CASE SCENARIO

Maria is aged 42 years, single mother with two young girls ages 7 and 5, formerly employed
part time as a waitress until the pandemic started. She now cares for her mother who has
Alzheimer’s disease.

Maria has no significant past medical history, although she frequently consults her family
physician about problems experienced by her and her children. She was moderately
depressed following her separation 10 years ago and was offered antidepressants but
declined them. She was referred for six sessions of counselling, which led to some
improvement in her symptoms.

On examination Maria complains of feeling ‘stressed’ all the time and constantly worries
about ‘anything and everything’. She describes herself as always having been a ‘worrier’ but
her anxiety has become much worse in the past 12 months since the community quarantines
started and her mother also became unwell.

She no longer feels that she can control these thoughts. When worried, Maria feels tension
in her shoulders, stomach and legs, her heart races and sometimes she finds it difficult to
breathe. Her sleep is poor with difficulty getting off to sleep due to worrying and frequent
wakening. She feels tired and irritable. She does not drink any alcohol nor smokes
cigarettes.

Her vital signs were the following: heart rate 100 beats per minute, respiratory rate 20 beats
per minute, temperature 36.2 degrees Celsius, height 1.5 meters, weight 60 kilograms. She
made no eye contact, constantly shuffling in her chair. The rest of her physical examination
was within normal.

Anxiety Topic Outline

1. Introduction & Epidemiology (easy)

Anxiety is an adaptation mechanism that can protect an individual from pain
and distress. It is a normal reaction towards stress and can be helpful in some
situations. It prepares an individual to possible danger, enabling the individual to take
precautionary steps to avoid harm.
On the other hand, anxiety disorders are feelings of excessive fear and
nervousness. It is characterized by physical symptoms such as sweating, dizziness,
trembling, and rapid heartbeat. Anxiety disorders are treatable and a number of
effective treatments are available.
The nature of the incident and its consequences on the individual's resources
and coping techniques determine whether or not it is seen as stressful. Anxiety
happens when an experience is so overwhelming that the person's resources are
insufficient to deal with it positively.
Globally and in the US: The proportion of the global population with anxiety
disorders in 2015 is estimated to be 3.6%. 2.7% of adults in the US had generalized
anxiety disorder and an estimate of 30% of adults experience anxiety disorders at
some time in their lives.
 Philippines and Region 6: Philippines has the third highest rate with mental
health problems in the Western Pacific Region with an estimate of 6 million Filipinos
having depression or anxiety. A population survey for mental health disorders by the
UPPGH Psychiatrist Foundation estimated that the prevalence of mental health
disorders in region 6 was 35% and anxiety was at the three most frequent diagnosis
in adults with a percentage of 14.3%.
There is a high lifetime prevalence of anxiety disorders in women compared
to men across all age groups (4.6% compared to 2.6% at the global level).
Prevalence also decreases with higher socioeconomic status and with
increasing age.
12-month health care use showed that only 36.9% were receiving treatment
(NIMH, 2014).
2.1% with anxiety disorders died during an average follow-up of 9.7 years
from a prospective cohort study with over 30 million person-years of follow-up.
(Meier, et al., 2016).Anxiety disorders significantly increased mortality risk.
Comorbidity of anxiety disorders and depression played an important part in the
increased mortality. (Meier, et al., 2016)

2. Pathophysiology
● Genetics
Some research suggests that family history plays a part in increasing the
likelihood that a person will develop an anxiety disorder.
● Environment
Anxiety disorders can be caused by trauma and stressful events such as
abuse, the death of a loved one, divorce, or moving professions or schools.
● Autonomic Nervous System
Certain symptoms are caused by autonomic nervous system stimulation,
such as tachycardia, headache, diarrhea, and tachypnea.
Some anxiety patients' autonomic nervous systems, particularly those with
panic disorder, have elevated sympathetic tone, adapt slowly to repeated stressors,
and respond excessively to mild stimuli.
● Neurotransmitters
The neurotransmitters serotonin, norepinephrine, and gamma-aminobutyric
acid (GABA) appear to mediate anxiety symptoms in the central nervous system.
❖ Norepinephrine: Panic episodes, sleeplessness, easily frightened, and
autonomic hyperarousal are all indicators of enhanced noradrenergic
function that people with anxiety disorder encounter.
● The basic idea on norepinephrine's participation in anxiety
disorders is that patients with anxiety disorders have a poorly
regulated noradrenergic system with periodic bursts of activity.
❖ Serotonin: An increase in anxiety is caused by serotonin sending
messages to other neurons in the circuit.
● Giving selective serotonin reuptake inhibitors (SSRIs) to a
patient has the same effect on the brain circuit as confronting a
frightening circumstance.
● As a result, as serotonin levels rise, anxiety-like behaviors rise
as well.
 ❖ GABA: It's an inhibitory neurotransmitter that suppresses nervous
system activity by blocking specific brain signals.
● GABA binds to the GABA receptor, generating a relaxing effect
that lowers anxiety and relieves mental and physical stress

3. Approach to diagnosis
a. Clinical manifestation
● Autonomic arousal/hyperactivity
Dizziness,excessive sweating, fastor pounding heart,dry mouth, GI
symptoms
● Mental tension
Undue worry, feeling tense/nervous, irritability, poor concentration,
sense of foreboding
● Physical/motor tension
Restlessness, headache, tremors, chest compressions, inability to
relax

b. Three main groups of anxiety disorder

First Group Second Group Third Group

● Panic Disorder ● Obsessive ● Post-traumatic

● Generalized Compulsive Stress Disorder
Anxiety Disorder ● Acute Stress
Disorder ● Body Disorder
● Social Anxiety Dysmorphic ● Adjustment
Disorder Disorder Disorder
● Agoraphobia ● Hoarding ● Reactive
● Specific Phobia Disorder Attachment
● Separation ● Trichotillomania Disorder
Anxiety (hair-pulling ● Disinhibited
Disorder disorder) Social
● Selective ● Excoriation Engagement
Mutism (skin-picking Disorder
● Substance/medi disorder)
cation-induced ● Substance/medi
anxiety disorder cation-induced
● Anxiety disorder obsessive
due to another compulsive and
medical related
condition disorders

c. Diagnostic test
● The clinician should evaluate for any concurrent medical disease or
substance use that can cause or present as anxiety symptoms by a
thorough clinical history and physical examination.
 ● A medical examination is recommended, especially if you are
experiencing troubling symptoms such chest discomfort, dyspnea, or
palpitations.

d. History and Physical Assessment

● Because somatic symptoms are more common than psychologic
symptoms, diagnosing patients with anxiety can be difficult.
● Most patients complain of vague or nonspecific somatic symptoms
such as shortness of breath, palpitations, fatigability, headache,
dizziness, and restlessness.
● Excessive, nonspecific anxiety and worry, emotional lability, difficulties
concentrating, and insomnia are all possible psychologic signs.
● Among the many factors linked to generalized anxiety are:
❖ Female gender, unmarried,poor health, low education,
presence of stressors
● The median age of presentation is 30 years.
● To assess the severity and diagnosis, many scales have been
devised.
● The GAD-7 has been proven to be a reliable diagnostic tool and
severity scale.

e. Diagnostic Tests to exclude medical illnesses

● The first step in the evaluation is to address any behavioral or physical
problems.
● Look for signs of psychosocial stress, psychosocial challenges, and
developmental problems.
● Go over your medical history, including any trauma, psychological
issues, or substance addiction.
● Diagnostic tests
❖ Complete blood count,blood chemistry,thyroid function
tests,routine urinalysis, urine drug screening,
Electroencephalogram, Lumbar Puncture, Brain Scan,
Electrocardiogram, Stress test, Testing for rapid plasma
reagent and HIV, Examining the cerebrospinal fluid, Toxicology
Screen

f. Impt medical contributors to rule out in anxiety disorders

Substance-induced
Intoxication (e.g., stimulants)
• Withdrawal (e.g., alcohol, benzodiazepines)
• Adverse effects of over-the-counter medications
o Decongestants
o Beta-adrenergic inhalers
o stimulants
• Effects of caffeine-related products
o Coffee
o Energy drinks/ supplements
 g. Chief complaint
feeling ‘stressed’ all the time and constantly worries about ‘anything and
everything’

4. Case discussion
a. Generalized Anxiety disorder (GAD)
● Characterized by excessive and persistent worrying about many
things in daily life to a degree that it impacts daily function
● Worrying could be multifocal such as finance, family, health, and the
future.
○ Difficult to control
○ Accompanied by many non-specific psychological and physical
symptoms.
○ Apprehensiveness, irritability, muscle tension, sleeplessness,
and fatigue.
● Prevalence: 0.9% among adolescents and 2.9% among adults.
○ Approximately one-third of the risk is due to genetic
predisposition
○ More commonly diagnosed among women than men
○ Often in 20s and 30s
● Distinguished from other anxiety disorders by longstanding, general
worry that spans across multiple aspects of life and the lack of a
specific trigger or focused, singular concern.
○ May exhibit Obsessive-compulsive disorder (OCD) like
counting, checking, and intrusive thoughts.
○ Features in GAD are not time consuming or ritualized, and
they tend to revolve around avoiding adverse outcomes in day-
to-day activities rather than focusing on intrinsic fears.
● This may co-occur with other disorders such as major depression,
panic disorder, social phobia, and specific phobias.
○ May have increased risk of various general medical conditions.
b. Etiology
● Stress
● Physical condition such as diabetes or other comorbidities such as
depression
● Genetic, first-degree relatives with generalized anxiety disorder (25%)
● Environmental factors, such as child abuse
● Substance abuse

c. Typical Presentation and Diagnostic Criteria of Generalized Anxiety

Disorder
● Excessive anxiety about ordinary, day-today situations
● Intrusive, causes distress or functional impairment, and often
encompasses multiple domains (e.g. finances, work, health)
● Associated with physical symptoms like: sleep disturbance,
restlessness, muscle tension, gastrointestinal symptoms, and chronic
headaches.
d. Diagnostic and Statistical Manual of Mental Disorders, 5th ed., (DSM-5)
● Factors associated with GAD:
○ Female sex
○ Unmarried status
○ Lower education level
○ Poor health
○ Presence of life stressors
● Age of onset is variable, with a median age of 30 years
● GAD-7 has been validated as a diagnostic tool and a severity
assessment scale, with a score of 10 or more having good diagnostic
sensitivity and specificity.
○ Greater score would indicate more functional impairment
5. Treatment and Management
GENERAL ALGORITHM FOR THE MANAGEMENT OF ANXIETY DISORDERS
a. General Management
● The main objective of management is not to eliminate anxiety but to
reduce it to manageable levels
● Initial treatment would be Non pharmacologic modalities
● Medications are given to those patients who become impaired in their
daily functioning due to anxiety
● Supportive psychotherapy
○ Involves reassurance and clarification of the patient’s concerns
● Psychodynamic Therapy
○ Good when patients exhibit intelligence, capacities for trust,
tolerance, introspection and an ability to relate to a therapist,
and self-control to bear painful feelings.
● Cognitive Behavioral therapy
○ Identify and label recurrent negative, irrational thoughts
correlated with anxiety
● Commonly used anxiolytics include:
○ Selective Serotonin Reuptake Inhibitors (SSRI)
○ Serotonin and Norepinephrine Reuptake Inhibitors (SNRI)
○ Tricyclic Antidepressants (TCA)
○ Monoamine Oxidase Inhibitors (MAOI)
○ Benzodiazepine
○ Hydroxyzine
● Patient Education
● Patients are advised to discontinue or at least decrease the
consumption of caffeine-containing products like coffee, tea, or colas.
● Panic attacks often subside spontaneously in 20 to 30 minutes
● The primary care physician should discuss with the family how
changes in the patient can affect the family system and how their
reactions and responses to these changes can help or get in the way
of treatment.
 ● Patients with anxiety disorders in general have good prognosis when
the symptoms have rapid onset and short duration (less than six
months)
● A consideration of prominent comorbidities such as substance abuse
disorders and personality disorders impact treatment strategies.
● Generalized anxiety disorders are chronic and may even be lifelong,
especially when there are comorbid medical conditions.

b. Non-pharmacologic
● Psychological Methods
○ Cognitive Behavioral Therapy
■ Identify and label recurrent negative, irrational thoughts
correlated with anxiety
■ CBT alone or combination with medications is the
treatment of choice for panic disorders
○ Psychotherapy
■ Good when patients exhibit intelligence, capacities for
trust, tolerance, introspection and an ability to relate to
a therapist, and self-control to bear painful feelings.
● Social Support
○ Reassurance of the patient and clarifications of his/her
concerns

c. Pharmacologic
● Medications depend on specific disorders

● Selective Serotonin Reuptake Inhibitors (SSRI)

○ First choice for anxiety disorders
○ Effective
○ Non-addictive
○ Negligible interference with psychotherapy
○ Side effects are minimal (usually decreased sexual stimulation
and gastrointertinal symptoms)
○ Tolerable adverse effects
○ Easier to use (once daily dosing schedule)
○ Sertraline, paroxetine, citalopram, and fluvoxamine have been
approved for use in:
■ Generalized anxiety disorders
■ OCD
■ Social Phobia
○ Also effective in managing depression

● Serotonin and Norepinephrine Reuptake Inhibitors (SNRI)

○ Approved for use in anxiety disorders
○ Venlafaxine for General anxiety disorder, panic disorder, social
anxiety disorder, PTSD, and OCD. High doses can increase
blood pressure
○ Duloxetine is used for GAD and diabetic neuropathy
 ○ Both drugs should be avoided in patients with narrow-angle
glaucoma or increased intraocular pressure.

● Tricyclic Antidepressants (TCA) and Monoamine Oxidase

Inhibitors (MAOI)
○ Use with caution because of reported higher toxicity and
potential lethality in high doses
○ Clomipramine is most selective for serotonin reuptake.
■ First drug approved for use in OCD
■ Increasing dose is titrated over 2 to 3 weeks to avoid
the associated adverse effects.

● Benzodiazepines
○ Generally reserved as adjunct medications for:
■ Severe and disabling anxiety
■ Acute situational anxiety
■ Rapid control of panic attacks
○ Recommended if treatment is anticipated to be less than 6
weeks
○ Alprazolam (0.25-0.5 mg tid) or Clonazepam (0.5-1 mg prn)
○ Tapering is done over 1 to 2 weeks before it is discontinued
○ Chronic usage of benzodiazepine may result in tolerance,
withdrawal, and even treatment-emergent anxiety.
○ Long-acting benzodiazepines should be avoided as much as
possible
○ Dividing the daily dose prevents adverse effects

● Antihistamine
○ Hydroxyzine is also used for generalized anxiety disorder

● Other Anti-anxiety agents

○ Mirtazapine, Buspirone, and Beta blockers
6. Preventive and Control Measures
a. Primary
● Proper mental health education to the general public and especially to
high-risk individuals which is centered on:
○ Early identification of stressors
○ Getting help to cope with crisis situations
○ Avoiding substances that can induce anxiety
b. Secondary
● Detect the condition early and prevent it from getting worse.
● Assessment of Stress and Anxiety
○ Review the patient’s history for stressors
○ Note the physiologic symptoms
○ Determine the degree of anxiety (mild to severe panic level)
○ Observe for behaviors noted in anxiety states (irritability,
anger, restlessness, pacing, crying, nervousness)
● Interventions for stress and anxiety (CALMER APPROACH)
○ C : Calm approach and environment
○ A : Awareness of anxiety, identify and describe feelings
○ L: Listen to both client and yourself
○ M: Medications
○ E: Environment. (walking, crying, working, and concrete tasks
that may help moderate the anxiety)
○ R: Reassurance provided. Implement trust
c. Tertiary
● Focuses on people who already have anxiety disorder.
● Improve quality of life by reducing disability, delaying complications,
and restoring function
● Done by treating the condition and providing rehabilitation
 ○ Psychotherapy - routine check-up with psychiatrist if needed
and compliance to the therapies, treatments, and medications
○ Slowly taper and discontinue the use of medications to avoid
tolerance and dependence
○ Family Education

7. Case Resolution
● Based on the data from the case, Maria shows symptoms of Generalized
Anxiety Disorder as she presented:
○ Anxiety or significant worry
○ Do not have physical health problem but are seeking reassurance
about somatic symptoms
○ feeling ‘stressed’ all the time and constantly worries about ‘anything
and everything’
○ Already a chronic disorder (more than 12 mos)
○ Physical/motor, autonomic symptoms, and mental tension like:
■ Irritability
■ tension in her shoulders, stomach and legs
■ Heart races
■ Difficulty in breathing
■ Sleep disturbances (difficulty in falling or staying asleep)
■ no eye contact
■ constantly shuffling in her chair
● Possible treatment for the patient:
○ CALMER approach and have enough rest and sleep
○ Discuss the use of over-the-counter medications and preparations
with people with GAD.
■ Explain the potential for interactions with other prescribed and
over-the-counter medications.
○ Give SSRI (drug choice) to help the patient sleep better and be more
relaxed
○ Give SSRI in the morning (does not induce sleep)
○ Example: (Sertraline drug - for depression) Since the patient is an
adult, at first, give 50mg once a day, taken either in the morning or
evening. Dosage may be adjusted but usually not more than 200mg
per day.
○ Example: (Paroxetine drug - for GAD) For adult, at first, 20mg once a
day, usually taken in the morning. The dosage may be adjusted but
usually not more than 50mg per day.
● Having Generalized Anxiety Disorder:
○ We should explain to the patient the course and nature of her illness.
○ We should identify her stressors, degree of her anxiety, physiologic
symptoms, and coping mechanisms through comprehensive
assessment would greatly help in order to know what appropriate
treatment and management for her.
○ It is necessary to conduct a comprehensive assessment that does not
rely solely on the number, severity, and duration of symptoms, but
also considers the degree of distress and functional impairment.
 ● As part of the comprehensive assessment, consider how the following factors
might have affected the development, course, and severity of the person's
GAD:
○ Any comorbid depressive disorder or other anxiety disorder
○ Any comorbid substance misuse
○ Any comorbid medical condition
○ A history of mental health disorders past experience of, and response
to treatments
● We can advise the patient to seek close relatives for emotional support and
help in taking care of her mother with Alzheimer’s disease.
○ This will help to lessen her workload since she is also a mother of two.
○ Also, we would suggest taking on hobbies in which she can have
income to help moderate her anxiety and provide for her family needs.

8. Summary of Care and Approaches