The Primary Care Toolkit for Anxiety and Related Disorders

Bianca Lauria-Horner

• Publisher: Brush Education
• Year: 2016
• ISBN:
  9781550596632
• Topic: Medizin
• Subtopic: Psychiatrie & geistige Gesundheit

Primary care physicians know from experience how many patients come to them needing help with anxiety and related disorders: these disorders have a lifetime prevalence rate of 30%, but they often seem to be present in a much higher proportion of primary care visits.

Time pressure challenges every primary care provider who responds to these disorders. The Primary Care Toolkit for Anxiety and Related Disorders —carefully aligned with the DSM-5—gives you the tools to help you treat your patients promptly and effectively.

Quickly find the information and strategies you need using summaries of diagnostic criteria and pharmacological therapies, severity assessments, treatment summaries, and case studies. Efficiently screen, diagnose, and manage common anxiety and related disorders, using visit-by-visit guides for mild, moderate, and severe disorders.

An accompanying CD puts the best, most effective diagnostic tools at your fingertips, ready to be printed and used by you and your patients: patient self-report forms and questionnaires, symptom checklists, functional impairment assessment scales, and more.

The Primary Care Toolkit helps prepare you for the 7 anxiety and related disorders that primary care physicians see most often:

• Generalized anxiety disorder,
• Panic disorder,
• Agoraphobia,
• Social anxiety disorder,
• Obsessive-compulsive disorder,
• Posttraumatic stress disorder,
• Adjustment disorder.

Whether you are a family physician, an ER doctor, a pharmacist, a nurse or nurse practitioner, or a medical student, the information and resources in The Primary Care Toolkit for Anxiety and Related Disorders will add to your clinical primary care knowledge and skills.

SECTION II
Anxiety Disorders

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In the DSM-5, the “Anxiety Disorders” chapter includes the following:

• Separation anxiety disorder

• Selective mutism

• Specific phobia

• Social anxiety disorder (social phobia)

• Panic disorder

• Agoraphobia

• Generalized anxiety disorder (GAD)

• Substance/medication-induced anxiety disorder

• Anxiety disorder due to another medical condition

• Other specified anxiety disorder

• Unspecified anxiety disorder

Here we will describe the screening, assessment, and management of 4 common anxiety disorders seen in primary care: GAD, panic disorder, agoraphobia, and social anxiety disorder.

4
Generalized Anxiety Disorder

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Introduction

Patients with GAD have frequent office visits for unexplained physical symptoms; consequently, as a primary care physician, you will most likely encounter GAD in the course of investigating a patient who has come in for one of GAD’s associated symptoms, such as restlessness, fatigue, concentration problems, headaches, and myalgia.¹ To learn about GAD, you can follow the diagnosis, treatment, and management of our patient, Mr. AG. You can progress through the practice case study from start to finish, or you can select your own learning path in the Practice Case Study Index. The choice is yours.

Clinical Presentation

Patients with GAD experience anxiety for most days during a 6-month period that is out of proportion to the actual danger or threat in a situation, a variety of events, or activities. This is the typical “worry wart.” Patients worry about “what if” scenarios—these types of worries are a key distinguishing feature of GAD. They worry about a number of future events or activities—about what might happen, not what is already happening. This is the hallmark feature of GAD patients. Worries typically involve the following:²

• Health

• Job and finances

• Competence

• Acceptance

• Family, friends, relationships

• Minor matters

The worry is difficult to control and is accompanied by a variety of associated symptoms, such as restlessness, fatigue, and muscle tension.³ The symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning.⁴

GAD is often chronic. When patients with GAD discontinue their medication,

• 25% relapse in the first month

• 60–80% relapse over the course of the next year.⁵

The diagnostic criteria for GAD can be found in Appendix XI.

Prevalence

The lifetime prevalence of GAD is approximately 4–7% of the general population.⁶

GAD is highly comorbid. It has been estimated that 90% of patients with GAD have lifetime comorbidity with either substance use disorder (SUD) or a psychiatric disorder.^7,8 Lifetime comorbidity includes:

• Major depressive disorder (MDD) (62%)

• Dysthymia (40%)

• Alcohol use disorder (38%)

• Simple phobia (35%)

• Social anxiety disorder (34%)

GAD is diagnosed twice as often in women as in men. The disease typically starts around 31 years of age.⁹

Generalized Anxiety Disorder Case Study: Meet Mr. AG

Mr. AG, a 39-year-old male lawyer, presents to your office with the following symptoms:

• Excessive anxiety for 20 years

• Chronic restlessness and nervous tension

• Difficulty concentrating

• Physical symptoms including tension headaches, tightness in the abdomen, palpitations, and difficulty breathing

• Sleeps only 3 hours per night

• Fatigue

Upon chart review, you notice that Mr. AG had a full cardiopulmonary workup 2 months ago that failed to reveal any abnormalities. You realize that you will not be able to offer him the time required for an in-depth investigation at this visit as your office assistant booked him for only a single appointment.

What should or can you do?

What are your options?

ASSESSMENT: SCREENING AND PROVISIONAL DIAGNOSIS

If you are pressed for time and there is no safety risk or clinical judgment of urgency, you can tell Mr. AG you understand his suffering and will help, but that you need him to schedule an appointment that will give you the time to assess him properly. Advise him to return should his condition get worse in the meantime. This is a very important step, particularly if time is an issue. This takes 1–2 minutes and reassures him that even if you don’t have time to spend with him this visit, you are still concerned about him and want to take the time to address his complaints properly. He will feel heard and relieved that someone will help. This lessens his distress while gaining his trust.

Note: You can arrange for any additional investigative workup as appropriate to rule out und...