Applied Sciences

shley S. Love, DNP, PMHNP-BCa,*, Rene Love, PhD, DNP, PMHNP-BC, FNAPb

KEYWORDS

� Anxiety disorders � Primary care � Pharmacologic treatment

KEY POINTS

� Anxiety disorders are the most common mental health disorders seen in primary care settings.

� Identification and treatment of anxiety disorders in primary care settings is difficult and often underdiagnosed due to lack of typical presentations and time constraints.

� Effective treatment of anxiety disorders can be improved with utilization of psychometric tools and pharmacologic treatment guidelines.

BACKGROUND AND SIGNIFICANCE

Anxiety disorders are the most common mental health disorders in the United States and one of the most common mental health problems seen in general medical settings.1 Lifetime prevalence of anxiety is estimated to be as high as 29% in the United States.2 However, identification and treatment of anxiety disorders are often difficult in general medical settings. The lack of common presentations with anxiety disorders and time constraints in the clinic setting pose challenges for medical pro- viders within the primary care setting. Results from one study show these rates of misdiagnosis to be as high as 71% for generalized anxiety disorder (GAD).3 When anx- iety is left untreated, societal costs are substantive. In the United States, societal costs of anxiety disorders are estimated to be more than $48 billion per year.4 Adults with untreated social anxiety disorders miss on average 24.7 days of work per year due to the diagnosis.5 Given the significance of health care costs, decreased quality of

The authors whose names are listed certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements) or nonfinan- cial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this article. a Serenity Psychiatric Care, Benson Health Clinic, 66 Club Road, Suite 140, Eugene, OR 97401, USA; b University of Arizona, College of Nursing, 1305 N Martin Avenue, PO Box 210203, Tucson, AZ 85721-0203, USA * Corresponding author. E-mail address: alove@serenitypsychiatriccare.org

Nurs Clin N Am 54 (2019) 473–493 https://doi.org/10.1016/j.cnur.2019.07.002 nursing.theclinics.com 0029-6465/19/ª 2019 Elsevier Inc. All rights reserved.

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life, and loss of workforce productivity for patients with anxiety disorders, it is imper- ative that medical settings understand how to properly identify, diagnose, and treat these disorders.

PATHOGENESIS OF ANXIETY DISORDERS

Multiple factors have been targeted for the development of GAD; however, most re- searchers agree that the cause is epigenetic in nature.6 Genetic studies of the devel- opment of anxiety disorders have found heritability estimates between 20% and 65%, with the earlier the onset of symptoms, the higher the likelihood of a genetic compo- nent.7 Research in both animal and human studies have found the cortico-amygdala circuitry system to have an important role in anxiety disorders, specifically, the hippo- campus, prefrontal cortex, and dorsal anterior cingulate cortex.8,9 Gene analysis and neuroimaging studies have found positive associations between the serotonin trans- porter gene (5-HTT) and the catechol-O-methyltransferase.8,10

The other 35% to 80% of factors are caused by environmental factors, including stressful life events, traumatic experiences, disrupted attachments, and parental emotional problems.6 Parenting styles and modeling can play significant roles in the development of anxiety disorders, especially, those parents who exhibit anxious, overly critical, insensitive, or overprotective parenting behaviors.11 Other ways in which children learn anxious or fearful responses from their environment include direct negative experiences (neglect, abuse), false alarms (perceiving a situation negatively with no evidence to support this believe), and/or vicariously witnessing or being told something is dangerous.8

ASSESSMENT

Patients with anxiety disorders are 2 times more likely than the general population to present initially with somatic complaints.12 These complaints range from one specific distressing symptom, such as diarrhea or insomnia, to numerous seemingly unrelated symptoms. Common presenting somatic complaints include palpitations, diapho- resis, nausea, abdominal distress, dizziness, and restlessness.13 Symptoms that have been medically worked up with no identified cause should warrant further assessment to rule out anxiety disorders. Table 1 provides an overview of common symptoms and characteristics of anxiety disorders.

GENERALIZED ANXIETY DISORDER

GAD is defined as excessive, uncontrolled worry and tension about daily events and activities occurring more days than not for at least 6 months. GAD occurs when the worries are persistent and cause notable impairments in day-to-day life. Typical symp- toms include irritability, fatigue, restlessness, sleep disturbances, and muscle tension.14 It is considered a chronic illness with symptom severity waxing and waning; however, remittance of symptoms is possible with proper identification and treatment.15

Children and Adolescents

Anxiety disorders are the most common childhood onset of psychiatric disorders8

affecting between 2.9% and 4.6% of children and adolescents.14 In childhood, distri- bution tends to be equal for both women and men; however, in adolescents the female-to-male ratio is as high as 6:1.8 Initial onset of symptoms occurs in school age years with typical onset around 7 years old.8

Table 1 Comparison of anxiety disorders

Anxiety Disorder Key Characteristics

Generalized Anxiety Disorder

Persistent and extremeworry, stress, and anxiety about day-to-day life events

Social Anxiety Disorder Excessive fear and worry around everyday interactions and social situations specifically with how one is perceived and judged by others

Posttraumatic Stress Disorder

Persistent fear or emotional distress as a result of injury or severe psychological shock to a traumatic event with ongoing intrusive symptoms related to the event

Obsessive Compulsive Disorder

Persistent, uncontrollable thoughts (obsessions) that cause fear, anxiety, and emotional distress. Obsessions are commonly accompanied by behaviors (compulsions) that are done to mitigate the anxiety and fear caused by the obsessions

Panic Disorder Characterized by reoccurring panic attacks or sudden feelings of terror and discomfort that arise within minutes

Data from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.

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Presentation of symptoms in both children and adolescents typically focus around fears about the family (health-related and safety concerns) and/or school perfor- mance. The symptoms are difficult to stop and/or control. These preoccupations tend to manifest in an “all or nothing” cognitive bias and perfectionism. If the child does not perform perfectly, they develop thoughts and feelings of negative self- worth (ie, they are no good). Rather than focusing on their successes, they tend to perseverate on their mistakes. Many of these children and adolescents have com- plaints of decreased sleep as a result; however, other clinical manifestations include somatic symptoms such as headaches, decreased appetite, and stomach aches, excessive need for reassurance, explosiveness and oppositional behavior, and/or avoidance.8

Adults

GAD is the most common anxiety disorder in primary care settings. It is estimated that 15% to 20% of patients meet criteria for anxiety disorders in primary care settings.16

Lifetime prevalence of GAD has been shown to be up to 33.7% of the general popu- lation.17 Women are twice as likely as men to have GAD.17

Although persistent worrying is considered the basis for GAD, most patients present with other symptoms related to autonomic hyperactivity, hyperarousal, and muscle tension. Many of these patients have complaints of fatigue, poor sleep, difficulty relax- ing, and somatic symptoms including headache and pain in back, shoulders, and neck areas. Younger adults tend to present with greater severity of symptoms than older adults and with more autonomic anxiety.14,18 Older adult worries tend to revolve around physical independence and physical health.18

Predictors of GAD include the following:

� Chronic physical illnesses, � Comorbid psychiatric diagnosis (depression, phobias, past history of GAD), � Recent adverse life events, � Poverty, � Female gender,

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� Parental loss, � History of mental problems in parents, and � Low affective support during childhood.15

SOCIAL ANXIETY DISORDER

Social anxiety disorder is characterized by excessive fear and worry over being scru- tinized, embarrassed, and/or humiliated in social settings.14 There are no significant differences in degree of impairment between lower-, middle-, and higher-income groups.5 Untreated, social anxiety disorder often leads to the development of major depression, substance abuse, and/or other mental health problems.19

Children and Adolescents

Social anxiety disorder commonly presents in childhood or adolescence.19 The average age of onset in the United States is 13 years.5

Typically, children and adolescents present with social anxiety in events or settings that involve peers or adults who are less familial. Children may exhibit symptoms such as crying, freezing, clinging, avoiding speaking, or tantrums. During the assessment interview, children and adolescents will generally be shy or withdrawn with minimal eye contact or responses to questions until they have had time to develop a rapport with the clinician. They will often describe fears of being laughed at, embarrassed, and/or of saying or doing the wrong thing. Their worries tend to revolve around what others think of them rather than what they think of themselves.20

Adults

Social anxiety disorder affects between 3% and 7% of adults in the United States per year; however, lifetime prevalence rates are as high as 12%.19 Lifetime risks of social anxiety disorder are associated with the following risk factors:

� Age of onset, � Female gender, � Unemployment, � Unmarried (never married or widowed/separated/divorced), � Lower educational status, and � Low household income.5

In social or performance situations, symptoms of social anxiety disorder in adults include physical manifestations of anxiety such as diaphoresis, tremors, heart palpita- tions, and facial flushing, which can sometimes result in a panic attack. The person will often worry for hours or days before the feared event or setting; however, there is commonly a fear that others will notice their irrational anxiety and thus symptoms may go unnoticed. They may even avoid the feared setting or event entirely, or if they participate, it is with immense anxiety or more subtle avoidance behaviors such as poor eye contact and/or not engaging in conversations with others. Common feared events and situations include public speaking, large crowds, eating or drinking in public, or even using a public urinal. After the event is over, the person may persev- erate on their shortcomings, feel depressed, and berate themselves.19

POSTTRAUMATIC STRESS DISORDER

Posttraumatic stress disorder (PTSD) presents with 4 main symptom clusters: intru- sion, avoidance, negative alterations in mood and cognition, and hyperarousal.14 To distinguish PTSD from other anxiety disorders, those with the diagnosis must have

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an event precipitating the symptoms. The reoccurring and uncontrollable thoughts, dreams, and emotional reactions are related to the traumatic event. In some individ- uals, dissociative reactions can be present to the extent that the person feels they are reliving the event and may be unaware of their present surroundings.14

Individual prerisk factors for the development of PTSD include the following:

� Female gender, � Lower education, � Lower socioeconomic status, � Previous trauma, � Age at trauma, � Childhood adversity, � Personal and/or family psychiatric history, � History of child abuse, � Poor social support, and � Initial severity of reaction to the traumatic event.21

Children and Adolescents

Although more than 60% of children and adolescence will experience some sort of traumatic event before adulthood, only about 15.9% will develop PTSD.22,23 Rates are similar between boys and girls; however, boys are more likely to experience phys- ical violence, whereas girls are more likely to be victims of sexual abuse.24 Those who experienced the trauma in childhood have more difficulty with affect regulation with an increased severity of symptoms.23

In children, nightmares are not always directly related to the traumatic event but can cause sleep difficulties, including a fear of awakening during or after the dream. Nega- tive emotions in children also increase, including fear, guilt, anger, and shame. Emotional reactivity increases and can present as symptoms of irritability, anger out- bursts, physical violence, or temper tantrums. In addition, anhedonia, decreased con- centration, and decreased social connectedness to others can result in the child or adolescent feeling detached or estranged.23

Adults

The lifetime prevalence of PTSD ranges from 6.1% to 9.2% with higher rates found in North American countries than other regions worldwide.5 Women are twice as likely to develop symptoms of PTSD after a traumatic event.21

Symptoms of PTSD are most often triggered by responses to trauma-related stimuli leading to flashbacks, anxiety, and fleeing or combative behavior. These individuals typically try to avoid the trauma-related stimuli to reduce this intense arousal; howev- er, this can result in anhedonia, emotional numbing, and even detachment from others.

OBSESSIVE COMPULSIVE DISORDER

Obsessive compulsive disorder (OCD) is characterized by uncontrollable, reoccurring thoughts, sensations, feelings (obsessions), behaviors that drive them to do some- thing repeatedly (compulsions), or both. The individual can attempt to ignore or sup- press the obsessive thoughts or to neutralize them by some other thought or action, such as performing a compulsion. Compulsive behaviors then are aimed at reducing anxiety or preventing some imagined event or situation; however, these acts are excessive and/or not realistically connected to what they are designed to neutralize.14

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Compulsions are not pleasurable for the individual and thus not to be mistaken for an impulsive act that is associated with immediate gratification (ie, gambling, shopping). Obsessions are also not associated with day-to-day worries, which occur in GAD or are regarding perceived defects in physical appearance, which occur in body dysmorphicdisorder.25

Children and Adolescents

OCD typically presents in childhood or adolescence and persists throughout a per- son’s life. Without treatment, symptoms are chronic but fluctuate for most individuals. Average onset of symptoms is between 9 and 11 years for male children and 11 and 13 years for female children. Mens are more commonly affected in childhood than women.26

Children with OCD are more likely to present with obvious compulsions than with obsessions such as the washing of their hands excessively. For some children, detect- ing obsessions can be difficult for practitioners because very young children may not be able to verbally describe their obsessions. Untreated and undiagnosed OCD in chil- dren and adolescents can lead to difficulty with separation-individuation from parents and occupational achievement as adults.27

Rarely, children may develop sudden onset of episodic symptoms with concomitant motor tics, hyperactivity, or choreiform movements. This presentation has been asso- ciated with underlying infectious agents in several case studies of children with OCD.28

Adults

The lifetime prevalence rate of OCD among adults in North America is estimated at 3.7%.29 Although the specific content of compulsions and obsessions varies among individuals, there are identifiable themes, or “symptom dimensions,” which include the following:

� Harm: examples include fears of harm to self or others and associated checking compulsions (eg, door locks)

� Symmetry: examples include alignment or symmetry obsessions and counting, ordering, and repeating compulsions

� Cleaning: examples include fear of contamination and cleaning compulsions (eg, excessive hand washing)

� Forbidden or unacceptable thoughts: examples include sexual, religious, and/or aggressive obsessions and related compulsions30

Because of the severity of symptoms, it is common for adults with OCD to exhibit avoiding behaviors and struggle with suicidal ideation.30 Beliefs around obsessions and compulsions can cause individuals to have dysfunctional beliefs including perfec- tionism, overvaluing need to control thoughts and their importance, and a tendency to overestimate threats.

PANIC DISORDER

Individuals with panic disorder suffer from reoccurring panic attacks that are either un- expected or triggered by something in their environment. Panic attacks are short ep- isodes of intense fear that culminate within minutes. Symptoms of panic attacks include the following:

� Feelings of impending doom, � Trembling or shaking,

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� Paresthesias, � Diaphoresis, � Heart palpitations, accelerated heart rate, or pounding heartbeat, � Sensations of choking, shortness of breath, chest pain, or not being able to catch one’s breath, and

� Feelings of being out of control.31

People with panic attacks often worry about when the next episode will occur and will actively try to avoid a reoccurrence of a panic attack by avoiding things, places, or behaviors that they associate with panic attacks.31 Concern over upcoming panic at- tacks causes significant disruption in a person’s life and can lead to the development of other psychological disorders such as agoraphobia.31

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