In primary care settings, clients may present with a physical problem (e.g., diabetes or cancer) and anxiety symptoms at the same time. It is important to do a clear differential diagnosis and determine whether the anxiety symptoms are a function of a general medical condition. If the symptoms are due to anxiety, an anxiety disorder diagnosis may be warranted. This chapter provides clinical descriptions of the anxiety disorders, as well as suggestions for how they can be treated. In the primary care setting, anxiety symptoms may present either as a sub-threshold or full-blown clinical syndrome.
Anxiety disorders are approached from a biopsychosocial perspective. This means that there are contributions from biology, psychology and society. These factors all interact before there is the expression of an anxiety disorder.
Screening and Assessment
Anxiety disorders present in many different ways. Given the frequency of the disorders, primary care practitioners should screen for them. Panic disorder, GAD and PTSD tend to present most frequently in primary care settings (Stein, 2003).
In terms of differential diagnosis, it is important to remember that panic attacks can occur within the context of any anxiety disorder. It is also important that the practitioner first determine if the symptoms associated with a panic attack are due to anxiety or to a medical condition (e.g., heart attack). A common differential diagnosis is between panic disorder and social phobia. If a client has panic attacks in social situations, a diagnosis of panic disorder may also be warranted if the panic attacks appear out of the blue. Another common differential diagnosis is between GAD and major depressive disorder. Worry and low mood frequently co-occur. However, if the worry has only been present within the context of a
depressive episode, then an additional diagnosis of GAD is not warranted.
A thorough clinical interview is often required to establish proper diagnoses. The clinical interview can be unstructured or structured, such as the SCID-CV (First et al., 1996). It is important to assess for all diagnostic criteria, including clinically significant distress and impairment.
Tools for Assessment
- Beck Anxiety Inventory
Cognitive Behavioural Therapy
CBT is the preeminent psychological treatment for anxiety disorders and should always be considered as a modality of treatment (e.g., Chambless & Ollendick, 2001). The mechanism of change is based on the premise that our thoughts, feelings and behaviours are interconnected and influence one another. CBT works on changing emotions by making changes in cognition and behaviour.
To ensure a client is a good candidate for CBT, look for factors such as the client's ability to access his or her thoughts, good focality and responsibility for being an agent of change in the therapy experience and the ability to put in the time and effort to complete homework (Safran et al., 1993).
The serotonin system has been implicated in all anxiety disorders. People with anxiety disorders may be more sensitive to side-effects, especially early in treatment. They may require larger doses and longer duration of treatment with antidepressants.
For all psychiatric medications, modifications may be required for older adults, children or people with medical conditions. An adequate trial of psychiatric medication takes six to 12 weeks. If the client shows substantial improvement, continuation (prophylactic) treatment may proceed for one to two years to minimize the risk that symptoms will return (Canadian Psychiatric Association [CPA], 2006).
Assessing Response to Treatment
To assess response to therapy, look for changes that clients have been able to make in their lives:
Self-report scales are also invaluable. It is a good idea to administer them over the course of treatment to determine treatment response. If answers to the above questions suggest that the client has not improved adequately, consider referring him or her to an anxiety disorder specialist.
Follow-Up and Referrals
Ideally, clients with anxiety disorder are followed up on regularly to determine treatment response. With CBT, outpatient treatment is typically done weekly.
Anxiety disorders rarely occur in isolation. They often occur along with other disorders, such as mood disorders and substance use problems. Comorbidity can make it more challenging to treat the anxiety disorder. External input may be required.
Another consideration for referral is whether care is required from a multidisciplinary team. Some mental health practitioners are able to deliver treatment within the context of such a team that includes psychiatrists, psychologists, nurses, occupational therapists, social workers and recreation therapists. For some clients, a broader-based comprehensive intervention is needed. Cost may be a concern in deciding whether to refer to services covered by provincial health care or to private practice practitioners.
Questions to ask when considering whether to refer to an anxiety specialist:
- Are there previously feared situations in which the client can now engage?
- Have the client's negative predictions decreased and is he or she catastrophizing less?
- Has the client's quality of life improved?
- Has the client met his or her treatment goals?
- Have the client's anxiety symptoms decreased?
- Is the client experiencing fewer panic attacks?
- Has the client's social and occupational functioning improved?
- Is the client less distressed by remaining anxiety symptoms?
- Has the client acquired relapse-prevention skills?
- Is an interpreter required?
Would the client benefit more from group or individual psychological treatment?
Has there been a failure of two first-line medication treatments?
Is there continuing or worsening functional impairment?
Does the client show signs of suitability for cognitive-behavioural therapy?