Case-Based Reviews: Anxiety disorders

Journal List > West J Med > v.176(4); Sep 2002

West J Med. 2002 September; 176(4): 249–253.

PMCID: PMC1071743

Case-Based Reviews

Anxiety disorders

Jian-Ping Chen,¹ Leonard Reich,² and Henry Chung³

¹Charles B Wang Community Health Center 125 Walker St New York, NY 10013

²Health Insurance Plan of Greater New York 7 West 34th St New York, NY10001

³Pfizer, Inc. 235 East 42nd St. New York, NY 10017

Correspondence to: Dr Chenjpchen20/at/aol.com

See "Depressive disorders in Asian American adults" on page 239.

see also p 239, 257

Summary points

Careful evaluation of an anxious patient will help to determine if thecause of the anxiety is organic or psychological
Use of herbal and over-the-counter substances should be determined becausesome herbal products (eg, ginseng, ma huang, and certain coughmedicines) contain stimulants that cause symptoms of anxiety
Anxiety is often associated with one or more other mood disorders that mayrequire management and treatment
Primary care practitioners should incorporate psychological techniques intheir medical management of Asian patients with anxiety

Ms M is a 60-year-old widowed Chinese woman with a 6-month history ofepisodic chest tightness, shortness of breath, pain that “moves all overmy body,” and numbness in her legs. These attacks, which occur once ortwice weekly, occur suddenly, reaching peak intensity within a few minutes.During an attack, pain travels from her chest to her abdomen, groin, and legs.The pain is often accompenied by a sensation of intermittent “hotQi” (air) coming from her abdomen to her throat, making her believe thatshe is being choked. She also describes feeling as if she is in a closed roomor small space.
Ms M is anxious and frustrated about her symptoms and thinks she might havea serious medical problem. She has had frequent medical evaluations by herprimary care physician and second opinions from various specialists. Ms Mconsulted a doctor of traditional Chinese medicine and tried some herbalmedications, but has had no relief. She has refused to see a psychiatrist.

ANXIETY DISORDERS IN THE PRIMARY CARE SETTING

Anxiety disorders are a group of mental disturbances characterized byanxiety as a core symptom. In this article, we discuss anxiety disorderscommon to primary care, specifically panic disorder, generalized anxietydisorder (GAD), and posttraumatic stress disorder (PTSD).

DIAGNOSIS

The diagnosis is made when the constellation of symptoms are consistentwith the diagnostic criteria for each disease listed in the Diagnostic andStatistical Manual of Mental Disorders, 4th edition (DSM-IV) (see Tablelinked to this article on our web site). When symptoms of anxiety becomepervasive, have signs and symptoms consistent with DSM-IV criteria, and affectthe patient's ability to function, the presumed diagnosis is an anxietydisorder.

Which organic illnesses can cause anxiety symptoms?

Some of the disease states associated with prominent anxiety are shown inbox 1. These diseases, however,are rare explanations for anxiety and anxiety disorders. Clinicalinvestigations to identify a particular disease entity should only beundertaken if the pre-test probability of the disease is high.

Box 1

Disease states associated with anxiety

What features are suggestive of an organic cause of anxiety?

An organic cause of anxiety should be suspected when the onset of symptomsis sudden, changes have recently occurred in the patient's medication, or thepatient has specific signs and symptoms suggestive of a new organic diseaseprocess.

When a patient presents with anxiety, the following features should promptclinicians to suspect an underlying nonpsychiatric disorder is thecause¹:

Onset of anxiety symptoms after the age of 35
Lack of personal or family history of an anxiety disorder
Lack of childhood history of significant anxiety, phobias, or separationanxiety
Absence of significant life events generating or exacerbating the anxietysymptoms
Lack of avoidance behavior
Poor response to anxiolytic agents

How do you evaluate an anxious patient?

The medical evaluation of anxious patients should include a completehistory and physical examination. Features of the history that merit specialattention are:

Substance use/abuse (eg, caffeine, amphetamines, marijuana, cocaine) andwithdrawal (eg, from alcohol or sedative-hypnotics)—both of these cancause anxiety symptoms
Use of medications with anxiogenic effects (β-adrenergic agonists,theophylline, corticosteroids, thyroid hormone, sympathomimetics,psychostimulants)

Asking Asian patients if they are using any herbs or medicines given byfriends or relatives is important because some may contain ma huang(a stimulant) or ginseng. These substances may cause or exacerbate anxiety(see below).

Laboratory and medical tests should be performed only as indicated bysymptom constellation and clinical judgment.

Which cultural issues are important to consider?

Issues that are important in diagnosing anxiety include the following:

Many Asian patients do not use the word anxiety. Instead, they discuss“nervousness,” “tension,” or “beingtense”
Because being anxious is viewed as being weak or incompetent, many Asianpatients with anxiety disorders tend to present with physical complaints. Aphysical problem often is seen as a more legitimate reason to get help and togain sympathy and support from family members and friends
Many patients with anxiety disorders also have depression. As many as 50%of patients with anxiety will have an episode of major depression at some timein their life²
Often patients may understand their symptoms as a defined illness that isknown only to the specific native culture. Examples include neurasthenia (a“nerve weakness,” see p 257), pa-leng (Chinese for“fear of cold”), hwa byung (Korean for “fireillness”) and taijin kyofusho (Japanese for “fear oflosing face and facing situations)
Psychosocial issues encountered by new immigrants can exacerbate or createnew anxiety
Some Chinese pharmaceuticals can cause or worsen anxiety. Ma-huangcontains ephedrine, a common ingredient in cold medication or diet pills,which increases heart rate, blood pressure, and sweating, all markers ofanxiety. Ginseng possibly increases the basal metabolic rate and increasesheart rate, which may trigger anxiety

TREATMENT

Treating anxiety with medication may be consistent with an Asian patient'sview that anxiety is a medical issue rather than a psychological one. Inaddition, adherence to a medical regimen hinges less on a good language matchbetween patient and physician than would be the case with a psychologicaltreatment program. Medication also has the benefit of relieving distressingphysical symptoms and rapidly returning patients to pre-existing functionallevels.

A major limitation of treating anxiety with medication alone is thatpatients do not evaluate their conditioned patterns, coping strategies, orenvironmental circumstances, which may be the root cause of their anxietydisorder. Failing to address these issues increases the risk of relapse whenmedication is discontinued.

Therefore, clinicians in primary care settings should emphasizepsychological treatments with the same conviction as medical ones. Researchfindings show thatpsychopharmacologic³^,⁴and cognitive behavioralpsychotherapeutic⁵^,⁶^,⁷interventions individually are effective in the treatment of approximately 60to 90% of patients with various forms of anxiety disorders. The combination ofmedication and psychotherapy produces the most effective long-termresults.⁸^,⁹^,¹⁰

SPECIFIC DISORDERS

Panic disorder

Clinical assessment

We have found that some Asian patients present with panic attacks that havestrong cultural overtones, characterized by only one or two predominantclassic symptoms. Our Chinese American patients with anxiety commonly complainof “hot and cold” symptoms (such as pa-leng). Despite aconsistent environment, they describe sensations of hot or cold Qi(air) going up and down their body, along with other bodily discomforts.

“Hwa byung” is also a common cultural idiom ofdistress seen in Koreanpatients.¹¹ Lin andcolleagues describe this syndrome as highly somatized with anxiety, insomnia,sensations of heat in the body and the impulse to “get out of thehouse.”¹¹Patients with these symptoms often recognize that the symptoms arepsychological and result from suppressing anger.

Obtaining a brief history of the patient's experience with panic attacks isuseful because panic attacks and agoraphobia (fear of being placed insituations where obtaining help is difficult, such as lonely open spaces ortraveling alone) may seriously limit the patient's ability to travel toappointments and comply with aftercare. If panic disorder with or withoutagoraphobia is diagnosed in Asian patients, time may be required to assesspatients' travel patterns and their ability to travel beyond their immediatecommunity.

Psychological treatments

Psychological treatments for panic have proven effective both independentlyand as an adjunct to medication. In a recent randomized controlled trial,investigators compared the effectiveness of cognitive-behavioral therapy,imipramine, or their combination, against placebo in the treatment of panicdisorder.¹² Eachtreatment individually was better than placebo, and the combination treatmentwas more effective than individual treatments at preventing relapse.

Cognitive-behavioral therapy is the psychological treatment of choice forpanic disorder. A protocol developed by Barlow and Craske, which involvesexposure, cognitive restructuring, breathing retraining, and relaxationtraining (box 2), has beenwell-validated.¹³We have found these treatments are effective in Asian American patients, yettheir use may be limited by a lack of bilingual therapists.

Box 2

Psychological therapies for panic disorder

Suggestions for practitioners

Provide a medical explanation that gives patients an understanding of theirphysical symptoms. Acknowledge that the symptoms are physical but are notrelated to a serious medical condition, such as heart disease
Instruct the patient on how to use abdominal breathing (breathingretraining) at the first sign of hyperventilation, anxiety, or a panicattack
Suggest that the patient use relaxation techniques
Encourage the patient to practice breathing retraining and relaxationtechniques during non-panic anxiety states
Provide helpful literature and/or relaxation tapes that reinforcerelaxation techniques

Generalized anxiety disorder (GAD)

Clinical assessment

Generalized anxiety disorder is defined as excessive anxiety or worry inthe absence of, or out of proportion to, situational factors. The symptoms ofthis disorder are restlessness or feeling on edge, being easily fatigued,difficulty concentrating or the patient's mind going blank, irritability,muscle tension, and sleep disturbance. The diagnosis requires that symptomshave been present for more than 6months.¹⁴

Pharmacotherapy

The treatment of GAD is similar to treatment for all other anxietydisorders. A selective serotonin reuptake inhibitor (SSRI) may be administeredat low doses and adjusted upward for a full therapeuticresponse.⁴Psychotherapy for patients with GAD has not been well studied.

Posttraumatic stress disorder (PTSD)

Clinical assessment

Posttraumatic stress disorder occurs after exposure to an event involvingdeath, serious injury, or a threat to the physical integrity of self orothers. Patients with the condition persistently re-experience the event, suchas through dreams and flashbacks; show persistent avoidance behavior, such asdiminished involvement in usual activities or relationships; and persistentsymptoms of increased arousal, such as irritability andhypervigilance.¹⁴Events that trigger the disorder include war; torture; natural disaster;violence to self or others, including rape; serious illness; surgery; andevents that have an idiosyncratic impact on a given patient.

Immigrants from the Pacific Rim may be at a higher risk of having beenexposed to traumatic events related to their journey to the United States orto their reasons for wanting to leave their home country. For example, someimmigrants from China have been tortured for political reasons or sufferedfrom enforcement of birth control policy resulting in forced terminations ofpregnancies. The prevalence of PTSD is high among Southeast Asianrefugees.¹⁵

Posttraumatic stress disorder is often associated with depression, otheranxiety disorders, and substance abuse. Clinicians should assess for theseother conditions in patients with PTSD because substance abuse and depressionincrease suicidal risk. The National Women's Study found that 31% of women whoare raped develop PTSD and that 13% of rape victims make a suicideattempt.¹⁶

Therapy

The treatment of choice for PTSD is SSRI medication and cognitivebehavioral psychotherapy, along with therapy for any associated psychiatricillness, such as depression.

Suggestions for practitioners

If you suspect that a patient has PTSD, assess for substance abuse. Ifpatients are abusing or misusing substances, you should explain what resourcesare available to help them and discuss the particular risks of using drugsthat may cause dependence, such as short-acting benzodiazepines
Encourage patients to use relaxation techniques
Explain that the physical symptoms they experience are common to manypeople who have experienced a traumatic event. One statement might be:“Sometimes symptoms such as chronic fatigue, headaches, and stomachaches are the body's communication for posttraumatic stress”
Identify feelings such as fear, anger, guilt, and helplessness, which mighthelp to alleviate the patient's physical symptoms

When Ms M experienced an attack of severe pain in the office of her primarycare practitioner, her physician contacted a psychiatrist for an immediateconsultation. The psychiatrist rendered the diagnosis of panic disorder andrecommended a treatment regimen involving an antidepressant agent, abenzodiazepine, and biweekly supportive and cognitive therapy. After 3 monthsof therapy, Ms M no longer had symptoms.
The dosage of the benzodiazepine was tapered and she continued to be wellfor another 6 months while taking the antidepressant alone. Belleving that shewas cured, Ms M then discontinued the use of the antidepressant against theadvice of her psychiatrist. Two months later, her symptoms recurred and sheresumed taking the antidepressant.
Table 3

Figure 1

Dwarf ginseng (Panax trifolius L.). The physiologic effects ofginseng may trigger or worsen anxiety

Figure 2

ROC/Taiwan Government Information Office

Notes

Competing interests: J-P Chen received speaker's fees from GlaxoSmith Kline and Pfizer, Inc; H Chung is Medical Director, Depression andAnxiety Management Team, Pfizer, Inc.

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