How To Diagnose and Manage the Anxious

Patient

Amy Huberman, MD
 Objectives

1.To distinguish between anxiety disorders

and anxiety associated with other
conditions.

2.To clarify which treatments are most

efficacious for anxiety disorders.
Disclosures of Financial Interest/Affiliation:

I have none to make.

 What is anxiety?
Anxiety is a natural state, common to all humans.
• A state of high arousal characterized by inhibition of the
parasympathetic system

• Prepares the body and brain to respond to potential

threats by facilitating the activation of fear

• Often a productive driving force

• Worry is the thought component of anxiety

 What about fear?
• The body’s response to acute danger

• Characterized by activation of the sympathetic nervous

system: “fight or flight”

• Even greater arousal than in anxiety

• Anxiety primes the body for fear

Anxiety is useful—until it isn’t
The Yerkes-Dodson Law
Most anxiety is not pathologic (unhelpful)…

…and most pathologic anxiety

is not an anxiety disorder.
 Pathologic anxiety is as non-specific as fever
Possible causes:
• Drug withdrawal or toxicity
• Medical conditions
• Dementia
• TBI
• Mood disorders
• Psychotic disorders
• Sleep deprivation
• Hormonal changes
• Anxiety disorders
 Medications can cause anxiety
Class Drug names Comments Class Drug names Comments
Medical illnesses can present as anxiety
 Mental illnesses can present as anxiety

• Data from Epidemiologic Catchment Area (ECA) study

– household population-based sample from 5 sites that has been
standardized to U.S. census data to be representative of adult U.S.
population (n=20,291)
• Assessed association between early onset (under age
21) fearful (fear of dying or going crazy) panic attacks
and odds of developing severe mental illness
 And, of course…
ANXIETY DISORDERS can cause anxiety
 The prevalence of anxiety disorders is higher in people
with schizophrenia than in the general population—
especially for OCD, panic disorder, and agoraphobia.
Anxiety Disorder Prevalence in Prevalence in General
Schizophrenia Population
Social Anxiety Disorder 14.9% 12%

Post-Traumatic Stress Disorder 12.4% 1-12%

Obsessive Compulsive Disorder 12.1% 1-2.5%

Generalized Anxiety Disorder 10.% 9%

Panic Disorder 9.8% 2-3%

Simple Phobia 7.9% 7-9%

Agoraphobia 5.4% 1.7%

Temmingh et al., 2015

How do you recognize
an anxiety disorder
when you see one?
 Obsessive Compulsive Disorder
Thoughts Feelings Behaviors
“Obsessions:” intrusive Fear, distress, or disgust. “Compulsions:” behaviors
and unwanted (often mental behaviors
thoughts, images, or that cannot be observed by
urges. others) that patients would
rather not “have” to do, but
that they feel compelled to
do in order to prevent
distress, disgust, anxiety, or
a feared outcome.

Reassurance-seeking

The Yale Brown Obsessive-

Compulsive Scale (YBOCS) is
a useful measure for aiding
in the assessment of OCD.
 Obsessions vs Delusions
Obsessions
• Recognized as patients’ own (i.e., not from an external source)
• Recognized as excessive or unreasonable
• Resisted
• Patient fears they might be true; usually doesn’t believe them with conviction
• Accompanying behaviors (compulsions) are recognized as excessive or
unreasonable

Delusions
• Recognized as patient’s own except in cases of thought insertion
• Recognized as justified or even self-evident
• Not resisted
• Believed with conviction

• Accompanying behaviors (e.g., checking medicine to make sure it isn’t poisoned)

are recognized as reasonable
 Obsessions vs Delusions
In OCD, not only can insight be lacking, but content of obsessions
can also be bizarre, making the obsessions hard to distinguish from
delusions.
– “I might stab my girlfriend’s vagina with an exacto knife.”
– “Maybe nothing that’s happening to me is real—like in The Matrix?”
– “I might never be able to stop thinking about swallowing.”
– “I might get contaminated by another person’s personality.”
– “I might be showing early signs of schizophrenia.”
– “People might be watching me through the showerheads.”
– “I might be possessed by Satan.”

If in doubt:
– Look for accompanying compulsions
– Administer a YBOCS
– Try treating it like OCD, just in case
Second-generation antipsychotics can cause
obsessive-compulsive symptoms
SGAs, and especially clozapine, have been associated
with treatment-emergent obsessive-compulsive
symptoms (Laroche and Gaillard, 2016). Symptoms
appear over 4 weeks to 12 months. Try:
– Decreasing dose of SGA
– Switching to a different neuroleptic
– Adding aripiprazole
– Adding an SSRI
– Cognitive behavioral therapy
 Panic Disorder
Thoughts Feelings Behaviors
“I’ll have a heart attack.” Fear of panic-related Avoidance of physical
symptoms and/or their sensations associated with
“I’ll go crazy.” consequences. panic.
“I’ll lose control.”
Use of safety behaviors to
“I’ll faint.” reduce the perceived risk of
experiencing panic.
“I’ll die.”

The Panic Disorder

Severity Scale is a
useful measure for
aiding in the
assessment of panic
disorder.
 Panic Attacks ≠ Panic Disorder
Panic attacks are a non-specific symptom.

Multiple medical and psychiatric conditions or states of

drug withdrawal or toxicity can cause panic.

Panic disorder occurs only when, in addition to panic

attacks, there are the following:

1) Fear of panic and/or its consequences.

2) Avoidance of panic-like symptoms or situations
likely to provoke them.
 Agoraphobia
Thoughts Feelings
“I won’t be able to Fear of panicking or
escape” developing incapacitating
or embarrassing
”I won’t be able to get symptoms, especially in
help” situations from which
escape would be difficult
or help would not be
available.
The Agoraphobia Scale is a useful measure for aiding in the assessment of agoraphobia.
Behaviors
Avoidance of situations
where escape would be
difficult or help would not
be available in the event of
feared symptoms:
• Cars, buses, planes,
trains
• Parking lots, bridges
• Shops, theaters
• In line or in a crowd
• At home alone
 Agoraphobia can occur without
Panic Disorder—and vice versa
Agoraphobia is a fear of not being able to escape or get help in
certain situations in the event of any sort of incapacitating or
embarrassing symptom attack. Feared symptoms are often
panic symptoms but could also be:
 Incontinence of bladder or bowel
 Vertigo or loss of balance
 Nausea or vomiting

Likewise, panic disorder can occur without fear or avoidance of

agoraphobic situations.
 Avoidance of agoraphobic situations
≠ Agoraphobia
Patients may avoid agoraphobic situations for many reasons:
 Social anxiety
 Fear of contamination
 Paranoid delusions
 Depressive avoidance (lack of energy or enjoyment)
 PTSD
 Specific phobias

For a diagnosis of agoraphobia, there must be a fear of not being

able to escape or get help in the event of a symptom attack.
 Social Anxiety
Thoughts Feelings Behaviors
“People will notice Shame Avoidance of situations
how anxious I am.” where a person would be
Embarrassment subject to others’
“People will think I’m evaluation
stupid.” Fear of others’ negative • Social gatherings
evaluation • Public places
“People will think I’m • Restaurants
boring.” • Public restrooms
• Telephone calls
• Performance situations

The Liebowitz Social Anxiety

Scale is a useful measure for
aiding in the assessment of
social anxiety.
 Social anxiety is highly prevalent in
schizophrenia—but easily missed
In one sample of 80 outpatients with schizophrenia, 36% had
comorbid social anxiety disorder (Pallanti et al, 2004).

These patients had:

 more suicide attempts
 more lethal attempts
 more substance abuse
 lower quality of life
 but no difference in positive or negative symptoms
compared to schizophrenic patients without social anxiety.

Their scores on the Liebowitz Social Anxiety Scale were no

different from the scores of non-schizophrenic patients with social
anxiety.
 Social anxiety is highly prevalent in
schizophrenia—but easily missed
Social anxiety symptoms can easily be misattributed to negative
symptoms of schizophrenia.

Thus, it’s crucial to screen specifically for social anxiety disorder.

 Use the Liebowitz Social Anxiety Scale
 Ask about the reason behind socially avoidant behavior
• Is there a fear of negative evaluation?
• Or are delusions motivating the behavior?
• Or disinterest?
 Clozapine can cause Social Anxiety

Clozapine has been associated not just with the

emergence of OC symptoms, but also with the
emergence of social anxiety (Pallanti et al, 2009).

8 out of 12 such patients treated with fluoxetine

responded.
 Post-Traumatic Stress Disorder
Thoughts Feelings Behaviors
“I’m bad.” Fear Avoidance of anything that
reminds a person of the
“It was all my fault.” Shame trauma
“No one can be trusted.”
Guilt Hypervigilance
“The world is completely
dangerous.” Anger Angry outbursts

Flashbacks and Dissociative reactions Reckless or self-destructive

nightmares behavior

The PTSD Symptom

Scale Interview is a
useful measure for
aiding in the
assessment of PTSD.
Always ask about these 4 things
when screening for PTSD:
H - Hyperarousal
A - Avoidance
R – Re-experiencing
T - Trauma
 PTSD is common in schizophrenia
After a first episode of psychosis (Rodrigues et al, 2016)
 2/3 of patients experience PTSD symptoms
 1/3 of patients meet full PTSD criteria

There is also evidence for considerable genetic overlap between the two
disorders (Duncan et al, 2018).

Schizophrenic patients with PTSD (Seow et al, 2015) have:

 higher rates of positive symptoms
 greater neurocognitive impairment
 worse functioning and quality of life

But symptoms of PTSD are easy to miss:

• Flashbacks can be confused with hallucinations
• Detachment from others can be attributed to negative symptoms
 Generalized Anxiety Disorder
Thoughts Feelings Behaviors
“I can’t stop worrying.” Anxiety Reassurance seeking

Worries tend to be less Muscle tension Analyzing

bizarre than obsessions
and are usually more
ego-syntonic.
Planning

Distracting

Irritable behavior

The GAD-7 is a useful

measure for aiding in
the assessment of
GAD.
 Do not diagnose GAD when:
 The patient is not complaining of worrying too much
 The anxiety is purely somatic
 The patient’s “worrying” is actually ruminating
 It’s easy to miss an anxiety disorder
when there’s comorbid psychosis
• Negative symptoms and cognitive limitations impair the
expression of anxious symptoms
• Obsessions are easily confused with schizophrenic delusions
• Flashbacks are easily confused with hallucinations
• Positive psychotic symptoms can hijack the psychiatrists’
attention and distract from anxious symptoms
• Anxiety and akathisia can sometimes be difficult to distinguish
from each other
• It can be helpful to administer disorder-specific scales to aid in
assessment and diagnosis.
How do you treat anxiety disorders?
 Cognitive Behavioral Therapy (CBT) is the most
effective treatment for anxiety disorders.
• When CBT is done well, 70% of patients achieve high end-state
function (as opposed to 60% with medication), and benefit is
more enduring than with medication management.
• It has repeatedly been shown to be more efficacious than other
forms of psychotherapy for the treatment of anxiety disorders.
• It appears to work even when there is comorbid psychosis.
• But, it’s hard to find therapists who do it well.
How does CBT for anxiety disorders work?
The Anxiety Cycle

 THOUGHTS
 MEMORIES
 PHYSICAL
SENSATIONS

AVOIDANCE
(provides momentary MISINTERPRETATION
relief from fear but Fear response ratchets up OF SITUATION AS
prevents corrective DANGEROUS
learning)
 CBT Disrupts the Anxiety Cycle
It works by encouraging patients to
approach anxiety willingly.
When they stop avoiding their fears,
they learn that they can face them courageously
and come out OK.
 Thus, any approach whose goal is to take
away patients’ anxiety—rather than
encourage them to face it—is doomed to fail.
 Medication-management of anxiety disorders
• SSRIs have the most evidence.
– Higher doses are often needed for maximal benefit, especially in
OCD (e.g., escitalopram 60 mg, fluoxetine 120 mg, sertraline 400
mg).
– In panic disorder and whenever there is anxiety about possible
side effects, start at the lowest possible dose to avoid activation.
Liquid formulations can be used to achieve low doses (e.g.,
escitalopram 1 mg).
– Watch out for cytochrome P450 interactions and Qct prolongation.
 Medication-management of anxiety disorders
• Other medications also have some evidence:
– Clomipramine for OCD (up to 250 mg) and imipramine for panic
disorder. Again, watch the Qct.
– MAOIs for social anxiety (beware of food and drug interactions).
– SNRIs or mirtazapine.
– Augmentation with neuroleptics (trifluoperazine or quetiapine for
GAD; aripiprazole or risperidone for OCD or SAD)
– Benzodiazepines can play a role in short-term management of anxiety,
but beware of long-term use (risk of dependence, falls, problems with
memory, interference with the efficacy of exposure therapy).
– Beware of gabapentin and pregabalin for similar reasons.
 Management of Secondary Anxiety
• First priority: treat or manage the underlying cause.
• Can also use the following modalities:
– Pet therapy
– Music therapy
– Yoga
– Guided relaxation
– Mindfulness practice
– Aromatherapy (lavender, rose, citrus, geranium)
 In Conclusion

• Not all anxiety is pathologic.

• Most pathologic anxiety is not an anxiety disorder.
• Anxiety disorders are more common in schizophrenia than in
the general population, and they result in greater disability.
• Anxiety disorders are easily missed in comorbid psychosis.
• The most effective treatment is CBT.
• The most effective medications are SSRIs, but there is also
evidence for augmentation with neuroleptics.
• Many non-pharmacologic interventions are available for
anxiety that is secondary to a medical condition or other
psychiatric disorder.
 Questions?
• Here’s my e-mail address:
psychiatrybaltimore@gmail.com