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Chapter 5: Anxiety, Obsessive-Compulsive, Trauma, and Stressor-Related Disorders

ANXIETY DISORDERS

Anxiety disorders are characterized by excessive or inappropriate fear or anxiety. Fear is manifested by a transient increase in sympathetic activity (“fight or flight” physiologic response, thoughts, feelings, behaviors) in a situation perceived as dangerous or threatening. By contrast, anxiety involves apprehension regarding the possibility of a negative future event. The criteria for most anxiety disorders involve symptoms that cause clinically significant distress or impairment in social and/or occupational functioning (see Table 5-1). DSM-5 anxiety disorders include generalized anxiety disorder, panic disorder, agoraphobia, social anxiety disorder, selective mutism, and specific phobias.

TABLE 5-1.Signs and Symptoms of Anxiety
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TABLE 5-1. Signs and Symptoms of Anxiety
Constitutional Fatigue, diaphoresis, shivering
Cardiac Chest pain, palpitations, tachycardia, hypertension
Pulmonary Shortness of breath, hyperventilation
Neurologic/musculoskeletal Vertigo, light-headedness, paresthesias, tremors, insomnia, muscle tension
Gastrointestinal Abdominal discomfort, anorexia, nausea, emesis, diarrhea, constipation

  • Anxiety disorders are caused by a combination of genetic, biological, environmental, and psychosocial factors.

  • Primary anxiety disorders are diagnosed after determining that symptoms are NOT due to the physiological effects of a substance, medication (see Table 5-2), or another medical condition (see Table 5-3).

  • Major neurotransmitter systems implicated: norepinephrine (NE), serotonin (5-HT), and gamma-aminobutyric acid (GABA).

  • Most common form of psychopathology.

  • More frequently seen in women compared to men, approximately 2:1 ratio.

TABLE 5-2.Medications and Substances That Cause Anxiety
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TABLE 5-2. Medications and Substances That Cause Anxiety
Alcohol Intoxication/withdrawal
Sedatives, hypnotics, or anxiolytics Withdrawal
Cannabis Intoxication
Hallucinogens (PCP, LSD, MDMA) Intoxication
Stimulants (amphetamines, cocaine) Intoxication/withdrawal
Caffeine Intoxication/withdrawal
Tobacco Intoxication/withdrawal
Opioids Withdrawal

LSD, lysergic acid diethylamide; MDMA, 3,4-methylenedioxy methamphetamine; PCP, phencyclidine.

TABLE 5-3.Medical Conditions That Cause Anxiety
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TABLE 5-3. Medical Conditions That Cause Anxiety
Neurologic Epilepsy, migraines, brain tumors, multiple sclerosis, Huntington disease
Endocrine Hyperthyroidism, hypoglycemia, pheochromocytoma, carcinoid syndrome
Metabolic Vitamin B12 deficiency, electrolyte abnormalities, porphyria
Respiratory Asthma, chronic obstructive pulmonary disease (COPD), hypoxia, pulmonary embolism (PE), pneumonia, pneumothorax
Cardiovascular Congestive heart failure (CHF), angina, arrhythmia, myocardial infarction (MI)

image  WARDS TIP

Assess for psychopathology if an individual's symptoms are causing Social and/or Occupational Dysfunction (use mnemonic SOD).

image  WARDS TIP

Late-onset anxiety symptoms without a prior history or family psychiatric history should increase suspicion of anxiety caused by another medical condition or substance use.

image  WARDS QUESTION

Q: In a patient with comorbid anxiety and depression, would treatment with a benzodiazepine be a first-line treatment?

A: No. Avoid use of benzodiazepines because they may worsen depression.

TREATMENT GUIDELINES

  • Determine treatment course based on the severity of symptoms.

  • Initiate psychotherapy for mild anxiety.

  • Consider a combination of therapy and medication for moderate to severe anxiety.

image  WARDS TIP

Use b...

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