By Gianna Melillo
We all experience anxiety at some point in our lives, explained Jaesu Han, MD. But when anxiety coincides with functional impairment, consider an anxiety disorder, he said during a Wednesday precourse at Internal Medicine Meeting 2024, titled “Primary Care Psychiatry: Practical Skills for Internal Medicine Physicians.”
Dr. Han, clinical professor in the department of psychiatry and family medicine at UCI School of Medicine in Irvine, Calif., outlined common anxiety disorders and best practices for clinical management.
Anxiety symptoms include negative ruminations that are excessive beyond what you’d expect for a given situation, along with physical manifestations like sweating and increased heart rate, Dr. Han said. Functional impairment is defined as activities avoided or opportunities lost, he added.
“We're big on functional impairment in psychiatry because we don't have biomarkers,” Dr. Han stressed. “So you want to ask the patients who are saying they're anxious, ‘What are some opportunities that you may have missed out on? … What are some activities that you stopped doing because of the anxiety?’”
When this has gone on for more than six months, that’s a strong indicator of an anxiety disorder like social anxiety disorder, generalized anxiety disorder, or agoraphobia. One exception to this timeline is panic disorder, which only requires one month of symptoms.
“It's very unusual to have just an anxiety disorder and nothing else,” Dr. Han noted. “So usually, there is a whole slew of other things that anxiety disorder is associated with; the most common would be another anxiety disorder.”
When physicians don’t have enough time to make a specific anxiety disorder diagnosis, it’s fine to code for unspecified anxiety disorder at the initial visit and then narrow down the diagnosis during subsequent visits, he said, because the first-line treatments are identical to those for other anxiety disorders.
“Do you have to determine that first visit whether it's panic disorder or social anxiety disorder? No, it's not even going to matter,” Dr. Han said. “You're going to start the same treatment anyway, so you don't have to figure that out right away.”
Before starting medication and talk therapy, it’s crucial to explain to patients why they will be helpful. Dr. Han recommends using a tool called the cognitive triangle. This tool outlines how stressors, lifestyle, or genetic factors lead to ruminating thoughts that typically involve overestimating danger and underestimating one’s ability to handle the situation. These thoughts in turn release stress hormones that induce physical symptoms, followed by additional negative thoughts like embarrassment. As a result, patients’ behaviors change, potentially exposing them to more environmental or lifestyle triggers, and the cycle continues.
“Usually, when I explain this to the patient in the examples of their own life and what they're telling me, they usually go, ‘Oh yeah, that makes sense,’” Dr. Han said. “I really find that going through this cycle is very helpful for adherence to treatment.”
First-line treatments for panic disorder, generalized anxiety disorder, and social anxiety disorder are selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) plus cognitive behavioral therapy. While both types of drugs are effective, SNRIs have a higher discontinuation rate due to side effects, Dr. Han said.
However, SSRIs can be associated with activation, or feelings of restlessness, and patients with anxiety may interpret this as worsening anxiety. “You’re more likely to trigger [activation] by aggressive dosing with medication,” Dr. Han explained.
For this reason, it’s crucial to start low and go slow. “Most aggressively I start sertraline at 25 milligrams a day for a week, and then go to 50. Sometimes I take 25 and break it in half, have 12.5 for a week or two, go to 25, then get to 50. … The key thing [to] treating patients with an SSRI is not which one you prescribe, it’s how you start it,” he said.
If a patient has tried at least two SSRIs and an SNRI, they can move on to other options like buspirone. Other options that are not FDA approved for anxiety disorders but can be prescribed include pregabalin, hydroxyzine, gabapentin, or propranolol.
Benzodiazepines can be used, but only after an assessment of the benefits and risks associated with the drug, including withdrawal, Dr. Han cautioned. “There are situations where a benzodiazepine is reasonable, but we have to definitely be concerned about the negatives as well,” he said. ■