Which mental health disorder can be a direct physiological result of hyperthyroidism

Treatment of Anxiety Disorders

When anxiety substantially impairs work, family, or social adjustment, mental health evaluation is indicated and treatment is appropriate. Panic disorder responds to most antidepressant medications, which are first-line therapies for this disorder. Benzodiazepines are also effective but are associated with physical dependence and abuse in a subset of patients. Cognitive behavioral therapy (CBT), a time-limited structured psychotherapy, is also effective for panic disorder.

Obsessive-compulsive disorder is treated with the SSRI antidepressants; however, titration to doses higher than needed to treat MDD is usually necessary for symptomatic improvement. A behavioral therapy technique, exposure and response prevention, is also effective for obsessive-compulsive disorder. Generalized anxiety disorder responds to a variety of antidepressant medications as well as CBT. PTSD is partially responsive to antidepressants, but psychotherapy or combination treatment increases response rates. The first-line medication treatment for social phobia is an SSRI, and CBT is helpful. Specific phobias are treated with focused desensitization therapy rather than medication. An excellent patient educational workbook on anxiety disorders is available (see Online Resources available atExpertConsult.com).

A risk-benefit evaluation for treatments during pregnancy must be individualized for the pregnant woman. If psychotherapy treatment is declined, not available, or ineffective, pharmacologic treatment is reasonable. The use of antidepressants in pregnancy and lactation has been reviewed in the section on MDD. Because abrupt discontinuation of chronic benzodiazepine may result in withdrawal symptoms, a monitored dose taper is recommended. The teratogenic risk from benzodiazepine exposure, if any, is very small.70 Maternal benzodiazepine use was associated with cesarean delivery (OR, 2.45; 95% CI, 1.36 to 4.40), LBW (OR, 3.41; 95% CI, 1.61 to 7.26), and neonatal ventilatory support (OR, 2.85; 95% CI, 1.2 to 6.9).69 At delivery, neonates exposed chronically to maternal benzodiazepine in utero may exhibit irritability, tremors, seizures or hypotonia.71 These CNS stress signs are accentuated with benzodiazepine coupled with SSRI exposure.

Little is known about the longer-term effects of benzodiazepines on neurologic development. An investigation in a Norwegian cohort revealed no association between anxiolytics and hypnotics exposure in utero and language competence of offspring at 3 years of age.

The concentration of benzodiazepines in breast milk varies by drug, dose, and frequency of use. Treatment of pregnant or lactating women with benzodiazepines optimally is short term with a focus on targeted symptoms. Intermittent use of short half-life benzodiazepines (lorazepam) is preferred for lactating women, as chronic use of long-acting benzodiazepines increases the risk for infant sedation. Mothers can be advised to observe for drowsiness and poor feeding.

Conclusion

Anxiety disorders are common across gender, age, and culture. Accurate diagnosis of an anxiety disorder rests on determining the specific feared stimuli and the presence of functional impairment or distress related to this fear. Generally speaking, CBT is the psychosocial treatment of choice for all anxiety disorders, and it has also been shown to be effective when treating clients with severe mental illness, dual diagnoses, and medical illnesses. Medication is frequently used to treat anxiety disorders and is often preferred by many for its initial lower cost in terms of money, time, and effort; however, medication tends to be less cost effective in the long term and involves higher relapse rates when discontinued than does CBT.

Chapter 102: Questions & Answers

102.1

Which of the following is the most common mental health disorder?

Anxiety

Bipolar

Depression

Schizophrenia

Substance abuse

Answer: A. Many of these patients never receive appropriate care, in part because they choose to present with a physical complaint and disguise their anxiety. Patients with chronic illnesses have higher rates of anxiety and depression than the rest of the population.

What is the most common cause of organic anxiety, anxiety that results from a physiologic origin?

Adrenal disorders

Alcohol and drug use

Cardiac disease

Hyperthyroidism

Pulmonary embolus

Answer: B. This may be from intoxication or withdrawal states.

A 52-year-old woman presents with 2 months of recurrent episodes of anxiety, mild chest pain, subjective palpitations, hand paresthesias, and occasional muscle spasms. They have occurred weekly in the past but are now increasing in frequency. Her only past history is a thyroidectomy 4 months prior. She is taking levothyroxine (Synthroid) and had normal thyroid levels 2 weeks ago. Her vital signs, physical examination, and electrocardiogram are normal. Laboratory evaluation shows sodium 141 mEq/L, potassium 4.1 mEq/L, creatinine 1.0 mg/dL, bicarbonate 26 mEq/L, chloride 100 mEq/L, and calcium 7.1 mg/dL; a complete blood count is normal. Which of the following should be the next step in her management?

Outpatient clonazepam

Parathyroid hormone level

Psychiatry consultation

Thyroid hormone levels

Urine drug screen

Answer: B. Anxiety is the predominant symptom in 20% of patients with hypoparathyroidism. Other symptoms include paresthesia, muscle cramps, and spasms. Most cases are idiopathic or due to inadvertent parathyroid gland harvest during thyroidectomy. The diagnosis is suggested by a low serum calcium and an elevated phosphate and is confirmed by a depressed parathyroid level.

Which of the following statements regarding anxiety and endocrine disorders istrue?

Anxiety can often be traced to reactive hypoglycemia.

Anxiety is not a manifestation of hypothyroidism.

Diabetics treated with antianxiety agents have improved hemoglobin A1c levels.

Less than 5% of diabetics experience anxiety.

Patterns of diaphoresis in pheochromocytoma mimic those of a panic attack.

Answer: C. Approximately 15% of diabetics have an anxiety disorder. Treatment improves hemoglobin A1c levels. Anxiety due to reactive hypoglycemia is rare despite the common perception among patients. Pheochromocytoma causes whole body diaphoresis, whereas panic disorders primarily cause sweaty palms. Hyperthyroidism or hypothyroidism can cause significant anxiety manifestations. It is more related to the rate of change than the level of thyroid hormones.

A 23-year-old woman with a history of asthma presents with increasingly frequent episodes of panic attacks. Her medications are an inhaled beta-agonist and an intermittent steroid inhaler. She reports subjective increasing asthma severity as her panic episodes have worsened. When counseling the patient, which of the following statements is most correct?

An anxiety disorder in an asthmatic patient does not increase morbidity.

Anxiety does not precipitate asthma attacks.

Anxiety does not worsen airflow.

Asthmatics are more likely to have an anxiety disorder.

It is difficult to differentiate dyspnea related to asthma from anxiety.

Answer: D. Anxiety can precipitate and prolong an asthma attack. Morbidity and mortality are increased in asthmatic patients who have a coexisting anxiety disorder. Patients who have asthma are twice as likely to have an anxiety disorder and five times as likely to have a phobia. Acute dyspnea from “panic” dyspnea can be differentiated from asthma by clear lungs on auscultation.

Which of the following syndromes is not associated with anxiety?

Left hemispheric strokes

Multiple sclerosis

Right hemispheric strokes

Transient ischemia attack

All of the above can be associated with anxiety.

Answer: E. Anxiety may be a component of seizures, tumors, arteriovenous malformations, and ischemic events. It may be the only manifestation of some disorders (eg, right hemispheric strokes and transient ischemic attacks [TIAs]). The coexistence of anxiety plays an important role in the prognosis and impairment of stroke patients.

A 38-year-old woman with a long history of anxiety and panic disorder presents with anhedonia, melancholy, sleep disruption, crying episodes, and some hostility feelings. She has no current anxiety symptoms. Her only medication is clonazepam. She has no known medical illness. Which of the following statements regarding this patient's symptoms istrue?

Approximately 50% of patients with panic disorder develop major depression.

Depression with anxiety and hostility is usually refractory to treatment.

The first diagnostic step should be a thyroid panel.

The majority of patients with depression have panic attacks.

This is likely a drug-induced depression.

Answer: A. Approximately 50% of patients with a primary panic disorder will later develop major depression. Twenty percent of patients with depression have panic attacks. Depression with panic attacks is less responsive to treatment, but depression with anxiety and hostility responds well to antidepressants. Although benzodiazepines can exacerbate symptoms of depression, there is already a high spontaneous rate of depression with anxiety disorders.

Which of the following statements regarding benzodiazepine use and anxiety istrue?

Benzodiazepines are first-line agents for anxiety disorders.

Several weeks of treatment are indicated after initial diagnosis.

Short-acting benzodiazepines produce a more severe abstinence syndrome.

They are particularly useful in patients with alcohol abuse.

Withdrawal rebound is less common than with selective serotonin reuptake inhibitors (SSRIs).

Answer: C. SSRIs are the first-line agents for anxiety and panic disorders, but the primary disadvantage is the several-week lag needed for maximal clinical benefit. Benzodiazepines work best for motivated, dependable patients when an immediate reduction of symptoms is indicated or a short-term treatment is necessary. Patients who do not benefit from benzodiazepines within a week are unlikely to do so. Patients with a history of alcoholism or drug abuse, who are excessively/emotionally dependent, or who become anxious from normal stress are at greater risk for dependency. Rebound withdrawal is more likely after short-acting agents.

A 29-year-old Caucasian female presents with excessive daytime somnolence. She states that she had been suffering from anxiety associated with her paralegal occupation, and 1 week ago her psychiatrist had started her on a 2-week course of once-daily benzodiazepine therapy, which she takes in the morning. Her anxiety symptoms are well controlled. She asks if you can change her to a new medication because the somnolence is significantly affecting her job performance. What would be the most appropriate course of action?

Counsel the patient that she should continue the medication as prescribed because she will soon adapt and the somnolence will likely subside.

Discontinue the benzodiazepine and refer her back to her psychiatrist.

Have her try dosing the benzodiazepine at bedtime, because this will likely continue to control her anxiety and limit daytime somnolence.

Switch the patient to a selective serotonin reuptake inhibitor (SSRI) and refer her back to her psychiatrist.

Switch the patient to a shorter-acting benzodiazepine.

Answer: C. Instituting an SSRI should be reserved for primary care physicians or psychiatrists who can monitor the patient more closely, because the response will be delayed. Some patients do adapt to the sedative effects of benzodiazepines but usually only after long-term use. Stopping the benzodiazepine may ultimately be necessary but at the risk of recurrent anxiety. Dosing benzodiazepines at bedtime may minimize daytime sedation and still provide an anxiolytic effect. Shorter-acting benzodiazepines produce a more severe abstinence syndrome when stopped abruptly, and thus most prescribers prefer longer-acting agents.

A 52-year-old male construction worker presents with chest pain. He states his symptoms began early this morning and have progressively worsened throughout the day. His symptoms include nervousness, tremors, chest pain, shortness of breath, and palpitations. He states that he has had anxiety for 30 years but has controlled it with the consumption of alcohol. He became unemployed 1 week ago, and his daily alcohol use has diminished significantly. His vital signs are blood pressure (BP) 185/95 mm Hg, heart rate 123 beats per minute, respiratory rate of 20 breaths per minute, and temperature of 98.9° F. His physical examination is remarkable for diaphoresis, tongue fasciculation, both resting and intention tremors, and mild psychomotor agitation while maintaining orientation with a congruent anxious mood and affect. What is the most likely etiology of this patient's symptoms?

Acute alcohol withdrawal syndrome

Exacerbation of endogenous anxiety secondary to diminished alcohol intake

Exacerbation of exogenous anxiety secondary to change in employment status

Hypertensive emergency with acute coronary syndrome

Reactive anxiety secondary to the onset of chest pain

Answer: A. Hypertensive emergency is unlikely given the level of this patient's BP. On the basis of the history alone, it may be difficult to differentiate organic versus functional anxiety or identify an exogenous trigger, but the abnormal vital signs and physical examination associated with a recent cessation of long-term alcohol consumption makes acute alcohol withdrawal the most likely cause. Given the significant morbidity associated with withdrawal states, this must be addressed acutely. Appropriate diagnosis and management of underlying psychiatric disease will be a secondary concern after the patient's withdrawal is managed.

Conclusion

Anxiety disorders in adolescence have gained research attention, but an expansion and further integration of the findings on adolescent development, anxiety disorders, and their treatment is still needed. Research has made substantial progress in delineating the expression, varying course, and the detrimental impact of anxiety disorders. It has also successfully indicated potential biological and psychosocial risk factors for these disorders in adolescence. However, more research is needed that focuses expressly on anxiety disorders in adolescence. Such research may play a pivotal role in clarifying the relationship between anxiety and commonly comorbid disorders, such as depression and externalizing disorders, which first become pronounced in this developmental period. The high level of concurrent and sequential comorbidity between depression and anxiety, in particular, has highlighted the current need for greater causal understanding of this co-occurrence as well as the review and potential revision of current diagnostic classification systems. The precise prevalence rates, risk factors, and manifestations of anxiety disorders in adolescence also remain uncertain in part due to a relative neglect of adolescent samples. The differentiation of childhood and adolescence indicated by developmental research is necessary to advance our understanding and effective treatment of anxiety disorders in this key time period.

Anxiety Disorders

Anxiety disorders are the most prevalent form of psychiatric illness in the general community.Anxiety is defined as a subjective sense of unease, dread, or foreboding. It can be a primary psychiatric illness, a reaction to or result of a medical illness, or a medication side effect. Anxiety is associated with distressing symptoms such as nervousness, insomnia, hypochondriasis, and somatic complaints. It is useful clinically to consider anxiety disorders as occurring in two different patterns: (1) generalized anxiety disorder and (2) episodic, often situation-dependent, anxiety. The γ-aminobutyric acid (GABA) neurotransmitter system has been implicated in the pathogenesis of anxiety disorders.

Anxiety resulting from identifiable stressors is usually self-limited and rarely requires pharmacologic treatment. Performance anxiety (stage fright) is a type of situational anxiety that is often treated with β-blockers, which do not produce sedation or allay anxiety but do eliminate the motor and autonomic manifestations of anxiety. The presence of unrealistic or excessive worry and apprehension may be cause for drug therapy. Buspirone, a partial 5-HT2A receptor antagonist, is a nonbenzodiazepine anxiolytic drug that is not sedating and does not produce tolerance or drug dependence. However, its slower onset of action (several weeks until full effect is reached) and the need for thrice-daily dosing have limited its use. Short-term and often dramatic relief is afforded by almost any benzodiazepine, which is not surprising since these drugs bind to GABA receptors. Other drugs with GABAergic properties such as gabapentin, pregabalin, and divalproex may also be effective in treating anxiety disorders. Supplemental cognitive-behavioral therapy, relaxation techniques, hypnosis, and psychotherapy are also very useful in treating anxiety disorders.

Panic disorders are qualitatively different from generalized anxiety. The patient typically experiences recurrent andunprovoked episodes of intense fear and apprehension associated with physical symptoms and signs such as dyspnea, tachycardia, diaphoresis, paresthesias, nausea, chest pain, and fear of impending doom or dying. Such episodes can be confused with, or indeed caused by, certain medical conditions such as angina pectoris, epilepsy, pheochromocytoma, thyrotoxicosis, hypoglycemia and cardiac dysrhythmias. Several classes of medications are effective in reducing panic attacks, including SSRIs, benzodiazepines, cyclic antidepressants and MAOIs. These drugs have comparable efficacy. Psychotherapy and education increase the effectiveness of drug treatment.

Abstract

Anxiety disorders are the most common group of psychiatric disorders in the general population. They are also important because of their association with significant impairment in functioning and with high direct and indirect costs. Anxiety disorders are often associated with depressive and substance use disorders and may have other complications. These conditions are often unrecognized, misdiagnosed, or trivialized, which is unfortunate because their timely recognition and treatment are beneficial to the sufferers, their families, and society. This chapter provides a brief review of each of the following anxiety disorders in adults: panic disorder, agoraphobia, social anxiety disorder, specific phobia, generalized anxiety disorder, and separation anxiety disorder. Clinical features, diagnostic issues, epidemiological data, etiological factors, and treatments of these disorders are summarized, with the similarities and differences between individual disorders being highlighted.

7.08.7 Summary

Anxiety disorders are the most prevalent of all psychiatric conditions among elderly people and they pose a major public health problem for this population. Nevertheless, research addressing the prevalence, nature, and treatment of these conditions among elderly is in an infancy stage. No data are available regarding the prevalence of PTSD among the elderly, and the clinical picture of many anxiety syndromes in this segment of the population is as yet unclear. Much of the available literature is limited due to the significant dearth of well-established measures of anxiety among elderly people and the failure to utilize strict diagnostic criteria in the selection of clinical groups. The utility of measures already established for use with younger groups deserves further study in this regard. Additionally, new instruments that target specifically the unique features of anxiety among elderly people will need to be developed. In this domain, the focus will need to be not only on self-report instruments, but also on systematic methods of behavioral observation, clinician rating, and psychophysiological assessment. The development of more refined measures will assist in clarifying the difference between anxiety disorders and other syndromes that may produce similar clinical features, including depression, various medical conditions, sleep disorders, and cognitive dysfunction.

With the establishment of psychometrically sound assessment tools, more sophisticated treatment research should emerge. Pharmacological trials might focus on the relative efficacy of various antianxiety and antidepressant medication, and psychosocial treatment comparisons should evaluate further the utility of CBT and alternative interventions in well-diagnosed groups of older patients. Emphasis in all of these investigations should be given not only to the effects of treatment on symptom reduction, but also to the transfer effects of the interventions on associated clinical features, physical health, and social functioning. Durability of treatment response following both pharmacological and psychosocial treatments will need to be examined with well-controlled evaluations over long-term follow-up intervals, and findings will need to be generalized to patients recruited from a variety of settings (e.g., psychiatric clinics, primary care clinics) and from diverse sociocultural backgrounds.

Presentation

In general, all anxiety disorders develop relatively early in life. The median age of onset for anxiety disorders is 11 years, with 75% developing the conditions between 6 and 21 years. Separation anxiety disorder and specific phobia have an early age of onset (median age 7), whereas other anxiety disorders occur during later ages (median range 19–31) (Kessler et al 2005a). It is estimated that fewer than 40% of people with a lifetime psychiatric disorder receive professional treatment (Kessler et al 1994). For those who do seek treatment for anxiety disorders, there is a delay in presentation ranging from 9 to 23 years. Delay in presenting for treatment is particularly associated with those who develop the disorder at an early age, who are married, who have poor educational attainment, or who are members of racial or ethnic minorities (Wang et al 2005).

Publisher Summary

This chapter concentrates on those anxiety disorders that are most common in children and adolescents. Most commonly, children experience separation anxiety disorder (SAD) where developmentally inappropriate anxiety occurs when the child is separated from the home or the primary caretaker. Some children and adolescents also experience generalized anxiety disorder (GAD), where daily functioning is characterized by persistent and excessive worry. Obsessive compulsive disorder (OCD) impairs functioning because persistent obsessions cause anxiety that is temporarily relieved by compulsions that often occupy a major portion of the day. For children, adolescents, and adults, the necessary symptoms for diagnosis of an anxiety disorder are similar; and usually include anxiety, fear, and hyperarousal that may be situational or may be present for most of the day.

COLLABORATIVE CARE PRACTICES

A review of interventions for anxiety disorders in children and adolescents indicates that cognitive-behavioral therapy alone and cognitive-behavior therapy plus family anxiety management are considered probably efficacious.2 The short-term (e.g., 3.5 years) and long-term (e.g., 6 years) treatment gains of cognitive-behavioral therapy have been supported by results of randomized clinical trials.199,200 After a 16-week cognitive-behavioral treatment program for primary anxiety disorders (e.g., GAD, social phobias), 60% to 70% of youth demonstrated a positive response to treatment in terms of reduced anxiety, as well as decreased substance use-related problems.201 Variables related to nonresponders, such as attrition and intensity of treatments, merit further exploration in the literature.201

Although promising interventions for pediatric anxiety disorders appear to exist, few youths are referred for, and fewer receive, such interventions. In general, only 16% to 20% of youths with identified psychosocial problems are referred for specialty treatment.30,44 With regard to identified anxiety disorders, reports suggest that about 50% of such youths are not referred for treatment.202 One report indicates that even among those who are referred, the majority (up to 72%) of children and adolescents with an anxiety disorder do not actually receive any treatment.29

These differential referral and treatment rates seem related to a variety of factors, with lower rates for children with mild problems and for those from ethnic minority backgrounds.30,203 Patients in managed care plans, in comparison with those in fee-for-service plans, receive fewer referrals for specialty care and psychotherapy.204 Such differing rates also may appear related to varying levels of treatment acceptability, stigma of mental health services, and early detection.203 If pediatricians are the “de facto mental health service” for many children with psychosocial problems, knowledge about effective treatment options and referral sources is essential to ensure timely intervention.44

Methods to enhance the ability of pediatricians to identify and treat psychosocial problems include interdisciplinary training, training in specialties such as developmental-behavioral pediatrics, and anticipatory guidelines and prevention strategies offered through the American Academy of Pediatrics.205 In addition, some strategies developed in tertiary care settings to identify and treat psychosocial problems could possibly be modified to make them feasible in primary care settings.206 For example, a group of investigators outline a three-tiered approach to enhance the role of primary care in children with psychosocial problems.207,208 The first level of care is more consistent identification and management by primary care and community professionals, such as home health care managers and case managers. The second tier is management by mental health specialists working in primary care settings. The third approach pertains to consultation-liaison, in which the mental health specialist supports management by the primary care physician but does not assume primary therapeutic responsibility. In an extension of this approach, pediatricians and psychologists work jointly within a practice team, to which developmental-behavioral pediatricians serve as consultants.209

A chronic disease management approach may be more applicable for youths with diagnoses of anxiety disorders, especially in view of the high frequency of somatic complaints observed in these children and adolescents. In one such approach, recommended by von Korff and colleagues,210 the “patient” works with the health care provider to manage his or her disease by monitoring symptoms, adhering to medical regimens, and adopting more adaptive health habits and coping skills. This approach can be modified by including patients and parents in collaboration with their primary care and mental health care professionals in managing pediatric anxiety disorders. As in the study by von Korff and colleagues210 on adult patients with GAD, children and adolescents with an anxiety disorder and their parents can be given written material on the characteristics and nature of GAD, pharmacological and psychological treatment options, and basic strategies for managing worry and anxiety. Allied health clinicians may then be available to provide more in-depth services and follow-up as needed. Parent involvement would be crucial in ensuring practice of skills outside of the clinic setting, supporting generalization of these skills, and offsetting modeling and reinforcement of anxious behaviors. Such involvement of the family is considered essential with regard to positive outcomes and maintenance of treatment gains.2,201

Within all these approaches, continuity of care is essential as continuity improves clinician recognition of psychosocial problems, receipt of preventive services, and patient satisfaction with care.30,31 In addition, continuing medical education programs are needed for primary care physicians and other medical specialists to ensure optimal identification, diagnosis, and effective treatment options for mental health disorders, including anxiety disorders in youths.39,210 Finally, strategies are needed to ensure effective collaboration between primary care pediatricians and mental health professionals, either working side by side or functioning as a consultants. The role of other consultants, such as developmental-behavioral pediatricians, also requires delineation in the management of youths with anxiety disorders.

Black and Nabors211 outlined optimal strategies for psychologists for collaborating with pediatricians in primary care settings. These strategies also apply to collaboration with other consultants and subspecialists, such as developmental-behavioral pediatricians. One recommendation centers on novel strategies for screening and interventions. Prompt identification may be fostered by consistent use of behavior screening measures during primary care appointments. Changes in behaviors across visits could be monitored and referrals made as soon as the information indicates that these behaviors are outside normative values. Another recommendation pertains to training of both medical and mental health professionals with regard to knowledge about development and behavior, as well as factors that affect busy practices. For example, consistent use of the DSM-PC212 may increase communication among professionals and agreement about when referrals need to be made to mental health professionals and other subspecialists. The type and range of stressful situations and problematic clusters could be used as an algorithm to determine referral patterns, especially challenges to primary support groups, emotions, and moods. Coordination of care also would be enhanced when referral procedures are efficient in terms of point of contact and appointment scheduling. Periodic meetings or telephone conference calls could be made between consultants to address referral difficulties and specific cases. A particularly relevant issue concerns performance and economic indicators necessary to demonstrate treatment effectiveness and “need” for services. The separation of health insurance plans into physical health and behavioral health segments has, unfortunately, reemphasized single-provider models of care that may be less effective although more fiscally viable.211 The role of pediatricians and psychologists as professional educators, clinicians, and researchers is evident from these approaches to care and in continued attention to strategies to support collaboration.209