SOAP. – Anxiety

Jan 7, 2020 admin TÂM THẦN 0

Anxiety

Karen M. Kress, Jill C. Cash, Cheryl A. Glass, and Alyson Wolz

Definition

  • A.Anxiety disorders are differentiated from transient fear and normal anxiety by persistence for 6 months or longer. Anxiety disorders are often comorbid with other psychiatric disorders, most often depression. They are characterized by excessive worry, tension, apprehension, and uneasiness from anticipated danger. Hypervigilance and avoidant behaviors are often features of anxiety disorder. It is the fight-or-flight response that is part of the survival instinct. The source of anxiety is largely unknown or unrecognized.
  • B.Anxiety in its chronic form is maladaptive and is considered a psychiatric disorder. Many cases of anxiety disorder in late life are chronic, having persisted from younger years. In its pathologic form, it interferes with developmental learning because it infers significant distress. Anxiety disorders include generalized anxiety disorder (GAD), panic disorder, social anxiety disorder, agoraphobia, and specific phobias.

Incidence

  • A.Anxiety disorders affect approximately 40 million adults yearly. The lifetime prevalence of anxiety disorders is estimated to be from 5.7% to 28%. Prevalence of diagnosis peaks in middle age and tends to decline in later life. Increased prevalence is noted among persons who are widowed, separated, or divorced. Although highly treatable, only 36.9% of individuals suffering from one or more anxiety disorders receive treatment.
  • B.Anxiety is present in many medical illnesses and must be distinguished to treat it appropriately. GAD and panic disorder are also associated with frequent suicide attempts.

Pathogenesis

  • A.Some degree of familial transmission of GAD, as well as panic disorder, has been noted. Unconscious conflict is thought to be the underlying cause of anxiety, which signals the ego to be careful expressing unacceptable impulses. Behavioral anxiety is considered a conditioned response to a stimulus associated with danger.
  • B.Clinically, however, identifying specific anxiogenic stimuli is difficult. The onset of GAD is also thought to be the cumulative effect of several stressful life events. Many studies have found that phobic/anxiety symptoms predated clinical alcoholism by a number of years. The gamma-aminobutyric acid (GABA)–benzodiazepine receptor complex, the locus coeruleus-norepinephrine system, and serotonin are three neurotransmitter systems implicated in the biologic basis of anxiety. These systems are thought to mediate normal anxiety and pathologic anxiety.

Predisposing Factors

  • A.Young to middle-aged women, onset usually at 20 to 30 years of age.
  • B.Single.
  • C.Lower socioeconomic status.
  • D.A childhood overanxious disorder.
  • E.Excessive worrying.
  • F.Unresolved unconscious conflict.

Common Complaints

  • A.Inability to control worrying.
  • B.Motor tension.
  • C.Autonomic hyperactivity vigilance.
  • D.Sleep disturbance.

Statements concerning self-medication with alcohol to help with sleep may indicate a coexistent alcohol abuse/dependence diagnosis that must be treated concomitantly.

  • E.Shortness of breath.
  • F.Increased heart rate and respirations.
  • G.Feelings of apprehension.
  • H.Dizziness.
  • I.Abdominal disturbances/nausea.
  • J.Increased perspiration.
  • K.Trembling.

Other Signs and Symptoms

  • A.According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), anxiety is excessive worry out of proportion to the likelihood or impact of the feared events that occurs for a period of 6 months or longer, during which the person has been bothered more days than not by these concerns.
  • B.At least three of the following six symptoms:
    • 1.Muscle tension.
    • 2.Restlessness or feeling keyed up or on edge.
    • 3.Easy fatigability.
    • 4.Difficulty concentrating or mind going blank because of anxiety.
    • 5.Trouble falling or staying asleep.
    • 6.Irritability.
  • C.Impaired social or occupational function. The anxiety, worry, or physical symptoms significantly interfere with the person’s normal routine or usual activities or cause marked distress.
  • D.The anxiety is not attributable to another medical condition or medication or substance effect.

Subjective Data

  • A.Review the onset, course, and duration of symptoms. How often does the anxiety occur (i.e., every day, week, or month)?
  • B.Review any history of anxiety and age of onset. If treated, how was the previous anxiety treated and what was the success of the treatment?
  • C.Determine whether there is a history of suicide attempts. Does the patient have a current plan or vague ideas of suicide? Ask the patient, Have you ever thought of hurting yourself or others? If there is any concern regarding suicide/homicide, immediately refer the patient to a psychiatrist.
  • D.Review drug history for prescription, over-the-counter (OTC), and recreational/illicit drug use, and the patient’s use of caffeine, which precipitates anxiety symptoms.
  • E.Review the patient’s history of alcohol consumption. Mild or moderate alcohol withdrawal presents primarily with anxiety symptoms. In patients who have developed tolerance to the effects of alcohol or benzodiazepines, abrupt cessation of these agents may produce heightened anxiety over baseline, as well as a risk of seizure.
  • F.Review the patient’s history for major stressors. Are these stressors new or chronic? If chronic problems, ask what made the patient come in today.
  • G.Determine how the patient has been coping with stress up until today (exercise, medication).
  • H.Review the patient’s history of other medical problems.
  • I.Does anyone else in the family have the same problem? How are they treated?

Physical Examination

  • A.Check pulse, respirations, blood pressure, and weight.
  • B.Inspect:
    • 1.Observe general appearance; note grooming, dress, ability to communicate, body movements, nail biting, playing with hair, and inability to sit still.
  • C.Administer mental exam of choice:
    • 1.DSM-5-TR Diagnostic Criteria for Generalized Anxiety Disorder available from the American Psychiatric Association (APA), DSM-5 (2013).
    • 2.Beck Anxiety Scale.
  • D.Physical examination as indicated by somatic complaints

Diagnostic Tests

  • A.Blood alcohol.
  • B.Thyroid profile.
  • C.Blood glucose.
  • D.Medication level (theophylline, etc.) if applicable.
  • E.Urine drug screen.
  • F.Additional testing related to suspected physical pathology.

Differential Diagnoses

  • A.Anxiety.
  • B.Psychiatric syndrome:
    • 1.Mood disorders, such as depression or bipolar disorder.
    • 2.Psychotic disorders.
    • 3.Somatoform disorders (characterized by physical complaints lacking known medical basis or demonstrable physical finding in the presence of psychological factors judged to be etiologic or important in the initiation, exacerbation, or maintenance of the disturbance).
    • 4.Personality disorders.
    • 5.Alcoholism and drug abuse/dependence.
    • 6.Adjustment disorders (posttraumatic stress disorder [PTSD]).
  • C.Medical conditions. Anxiety syndromes mimic many medical illnesses, including intracranial tumors, menstrual irregularities, hypothyroidism, hyperparathyroidism and hypoparathyroidism, postconcussion syndrome, psychomotor epilepsy, and Cushing’s disease:
    • 1.Hypoglycemia if anxiety is chronic.
    • 2.Hypothyroidism.
    • 3.Hyperthyroidism: Rapid-onset anxiety could be symptom of hyperthyroidism.
    • 4.Tumor.
    • 5.Cushing’s disease.

Plan

A.General interventions:

    • 1.Treat medical conditions as appropriate.
    • 2.Refer the patient for cognitive behavior therapy. Counseling is effective for learning new techniques to help with alleviating symptoms. Cognitive behavior therapy may be effective alone and/or may also be used as adjunct to medication treatment.
    • 3.Encourage the patient to perform self-calming techniques such as deep breathing/relaxation techniques and exercise.

B. See Section III: Patient Teaching Guides Sleep Disorders/Insomnia and Alcohol and Drug Dependence.

C.Pharmaceutical therapy:

1.Selective serotonin reuptake inhibitors (SSRIs) or selective serotonin norepinephrine reuptake inhibitors (SNRIs):

    • a.Fluoxetine (Prozac), 5 to 10 mg/d orally initially; usual dose 20 to 80 mg/d; long half-life; alters metabolism of cytochrome P-450 2D6-cleared agents; use caution.
    • b.Paroxetine (Paxil), 10 mg/d orally initially; usual dose 25 to 50 mg/d.
    • c.Sertraline (Zoloft), 25 to 50 mg/d orally initially; usual dose 50 to 200 mg/d.
    • d.Venlafaxine (Effexor), 37.5 mg/d initially; usual dose 75 to 300 mg/d.
    • e.Citalopram (Celexa), 5 to 10 mg/d orally initially; usual dose 20 to 40 mg/d. Caution: Risk for QT prolongation, contraindicated in patients with congenital long QT syndrome and should not exceed 20 mg daily if prescribed to patients also taking CYP2C19 inhibitors (cimetidine, fluconazole, and omeprazole).
    • f.Escitalopram (Lexapro) 10 mg/d orally initially; usual dose 10 to 20 mg/d.
    • g.Duloxetine (Cymbalta), 20 mg/d orally initially; titrate to 30 to 60 mg/d.
    • h.These medications can take 4 to 6 weeks to take full effect.
    • i.Warn patients that they should not stop these medications abruptly; they should taper off gradually.

2.Nonbenzodiazepine anxiolytic:

    • a.Buspirone (Buspar), 7.5 mg twice a day.
    • b.May increase by 5 mg/d orally every 2 to 3 days.
    • c.Usual range: 20 to 30 mg orally every day, maximum 60 mg orally every day.
    • d.Therapeutic effects may be delayed from 1 to 4 weeks.

3.Short-acting benzodiazepines:

    • a.Alprazolam (Xanax), 0.25 to 0.5 mg orally two to three times daily.
    • b.Clonazepam, 0.25 to 0.5 mg orally one or two times daily, titrated up to 1 mg two to three times daily as needed
    • c.Lorazepam (Ativan), 0.5 to 2 mg, up to 6 mg orally every day in divided doses; maximum dose of 10 mg/d in divided doses:
      • i.Use for initial short-term stabilization while simultaneously prescribing buspirone or SSRI/SNRI, because therapeutic effects are delayed from 1 to 4 weeks.
      • ii.Limit use to several weeks to a few months to prevent dependence.

Follow-Up

  • A.Follow up in 1 to 2 weeks to assess the patient’s status.
  • B.Follow up every 2 to 4 weeks after that to evaluate the patient’s progress.
  • C.Assess suicide potential with every office visit.

Consultation/Referral

  • A.Refer to a psychiatric clinician for complex medication management and psychotherapy after initial assessment.
  • B.If the patient expresses suicidal thoughts, immediately refer for an emergency mental health evaluation; this may be through the local emergency room or mental health center.

Individual Considerations

A.Pregnancy:

  • 1.Caution should be used in prescribing medications for anxiety during pregnancy; the benefits must be weighed against the risks.
  • 2.If the patient becomes pregnant while taking these medications, taper medication dose instead of ceasing abruptly.

B.Geriatrics:

  • 1.Anxiety is often unrecognized and inadequately treated in this population because of concomitant medical illness, overlap with cognitive disorders, comorbid depression, ageism, and cohort effects.
  • 2.Elderly patients may be hesitant to discuss mental health concerns and needs, due to the history of cultural stigma associated with mental illness.
  • 3.Start with the lowest dose of medication and increase slowly.
  • 4.Older adults may have increased sensitivities to benzodiazepines and decreased metabolism of long-acting agents. Benzodiazepines increase risk of cognitive impairment, delirium, falls, and fractures. Avoid short- and intermediate-acting benzodiazepines.
  • 5.SSRIs and SNRIs are to be used with caution because they may exacerbate or cause syndrome of inappropriate antidiuretic hormone excretion or hyponatremia: monitor sodium level closely when starting or changing doses in older adults.

C.Partners:

  • 1.If available in the community, provide resources for partners, such as the National Alliance for the Mentally Ill.
  • 2.Psychotherapy for the patient and partner is often helpful.

 

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