Misconceptions About Anxiety

Because anxiety is universal and every individual has experienced it at some point in his or her life, it may seem logical for a person to view another’s experience with anxiety through his or her own “eyes.” If one has never experienced a significant amount of anxiety for a prolonged time (and consequently does not have an anxiety disorder), the person may interpret the meaning and experience of anxiety in another person as mild and acceptable rather than a disorder that requires attention and treatment. Consequently, the public as well as many healthcare professionals may not view anxiety disorders as serious health problems with problematic and even tragic consequences when left untreated. They may have less difficulty relating to other psychiatric disorders illnesses such as schizophrenia or bipolar disorders as a problem because these are often outside the realm of normal human experiences. Often, anxiety disorders are discounted in terms of their levels of intensity and their need for treatment. Some people may view an anxiety disorder as the psychiatric equivalent of the common cold. However, given the high prevalence of these disorders and the impairment they cause, healthcare professionals need to re-examine their understanding of what constitutes an anxiety disorder.

Prevalence of Anxiety Disorders

Before recent epidemiological studies were conducted, many practitioners thought of anxiety disorders as occurring relatively infrequently and posing minor difficulties in people’s lives. Two important studies, the Epidemiologic Catchment Area (ECA) Study, conducted in 1989, and the National Comorbidity Study (NCS), conducted in 1992, yielded a much more impressive picture. In the ECA study, as many as 20% of the adult population was found to have an anxiety disorder. In addition, 1 in 5 people had not sought treatment in the last year. The NCS results further refined these numbers and found that up to 25% of the American adult population can expect to have an anxiety disorder in their lifetime. The actual incidence can vary between 15%-25% when taking into account whether these disorders interfere with daily functioning or impair social and occupational areas of a person’s life. One of the most common psychiatric illnesses, anxiety disorders affect females more than males. TABLE 1 shows the lifetime prevalence of the anxiety disorders in the United States.

Common Anxiety Disorders

Once the essentials of a panic attack are understood, the specific disorders that fall under the umbrella of “anxiety disorders” can be put into perspective. There are five common, but distinctly different, types of anxiety disorders: panic disorder (PD), generalized anxiety disorder (GAD), social phobia (SP), obsessive compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). (Specific phobia and acute stress disorder, while clinically significant, will not be discussed, as there is very limited pharmacologic treatment for these two disorders.) All of these disorders are distinct entities with their own characteristic presentation; however, the similarities will be emphasized to promote better understanding and to help pharmacists recognize these undertreated and often-overlooked disorders.

There are two ways to describe the causes of agitation and aggression: by the underlying disease state (see Table 1), or the exact pathophysiology that causes the aggression. The DSM-IV-TR has several diagnostic categories describing the relationship between a medical condition or substance and the specific psychiatric symptoms or syndrome they cause. Examples of medical conditions that more commonly cause aggression and agitation symptoms include central nervous system disorders such as head trauma, stroke, tumor, and epilepsy; metabolic disorders such as fluid and electrolyte abnormalities, acid-base abnormalities, thiamine deficiency, hyper- and hypothyroidism, and hypoglycemia; infections such as sepsis, HIV, encephalitis, and urinary tract infections; and others such as systemic lupus erythematosus, postoperative states, especially in transplant or hip replacement procedures, terminal illnesses, and dialysis. Table 2 identifies medications and drugs that may be associated with inducing symptoms of agitation or aggression.

Four characteristics contribute to aggression and violence among people with serious mental illness: acute, poorly controlled mental illness, medication noncompliance, substance abuse, and previous violent behavior. Each is an independent risk factor, and the risk is heightened when factors are combined. People with and without mental illness who use drugs and alcohol have an increased risk for agitation and aggression.

There is no single unifying theory for the underlying pathophysiology of aggression. Brain lesions and changes in neurotransmitter function are two widely accepted theories. As the frontal lobes are responsible for higher order thinking, censoring, disciplining, planning and decision-making, damage to the frontal cortex produces a variety of disinhibited behaviors (patient becomes more agitated or aggressive than prior to receiving medication). Lesions or injury to the basal ganglia, limbic system, thalamus, hypo-thalamus, hippocampus and temporal lobes may also result in abnormal behavior. In a simplistic approach, agents that reduce dopaminergic or noradrenergic tone or increase serotonergic or GABAergic tone decrease aggression (such as any benzodiazepine or antipsychotic agent), no matter what the cause.

There is specific evidence demonstrating an inverse correlation between 5-HIAA, the major meta-bolite of serotonin, and aggressive behaviors.Other theories propose that the mechanism of agitated depression is increased serotonergic responsiveness and decreased GABAergic tone, whereas acute psychosis results from increased dopamine.The pathophysiology is generally more important when planning a long-term strategy to treat the underlying disease rather than when managing an acutely agitated patient who needs immediate attention.

A thorough history, physical examination, and basic laboratory studies are important to fully evaluate the patient and rule out medical and medication-related causes of insomnia and depression. Additionally, the selection of the appropriate antidepressant medication (selective serotonin reuptake inhibitors, tricyclic antidepressants [TCAs], monoamine oxidase inhibitors, or atypical antidepressants), adequate dosages, and a sufficient trial period are imperative in the treatment of depression in the elderly. In seniors, an adequate antidepressant trial is longer than that for younger adults, with a complete response often seen after six to 12 weeks. Nuances related to medication therapy in the geriatric population should be clearly expressed by pharmacists in recommendations and educational communications. The impact of aging and medical conditions associated with aging on the pharmacokinetic profile of a medication and the increased risk of associated side effects must be understood with regard to geriatric dosage guidelines, disease-drug contraindications (eg, TCAs and cardiac conduction defects), and drug interactions (eg, CYP450 inhibition and possible toxicities).

When sleep medication is deemed the best course of treatment after careful consideration of nonpharmacologic interventions (eg, sleep hygiene, stimulus-control therapy, and sleep-restriction therapy) in the elderly, short-acting nonbenzodiazepine hypnotics (zolpidem or zaleplon) are recommended. These medications reduce both sleep latency, due to their quick absorption and onset, and the risk of daytime sleepiness the following day, due to their short half-life. Caution should be exercised when a longer-acting hypnotic is prescribed in a geriatric patient since associated side effects may be particularly pronounced in seniors. Longer-acting hypnotic agents may be associated with changes in sleep architecture such as a reduction in delta or deep sleep, morning hangover with excessive daytime sleepiness, impaired motor coordination, and visuospatial problems that may contribute to an increased risk of injury. In an attempt to prevent rebound insomnia, a very gradual taper is recommended when termination of treatment is warranted.

Conclusion

When caring for older patients, it is important to make the distinction between pathological changes and normal aging. Remaining cognizant of this helps to avoid not only dismissing a treatable pathology as merely an accompaniment to old age but also treating a natural aging process as a disease while overlooking the possibility of iatrogenic effects.

Insomnia may be a symptom of medical and psychiatric conditions, changes in lifestyle, or medications, among other precipitating factors. When an elderly patient presents with complaints of insomnia, the clinician should assess for possible depression since many seniors do not seek help for or verbally express symptoms of this condition, which is common among them and is associated with morbidity and mortality. By raising awareness that insomnia, a symptom of depression for many people, may be reported more readily than depressive symptoms, pharmacists may become involved in identifying those at risk for depression and in facilitating the appropriate evaluation, intervention, and education of patients and their families and caregivers.

Treatment for anxiety disorders often involves a combination of pharmacologic and psychological approaches. Nonpharmacologic interventions and therapies are essential at some point of treatment, and pharmacists need to be familiar with these approaches. Once an accurate diagnosis of the anxiety disorder is made by physical and/or laboratory assessment, any drugs or substances that the patient may be taking that exacerbates the anxiety disorder need to be identified and stopped. Treatment should start with bibliotherapy–essentially giving large doses of information about the nature, etiology, presentation, and treatment of the anxiety disorder. (See TABLE 5.)

This patient education should be followed by effective pharmacologic treatment to stop the panic attacks and to help with anticipatory anxiety around having another panic attack or anxiety symptoms. Once the actual physical anxiety events are eliminated, a wide variety of cognitive, behavioral and supportive psychotherapies are available to help reshape the behavioral effects of the disorder. This will allow patients to make changes in their lives and resume the social, occupational, and day-to-day activities that have been impaired by the anxiety disorder.

Post-traumatic Stress Disorder (PTSD) has become much more recognized and appreciated following the traumatic events of September 11th. The estimated lifetime prevalence for PTSD is almost 8%. This anxiety disorder centers on a person re-experiencing an extremely traumatic event, such as a natural disaster, war, crime, rape, or abuse, whether the abuse is physical, mental or sexual in nature. Because of this experience, a person may have recurrent thoughts about the event or actually re-experience some of the same feelings and reactions that occurred during the initial exposure. A person with Post-traumatic Stress Disorder (PTSD) will try to avoid activities or thoughts associated with the initial traumatic event. In addition, the person will usually experience autonomic arousal or panic symptoms when encountering or thinking about the triggering situation.

Social Phobia (SP)

Social phobia affects between 3% and 13% of the adult population and can occur in patients as young as in early childhood. Social phobia is not about being shy, bashful, or not liking people; instead it is a disorder in which patients experience intense feelings of humiliation and/or scrutiny when in a social situation. This situation can be specific, such as giving a talk in a class, or generalized to almost every encounter with any person throughout the day, whether this involves one person or many people. Social phobia is a chronic, unremitting anxiety disorder that has a significant genetic component and a biological basis. Social Phobia (SP) has high comorbidity with other anxiety disorders, as well as depression and alcohol and substance use disorders. The impairment can have extreme ramifications, ranging from not ever applying for a job or a school to quickly quitting because of the intense discomfort experienced when the patient is forced to talk or interact with others. Common symptoms include flushing, blushing, tachycardia, sweating, stuttering, and tremor. In essence, the patient has panic-attack symptoms when he or she is only placed in social situations. The person can experience either limited symptoms or a full-blown attack that affects every body system. TABLE 4 lists some situations in which people with social phobia experience extreme anxiety and thus make every effort to avoid.

Comorbidity of other anxiety disorders such as panic disorder, social phobia and obsessive compulsive disorder (OCD) is common, as well as of other psychiatric disorders such as depression and substance use disorders. Patients with untreated generalized anxiety disorder (GAD) are high users of medical services as they attempt to understand and treat their excessive anxiety.

Patients with obsessive compulsive disorder (OCD) experience these thoughts as ridiculous, absurd, repugnant, and quite illogical; the thoughts may even be quite foreign to the person’s core values and beliefs. Given these characteristics, one begins to understand why many patients do not report these symptoms or seek treatment for fear of ridicule and embarrassment.

Many patients experience an early onset of symptoms, with 30% of patients developing the disorder by adolescence. Strong evidence exists for a definite neuroanatomical abnormality, with hyperactivity found in the basal ganglia, claudate nucleus and orbital frontal cortex. Concomitant neurological syndromes such as Tourette’s add further evidence for a biological etiology for obsessive compulsive disorder (OCD). Comorbid psychiatric disorders such as depression and alcoholism have a high likelihood of occurring in individuals with untreated OCD. Common obsessions and compulsions that manifest in obsessive compulsive disorder (OCD) are shown in TABLE 2.

Attitudes and behaviors on both the patients’ and practitioners’ behalf contribute to the patient’s reticence in seeking treatment. Patients may think, “Am I the only person who has this problem?” or, “I should be able to get over this on my own.” or, “What do I have to be anxious about?” Practitioners and their staff may trivialize the illness or concur with the patient’s doubts over, “What do you have to be anxious about?” Practitioners may offer ineffective recommendations, such as, “Just relax”, or, “There’s nothing to worry about.” or, “Go for a walk… take the day off.” These recommendations, coupled with past ineffective pharmacological treatments, may prevent many patients from seeking treatment for a condition in which both the patient and practitioner have concern that the condition actually exists. Patients who experience cardiovascular symptoms may seek treatment in the emergency department for a wide range of catastrophic fears, from that of having a “heart attack” to a “stroke,” only to be told, “There is nothing wrong with you. You are perfectly healthy!” The objective signs of anxiety are often transient, and there is a wide overlap with other possible disorders. Coupled with a lack of sophisticated technology to detect a panic attack, both patients and practitioners may have persistent doubt as to the validity of a panic attack.

Patients may feel embarrassed when describing symptoms or be at a loss to adequately describe them and feel inadequate for not having a better description. They may fear that others will judge them harshly. Alternatively, they may judge themselves harshly, with thoughts such as: “Nothing can be done,” “There’s nothing wrong,” “I think I’m going crazy,” “People will think I’m crazy,” or, “I will be committed to a mental institution.”

When anxiety disorders, especially panic disorder, remain untreated or are inadequately treated, one can expect patients to contribute to high medical utilization with subsequent increase in costs, time, and procedures, and a decrease in available services to others.

A large number of patients with an anxiety disorder never seek treatment. These reasons will be discussed in depth in the next section. Those who do seek help often turn to practitioners in acute care clinics or emergency departments. As many as 28% to 57% of patients with panic attacks will seek treatment in the emergency room of a hospital. This is the most logical place for the patient to go, since a panic attack is usually experienced as “life-threatening” to the patient. Patients seldom seek initial treatment from psychiatrists, even though psychiatrists are often the best informed and educated to deliver effective treatment.

Because so many patients seek treatment from their primary care providers, there has been an increased effort to train these practitioners to recognize and treat the most common anxiety disorders. Primary care settings in which patients may seek treatment include family medicine, obstetrics-gynecology, and dermatology. Often, patients may seek treatment from specialists based on the primary organ system that is affected; patients tend to focus on one symptom above the others and seek out specialists to treat that problem.

When the adrenergic nervous system is forced into excessive stimulation both in intensity and duration, numerous negative consequences can result, especially when this system did not need to be activated at all. Some of these negative consequences include possible increased cardiovascular risk, such as hypertension and heart disease, and direct psychiatric effects, such as depression and suicide. In addition, excessive cortisol production/release has been shown to result in decreased brain size.

When the adrenergic nervous system is continuously being activated in patients with untreated panic disorder, the indirect results are decreased enjoyment in daily activities, decreased work, and increased disability. Increased utilization of health services can occur from both an acute need, such as seen with an increased number of emergency room visits, and in ongoing needs, such as in seeking diagnostic help and treatment for many chronic manifestations of panic attacks.The costs incurred by unrecognized panic disorder have been examined for patients in primary care settings and have been found quite high.