anxiety disorder
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Etiology
- fear is the central emotion in anxiety disorders
- precipitating emotional stressor (50%)
- disturbance in neurotransmitters
- medications associated with anxiety
- hypoxia
- ill-health, comorbid medical illness
- comorbid psychiatric disease
Epidemiology
- most common psychiatric disorders in the elderly
- prevalence 2.8% in elderly[14]
- 1/3 of elderly with depression
- older patients are less likely to present with anxiety as a chief complaint[3]
- prevalence of ~34% in the U.S.,
- generalized anxiety disorder (lifetime prevalence = 6%)
- social anxiety disorder (lifetime prevalence = 13%)
- panic disorder (lifetime prevalence = 5%)[38]
Genetics
Clinical manifestations
- excessive worry that is intrusive & interferes with daily functioning
- at least 6 months duration[2][4]
- social & performance fears[38]
- agoraphobia[38]
- panic attacks
- avoidance behaviors[38]
- arousal symptoms
- fatigue
- irritability
- insomnia
- muscle tension, restlessness
- autonomic dysfunction
- chest pain
- palpitations
- smothering sensation, dysnea
- agitation
- tremor
- scattered mentation, difficulty concentrating
- hyperventilation
- dizziness
Laboratory
- complete blood count (CBC)
- serum glucose
- serum electrolytes
- thyroid function testing
- urinalysis
- urine toxicology
- pulse oximetry (rule out hypoxia-induced anxiety)[3]
Diagnostic procedures
- electrocardiogram (if associated with cardiac symptoms)
- generalized anxiety disorder scale (GAD-2, GAD-7)
- other specialized testing:
- Sheehan patient rated anxiety scale
- Hopkins symptom checklist (SCL90)
- Hamilton anxiety & depression scale
- Zung anxiety self-assessment scale
- Covi anxiety & Raskin depression scales
- Beck anxiety inventory
Complications
- disease interaction(s) of psychosis & agitation in the elderly with anxiety disorder
- disease interaction(s) of bipolar disorder with anxiety
- disease interaction(s) of depression with anxiety
- disease interaction(s) of anxiety disorder(s) with functional incontinence
- disease interaction(s) of depression in the elderly with anxiety disorder(s)
- disease interaction(s) of major depression with anxiety disorder(s)
Differential diagnosis
- somatic disorders
- mental disorder
- bipolar disease
- depression
- symptoms common to anxiety & depression
- fatigue, tearfulness, eating disturbances, irritability, worry, difficulty concentrating
- symptoms characteristic of anxiety
- symptoms characteristic of depression
- depression may coexist with anxiety disorder[13]
- symptoms common to anxiety & depression
- agitation
- substance abuse
- panic attack (intense fear of impending doom)
Management
- psychotherapy
- cognitive behavioral therapy[3][6][9][15][17]
- psychodynamic psychotherapy
- both effective[5]
- effective in elderly[3]
- cognitive therapy alone not effective in elderly[3]
- mindfulness-based stress reduction as effective as escitalopram[37]
- pharmaceutical agents
- antidepressants
- selective serotonin reuptake inhibitor (SSRI)*
- serotonin-norepinephrine reuptake inhibitor (SNRI)
- SSRI or SNRI generally drugs of choice in the elderly[3][7]
- duloxetine, venlafaxine, escitalopram effective[29]
- fluoxetine, sertraline also effective[29]
- escitalopram safe & effective for reducing anxiety in patients with coronary artery disease[33]
- SSRI & SNRI modestly better than placebo for treating anxiety in children & adolescents[26][27]
- mirtazapine is sometimes useful as an alternative or adjunctive agent, especially if sedation may be beneficial[3]
- tricyclic antidepressants
- generally used in connection with another agent
- occasionally effective alone
- evidence of benefit for children insufficient[27]
- increased risk for relapse in the year after treatment discontinuation[28]
- continue antidepressant for at least a year after treatment response[28]
- buspirone (BuSpar)
- initial treatment of anxiety in younger patients
- generally well tolerated
- does not cause drug dependency
- very slow to work (2-4 weeks)
- not always effective
- benzodiazepines
- prompt action
- effective for patients with history of substance abuse
- rarely addicting; ref[34] notes addiction potential
- avoid if history of substance use disorder (MKSAP19)[3]
- reserve long-term use for patients with refractory panic disorder
- although both benzodiazepines & anxiety disorders increase risk of dementia in the elderly, benzodiazepine use in elderly with anxiety disorder does not increase risk of dementia[26]
- evidence of benefit for children insufficient[28]
- pregabalin effective
- vilazodone & vortioxetine efficacy is poor[29]
- quetiapine less tolerated than placebo[29]
- high dose vitamin B6 may reduce generalized anxiety & social anxiety[39]
- antidepressants
- SSRI + cognitive behavioral therapy may provide benefit over either alone[6][28]
- integrated mental health & primary care can improve overall function[11]
- screening for anxiety
- generalized anxiety disorder scale (GAD-2, GAD-7)
- screening for anxiety recommended for females >= 13 years of age[32]
- depression frequently coexists with anxiety; also screen for depression[32]
- USPSTF recommends screening for anxiety disorders in adults, including pregnant & postpartum women[40]
- USPSTF concludes that current evidence is insufficient to assess the balance of benefits & harms of screening for anxiety disorders in older adults[40]
- patient education
- patient & family psychoeducation helpful for elderly[3]
- exercise has antianxiety effects[3]
- supportive groups probably offer nonspecific benefits[3]
- meditation & relaxation helpful, meditation may be more so[30]
* according to[3] patients should be counseled on potential of adverse effects & when they due occur are likely to be benign & shortlived, often a manifestation of the underlying disorder
More general terms
More specific terms
- death anxiety; fear of death
- generalized anxiety disorder (GAD)
- obsessive-compulsive disorder (OCD)
- panic disorder
- phobia
- posttraumatic stress disorder (PTSD); includes acute stress disorder
- social phobia; social anxiety disorder
Additional terms
- anxiety assessment
- medications associated with anxiety
- Screen for Child Anxiety Related Disorders (SCARED)
- screening for anxiety
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1119-20
- ↑ 2.0 2.1 2.2 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2018, 2021.
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004;
Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010
Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022 - ↑ 4.0 4.1 Kroenke K et al, Anxiety disorders in primary care: Prevalence, impairment, comorbidity, detection. Ann Intern Med 2007, 146:317 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17339617
Katon W & Roy-Byrne P Anxiety disorders: Efficient screening is the first step in improving outcomes. Ann Intern Med 2007, 146:390 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17339624 - ↑ 5.0 5.1 Leichsenring F et al Short-term psychodynamic psychotherapy and cognitive-behavioral therapy in generalized anxiety disorder: A randomized, controlled trial. Am J Psychiatry 2009 Jul 1; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19570931 <Internet> http://dx.doi.org/10.1176/appi.ajp.2009.09030441
- ↑ 6.0 6.1 6.2 Wetherell JL et al. Antidepressant medication augmented with cognitive-behavioral therapy for generalized anxiety disorder in older adults. Am J Psychiatry 2013 May 17 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23680817 <Internet> http://ajp.psychiatryonline.org/article.aspx?articleID=1688270
- ↑ 7.0 7.1 Baldwin D1, Woods R, Lawson R, Taylor D. Efficacy of drug treatments for generalised anxiety disorder: systematic review and meta-analysis. BMJ. 2011 Mar 11;342:d1199. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21398351
- ↑ Chou KL, Mackenzie CS, Liang K, Sareen J. Three-year incidence and predictors of first-onset of DSM-IV mood, anxiety, and substance use disorders in older adults: results from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2011 Feb;72(2):144-55 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21382305
- ↑ 9.0 9.1 Stewart RE, Chambless DL. Cognitive-behavioral therapy for adult anxiety disorders in clinical practice: a meta-analysis of effectiveness studies. J Consult Clin Psychol. 2009 Aug;77(4):595-606. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19634954
- ↑ Wolitzky-Taylor KB1, Castriotta N, Lenze EJ et al Anxiety disorders in older adults: a comprehensive review. Depress Anxiety. 2010 Feb;27(2):190-211 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20099273
- ↑ 11.0 11.1 Huffman JC et al. Collaborative care for depression and anxiety disorders in patients with recent cardiac events: The management of sadness and anxiety in cardiology (MOSAIC) randomized clinical trial. JAMA Intern Med 2014 Apr 14; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24733277 <Internet> http://archinte.jamanetwork.com/article.aspx?articleid=1860496
Davidson KW et al. An innovative or disconcerting approach to the psychosocial care of your patient with a cardiac condition: Are you a lumper or a splitter? JAMA Intern Med 2014 Apr 14; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24733142 <Internet> http://archinte.jamanetwork.com/article.aspx?articleid=1860492 - ↑ Bradford A, Cully J, Rhoades H et al Early response to psychotherapy and long-term change in worry symptoms in older adults with generalized anxiety disorder. Am J Geriatr Psychiatry. 2011 Apr;19(4):347-56 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21427643
- ↑ 13.0 13.1 King-Kallimanis B, Gum AM, Kohn R. Comorbidity of depressive and anxiety disorders for older Americans in the national comorbidity survey-replication. Am J Geriatr Psychiatry. 2009 Sep;17(9):782-92 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19700950
- ↑ 14.0 14.1 14.2 Mackenzie CS, Reynolds K, Chou KL, Pagura J, Sareen J. Prevalence and correlates of generalized anxiety disorder in a national sample of older adults. Am J Geriatr Psychiatry. 2011 Apr;19(4):305-15. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21427639
- ↑ 15.0 15.1 Gould RL, Coulson MC, Howard RJ. Efficacy of cognitive behavioral therapy for anxiety disorders in older people: a meta-analysis and meta-regression of randomized controlled trials. J Am Geriatr Soc. 2012 Feb;60(2):218-29 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22283717
- ↑ Lenze EJ, Wetherell JL. Bringing the bedside to the bench, and then to the community: a prospectus for intervention research in late-life anxiety disorders. Int J Geriatr Psychiatry. 2009 Jan;24(1):1-14. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18613267
- ↑ 17.0 17.1 Stanley MA, Wilson NL, Novy DM et al Cognitive behavior therapy for generalized anxiety disorder among older adults in primary care: a randomized clinical trial. JAMA. 2009 Apr 8;301(14):1460-7 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19351943
- ↑ van't Veer-Tazelaar PJ, van Marwijk HW, van Oppen P et al Stepped-care prevention of anxiety and depression in late life: a randomized controlled trial. Arch Gen Psychiatry. 2009 Mar;66(3):297-304 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19255379
- ↑ Wetherell JL, Lenze EJ, Stanley MA. Evidence-based treatment of geriatric anxiety disorders. Psychiatr Clin North Am. 2005 Dec;28(4):871-96, ix. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16325733
- ↑ Lenze EJ, Wetherell JL. Anxiety disorders: new developments in old age. Am J Geriatr Psychiatry. 2011 Apr;19(4):301-4. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21427638
- ↑ Bryant C, Jackson H, Ames D. The prevalence of anxiety in older adults: methodological issues and a review of the literature. J Affect Disord. 2008 Aug;109(3):233-50. Epub 2007 Dec 26. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18155775
- ↑ Schuurmans J, van Balkom A. Late-life anxiety disorders: a review. Curr Psychiatry Rep. 2011 Aug;13(4):267-73. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21538031
- ↑ El-Gabalawy R, Mackenzie CS, Shooshtari S, Sareen J. Comorbid physical health conditions and anxiety disorders: a population-based exploration of prevalence and health outcomes among older adults. Gen Hosp Psychiatry. 2011 Nov-Dec;33(6):556-64. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21908055
- ↑ Roy-Byrne PP, Davidson KW, Kessler RC et al Anxiety disorders and comorbid medical illness. Gen Hosp Psychiatry. 2008 May-Jun;30(3):208-25. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18433653
- ↑ Sanna L, Stuart AL, Pasco JA, Kotowicz MA et al Physical comorbidities in men with mood and anxiety disorders: a population-based study. BMC Med. 2013 Apr 24;11:110. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23618390 Free PMC Article
- ↑ 26.0 26.1 26.2 Locher C, Koechlin H, Zion SR et al Efficacy and Safety of Selective Serotonin Reuptake Inhibitors, Serotonin-Norepinephrine Reuptake Inhibitors, and Placebo for Common Psychiatric Disorders Among Children and Adolescents. A Systematic Review and Meta-analysis. JAMA Psychiatry. Published online August 30, 2017. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28854296 <Internet> http://jamanetwork.com/journals/jamapsychiatry/fullarticle/2652447
Merry SN, Hetrick SE, Stasiak K. Effectiveness and Safety of Antidepressants for Children and Adolescents. Implications for Clinical Practice. JAMA Psychiatry. Published online August 30, 2017. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28854300 <Internet> http://jamanetwork.com/journals/jamapsychiatry/fullarticle/2652446 - ↑ 27.0 27.1 27.2 27.3 Wang Z, Whiteside SPH, Sim L et al Comparative Effectiveness and Safety of Cognitive Behavioral Therapy and Pharmacotherapy for Childhood Anxiety Disorders. A Systematic Review and Meta-analysis. JAMA Pediatr. Published online August 31, 2017. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28859190 <Internet> http://jamanetwork.com/journals/jamapediatrics/fullarticle/2650801
Asarnow JR, Rozenman MS, Carlson GA Medication and Cognitive Behavioral Therapy for Pediatric Anxiety Disorders. No Need for Anxiety in Treating Anxiety. JAMA Pediatr. Published online August 31, 2017. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28859188 <Internet> http://jamanetwork.com/journals/jamapediatrics/fullarticle/2650800 - ↑ 28.0 28.1 28.2 28.3 28.4 Batelaan NM et al Risk of relapse after antidepressant discontinuation in anxiety disorders, obsessive-compulsive disorder, and post- traumatic stress disorder: systematic review and meta-analysis of relapse prevention trials. BMJ 2017;358:j3927 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28903922 <Internet> http://www.bmj.com/content/358/bmj.j3927
- ↑ 29.0 29.1 29.2 29.3 29.4 Slee A, Nazareth I, Bondaronek P, Liu Y, Cheng Z, Freemantle N. Pharmacological treatments for generalised anxiety disorder: A systematic review and network meta-analysis. Lancet 2019 Jan 31; PMID: https://www.ncbi.nlm.nih.gov/pubmed/30712879
Bandelow B, Wedekind D. Network analyses to rank pharmacological treatments for generalised anxiety disorder. Lancet 2019 Jan 31 PMID: https://www.ncbi.nlm.nih.gov/pubmed/30712877 - ↑ 30.0 30.1 Montero-Marin J, Garcia-Campayo J, Perez-Yus MC et al. Meditation techniques v. relaxation therapies when treating anxiety: A meta-analytic review. Psychol Med 2019 Oct; 49:2118. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31322102 https://www.cambridge.org/core/journals/psychological-medicine/article/meditation-techniques-v-relaxation-therapies-when-treating-anxiety-a-metaanalytic-review/6F167C7F5B2A00CB2039C05E89F6E5C2
- ↑ 31.0 31.1 van Dis EAM, van Veen SC, Hagenaars MA et al Long-term Outcomes of Cognitive Behavioral Therapy for Anxiety-Related Disorders. A Systematic Review and Meta-analysis. JAMA Psychiatry. Published online November 23, 2019 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31758858 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2756136
- ↑ 32.0 32.1 32.2 Gregory KD, Chelmow D , Screening for Anxiety in Adolescent and Adult Women: A Recommendation From the Women's Preventive Services Initiative. Ann Intern Med. June 9, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32510990 https://www.acpjournals.org/doi/10.7326/M20-0580
Nelson HD, et al. Screening for Anxiety in Adolescent and Adult Women: A Systematic Review for the Women's Preventive Services Initiative. Ann Intern Med. June 9, 2020. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32510989 https://www.acpjournals.org/doi/10.7326/M20-0579
Smolderen KG, Burg MM Awareness for Anxiety in Women: A Great Start. Ann Intern Med. June 9, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32510991 https://www.acpjournals.org/doi/10.7326/M20-3116 - ↑ 33.0 33.1 33.2 Blumenthal JA, Smith PJ, Jiang W et al. Effect of Exercise, Escitalopram, or Placebo on Anxiety in Patients With Coronary Heart Disease. The Understanding the Benefits of Exercise and Escitalopram in Anxious Patients With Coronary Heart Disease (UNWIND) Randomized Clinical Trial. JAMA Psychiatry. Published online August 18, 2021 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34406354 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2783295
- ↑ 34.0 34.1 Soreff S Fast Five Quiz: Anxiety Medscape. August 9, 2021 https://reference.medscape.com/viewarticle/955963
Bhatt NV, Bienenfeld D Anxiety Disorders Medscape. March 27, 2019 https://emedicine.medscape.com/article/286227-overview - ↑ Ramos K, Stanley MA. Anxiety disorders in late life. Psychiatr Clin North Am. 2018;41(1):55-64 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29412848 https://www.sciencedirect.com/science/article/abs/pii/S0193953X17300990
- ↑ Penninx BW et al. Anxiety disorders. Lancet 2021 Mar 6; 397:914 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33581801 PMCID: PMC9248771 Free PMC article
- ↑ 37.0 37.1 Anderson P Meditation Equal to First-Line Medication for Anxiety. Medscape. November 11, 2022 https://www.medscape.com/viewarticle/983912
Hoge EA et al. Mindfulness-based stress reduction vs escitalopram for the treatment of adults with anxiety disorders: A randomized clinical trial. JAMA Psychiatry 2022 Nov 9; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36350591 https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2798510 - ↑ 38.0 38.1 38.2 38.3 38.4 Szuhany KL, Simon NM. Anxiety Disorders. A Review. JAMA. 2022;328(24):2431-2445 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36573969 https://jamanetwork.com/journals/jama/fullarticle/2799904
- ↑ 39.0 39.1 39.2 Field DT, Cracknell RO, Eastwood JR et al High-dose Vitamin B6 supplementation reduces anxiety and strengthens visual surround suppression. Human Psychopharmacology: Clinical & Experimental. 2022 July 19:e2852 PMID: https://www.ncbi.nlm.nih.gov/pubmed/35851507 https://onlinelibrary.wiley.com/doi/10.1002/hup.2852
- ↑ 40.0 40.1 40.2 US Preventive Services Task Force Screening for Anxiety Disorders in Adults. US Preventive Services Task Force Recommendation Statement. JAMA. 2023;329(24):2163-2170 PMID: https://www.ncbi.nlm.nih.gov/pubmed/37338866 https://jamanetwork.com/journals/jama/fullarticle/2806250
O'Connor EA, Henninger ML, Perdue LA et al Anxiety Screening. Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2023;329(24):2171-2184 PMID: https://www.ncbi.nlm.nih.gov/pubmed/37338868 https://jamanetwork.com/journals/jama/fullarticle/2806251 - ↑ Brieler JA, Salas J, Amick ME et al Anxiety disorders, benzodiazepine prescription, and incident dementia. J Am Geriatr Soc. 2023. Nov 71(11):3376-3389 PMID: https://www.ncbi.nlm.nih.gov/pubmed/37503956 https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.18515
- ↑ Anxiety Disorders http://www.nimh.nih.gov/publicat/anxiety.cfm
- ↑ Anxiety Disorder PDQ, National Cancer Institute http://www.nci.nih.gov/cancertopics/pdq/supportivecare/anxiety/HealthProfessional