#335 Generalized Anxiety Disorder

May 16, 2022 | By Beth Garbitelli

Video

Take the stress out of managing anxiety in primary care!

Join us as we de-mystify the diagnosis, talk treatment strategies, parse through pharmaceutical options, and figure out follow-up in Generalized Anxiety Disorder with Dr. Dheepa Sekar (@DheepaSekarMD)! Anxiety disorders are one of the most common mental health concerns in our country and this episode will give you the tools to address it in clinic!

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Credits

• Producer, Scriptwriter, Show Notes, Infographic/Cover Art: Beth Garbitelli
• Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP, Beth Garbitelli   
• Reviewer: Emi Okamoto MD
• Showrunner: Matthew Watto MD, FACP
• Production Team: PodPaste
• Guest: Dheepa Sekar MD

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Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner, Picks of the Week*
• Case from Kashlak; Definitions
• Differential diagnosis for GAD
• Counseling about diagnosis
• Initial guidance on first-line management, apps for mindfulness
• Prescribing basics, SSRI and SNRI considerations
• Bridging with hydroxyzine and buspirone
• Monitoring treatment response
• Managing side effects
• Tapering medication
• Alternative agents, atypical antipsychotics, and benzos
• Take Home points, Outro

Generalized Anxiety Disorder Pearls

1. Not all patients with anxiety may fit the traditional paradigm. Be thoughtful during your assessment, especially when patients present with unexplained somatic complaints.
2. GAD-7 can be used as a tool to monitor illness progression/remission as well as a screening tool!
3. Recommend therapy if the patient is open to it. Mindfulness techniques and apps, especially if obtaining a therapy appointment is difficult, can be a useful strategy as well. Patients receiving CBT or undergoing therapy are less likely to relapse (White 2013). 
4. SSRIs are often the first-line choice for medication.  Use shared decision making and online tools to discuss side effects and keep in mind that some SSRI are more activating than others. Consider utilizing the Mayo Clinic Shared Decision Making Tool (for depression, but also useful for SSRI/SNRI use in all conditions)! 
5. Consider bridging patients with hydroxyzine or buspirone during the initiation of an SSRI.
6. When thinking about tapering off of SSRI/SNRI, Dr. Sekar recommends asking patients about missed doses and how that impacts their symptoms. If they notice symptoms, that is a flag to do a very slow taper!
7. If patient is experiencing sexual side effects, it is in Dr. Sekar’s expert opinion to consider bupropion as an adjunct therapy.
8. Refer to a psychiatrist if a patient has 1-2 trials of SSRI/SNRI without benefit or worsening psychiatric symptoms (De Martini 2019). 

Generalized Anxiety Disorder Show Notes

Making a Diagnosis of Anxiety

Not all patients with anxiety may fit the traditional paradigm. Be thoughtful during your assessment, especially when patients present with unexplained somatic complaints. Common physical manifestations include insomnia, headache, and fatigue (Stein 2015).  Anxiety may also be explored when evaluating patients for substance use and alcohol use. 

Generalized anxiety disorder (GAD) can be summarized as persistent, excessive worry about multiple spheres of life with functional impairment.  Per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition definition, anxiety symptoms and worry should be persistent for more days than not, for at least 6 months. Other features of GAD include difficult-to-control worry and at least 3 of the following associated symptoms: restlessness or a feeling of being keyed up or “on edge,” fatigue, irritability, muscle tension, concentration challenges, and sleep disturbance (Stein 2015). 

GAD-7 is a helpful tool to assess anxiety disorder (Stein 2015, Locke 2015). In addition to providing criteria for diagnosis with a baseline quantification of the patient’s anxiety, it also serves as a tool to monitor anxiety symptoms over time (De Martini 2019). Dr. Watto recommends using it as a way to offer positive framing to patients who experience partial remission. 

Differential for Anxiety Disorders

Dr. Sekar reports that the traditional psychiatric differential for anxiety disorders includes generalized anxiety disorder, panic disorder, ADHD, OCD, and bipolar disorder.  Dr. Sekar recommends assessing briefly for hypomania if a patient reports inability to sleep, as restlessness and agitation (“increased energy”) can be a presentation of bipolar disorder (Fredskild 2019). 

Thyroid dysfunction and cardiac dysfunction should usually be assessed in patients reporting symptoms of anxiety, as anxiety symptoms can be a manifestation of these underlying conditions (Muller 2005). Dr. Sekar recommends teasing out the nuance of any cardiac symptoms, especially red flag symptoms such as dyspnea or chest pain during episodes of anxiety.

Dr. Sekar always recommends assessing suicidal ideation when addressing anxiety symptoms in a patient. 

Opening Up The Discussion

Some patients may be surprised by a diagnosis of anxiety. Dr. Sekar recommends normalizing anxiety (ie: “We see this very often” and “Having these symptoms is not unusual”) and offering reassurance about treatment options. She recommends giving patients a sense of ownership when discussing (ie: “There are many routes we can go to manage anxiety, including therapy or medication, and it is really about what you want to work towards.”) Some patients may present knowing anxiety is something they want to address. For these patients, you may review what they know about anxiety as well as what treatments they may be interested in, per Dr. Sekar. 

Treatment Paradigms

Non-Pharmaceutical Interventions

Therapy and medications for anxiety (and depression) may have some stigma associated with them for patients. Basic needs should be assessed (safe home environment, access to food, stable social situation) and addressed via referrals as needed.  Sleep strategies can also be addressed in an initial discussion, per Dr. Sekar. 

Cognitive behavioral therapy is an important modality to offer to patients  (Stein 2015, Locke 2015).  However, Dr. Sekar reports that obtaining timely therapy appointments during the past few years has been challenging.  One motivational interviewing strategy Dr. Sekar recommends asking the patient about  their coping strategies and their support network.  She also recommends some teaching about mindfulness techniques, such as focused breathing (ex: instruct patients to take a deep breath in and a deep breath out while tracing their hand) and progressive muscle relaxation after muscle clenching (ex: clench muscles in sequence and then relax).  

Emerging data suggest improvement in symptom burden may be associated with usage of mindfulness applications on mobile devices (Graham 2020).  Apps that patients can try include Calm, Headspace, and Worry Knot (which is free!)

Medications and Prescribing for Anxiety

First-line medications for GAD include selective serotonin reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) (De Martini 2019).  Pharmacotherapy for anxiety disorders are efficacious and one meta-analysis showed greater benefit from medication than psychotherapy (Bandelow 2015). 

Consider being thoughtful in prescribing SSRIs as some are more associated with sedation and others are more associated with activating side effects (Marken 2000, Santarsieri 2015). Per Dr. Sekar:

• Sertraline and Fluoxetine – More activating
• Paroxetine and Citalopram – More sedating 

There is not a huge amount of class difference in SSRIs for anxiety (Craske 2016).  The Mayo Clinic Shared Decision Making Tool (for depression, but also useful for SSRI/SNRI use in all conditions) is a helpful way to review side effects and engage in shared decision making about drug choice, per Dr. Williams. Choosing medication with the patient is a way to build the patient-provider relationship and give the patient ownership over their management of this condition. 

Dr. Sekar recommends starting the patient at the lowest dose possible; generally speaking, SSRIs in anxiety disorders are started at approximately half the dose that would be used for depression (Metzler 2016, Craske 2016). If a medication has worked for a family member, there is some indication that it may be helpful for relatives (Kovacs 2014). 

Setting up for Success

Counsel patients that there will be a trial period. Efficacy for SSRIs and SNRIs can take up to 6 weeks for treatment effect (Stein 2015).

If symptoms are severe and the patient is unable  to wait for the SSRI to be fully effective, consider offering patients hydroxyzine or buspirone bridging (Dr. Sekar’s Expert Opinion). Hydroxyzine may be added as a PRN. Per Dr. Sekar, patients start to see the effects of this a bit sooner than SSRI. Hydroxyzine (prescribed at nighttime) is helpful for younger patients with insomnia, per Dr. Williams. 

Buspirone is generally prescribed 2x a day and this can give patients a sense of control during their initiation of SSRI as well, per Dr. Sekar.  Buspirone can sometimes come with orthostatic symptoms, so if a patient may be susceptible to those side effects (female gender, low BMI) consider a lower starting dose (5mg BID), per Dr. Sekar. An intermediate dose would be 10-15mg BID.  Patients who do not have higher than normal risk for orthostasis could be started on an initial dose of 15mg BID. 

Gabapentin or pregabalin can be considered as bridging agents if there are complaints of neuropathic pain or insomnia in addition to anxiety (Berlin 2015). If a patient has IBS or GI symptoms, consider an SNRI (Lacy 2009). Venlafaxine is short-acting, so if the patient is very sensitive to the medication and not taking at same time/missing dose, this may not be the best choice. Dr. Sekar prefers venlafaxine to duloxetine, as there is some data that it is more effective for anxiety symptoms than duloxetine. 

It is important to counsel patients about side effects for any medications. GI symptoms and sexual side effects are common in SSRI/SNRIs usage (Marken 2000, Santarsieri 2015) and should be discussed during initial visit. 

Follow-up on Medications and Troubleshooting

Dr. Sekar likes to check in with patients at about 4 weeks (although she offers patients to reach out if they’re having side effects) to ensure progress.  

Options for patients who experience severe sexual side effects (anorgasmia, etc) include buspirone alone or addition of bupropion, per Dr. Sekar.  It would not be prudent to start bupropion initially for GAD, as it is associated with anxiety symptoms, but can be added (consider a 75 mg IR daily test dose for one week, before uptitrating to 150 XL) as adjcuntive for mitigating sexual side effects in Dr. Sekar’s expert opinion. There is some evidence this strategy may work in depression (Jing 2016).  If a patient reports mental fogginess, Dr. Sekar recommends switching to nighttime dosing. 

Standard treatment time is approximately 1 year (Craske 2016).  These medications do not cause dependence (Haddad 1999) and patients may be tapered off if they would like.  Patients receiving CBT or undergoing therapy are less likely to relapse (White 2013). 

Escitalopram, venlafaxine, should be tapered slowly because they are shorter-acting, per Dr. Sekar. Dr. Sekar recommends asking patients about missed doses and how that impacts their symptoms. If they notice symptoms, that is a flag to do a very slow taper.  Venlafaxine can be as slow as increments every 2 weeks. Longer-acting SSRI can be tapered more quickly, at a rate of 1/2 dose every week, per Dr. Sekar. 

Atypical antipsychotics are not a first-line treatment due to poor tolerability, and most are not FDA approved for this indication (Garankani 2020). For Dr. Sekar, a patient failing SSRI or SNRI and you are considering atypical antipsychotics, it is a flag to involve patients with psychiatry.  Other causes for referrals include exhausting options (ie: 1-2 trials of SSRI/SNRI without benefit) or worsening psychiatric symptoms (De Martini 2019).

Benzodiazepines should not be prescribed if there is a history of any substance use per Dr. Sekar. Dr. Sekar prefers hydroxyzine with a beta blocker for panic disorder over benzodiazepine usage.

Take Home Point:  Be a listener! Listen to patients and what they hope to get out of treating their anxiety disorder, as well as to better understand why they have anxiety.

Links

1. American Dirt (book)
2. Notes from a Young Black Chef (book)

Goal

Listeners will develop a framework to approach the screening, diagnosis, and treatment for generalized anxiety disorder in primary care.

Learning objectives

After listening to this episode listeners will…  

1. Be able to develop a diagnostic framework for generalized anxiety disorder (GAD).
2. Build a strategy for initial patient discussions of anxiety disorders and guide patients about non-pharmacologic options such as therapy, mindfulness, and relaxation techniques. 
3. Confidently prescribe, monitor, and taper pharmaceutical agents for GAD.

Disclosures

Dr. Sekar reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Citation

Garbitelli EC, Sekar D, Williams PN, Watto MF. “#334 Generalized Anxiety Disorder”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. May 16, 2021.