrong by providing a prescription for a serotonergicantidepressant and referral for psychotherapy. Psychotherapy is important for

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adequate treatment and many online and manualized treatments have greatlyincreased patients’ access to care.Although this article serves as an overview, individual cases can vary in presentation

and course. Of all challenging cases, those determined to be treatment-resistantcases can be the most problematic.In conclusion, PCPs can effectively diagnose and manage patients with a variety of

anxiety disorders. Many patients would benefit from psychotherapy and/or psycho-pharmacology. More complex or severe anxiety disorders are best managed withconsultation and collaboration with colleagues in psychiatry and psychology.

REFERENCES

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