What doctors wish patients knew about managing anxiety disorders

Anxiety is a shared human experience. For instance, the prospect of speaking in front of a large group of people or taking a test can trigger anxiety. Yet this unease can also serve as a catalyst for diligent preparation and rehearsal. But if feelings of extreme fear and turmoil become overpowering and hinder routine activities, this may indicate an underlying anxiety disorder.

In the U.S., the lifetime prevalence of anxiety disorders in adults is 26.4% for men and 40.4% for women. During pregnancy, generalized anxiety disorder has a prevalence of up to 10.5% and in the postpartum period, it is up to 10.8%. And while anxiety disorders typically begin in childhood and early adulthood, symptoms appear to decline with age. With that, the U.S. Preventive Services Task Force (USPSTF) recommends that physicians screen for anxiety disorders in all adults up to 65, including people who are pregnant have just given birth, according to the task force’s statement published in JAMA^®.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

For this installment, two psychiatrists took time to discuss what patients need to know about recognizing and managing anxiety disorders. They are:

• Nicolas Fletcher, MD, a psychiatry resident at Authority Health in Detroit and an American Psychiatric Association board member. He is also an AMA Resident and Fellow Section delegate representing the Michigan State Medical Society in the AMA House of Delegates.
• Sandra Swantek, MD, a geriatric psychiatrist in Chicago, and an alternate delegate in the House of Delegates representing the American Association for Geriatric Psychiatry (AAGP) and the president-elect of the AAGP.

“Everyone at some point or another in their life has anxiety or stress. It’s a normal part of our daily living. When we begin to consider it a disease or an illness is when that anxiety is interfering with a person’s everyday functioning,” Dr. Swantek said, noting “they’re having trouble leaving the house, they’re having trouble getting work done, participating in the activities they would normally want to participate. 

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“About one-third of Americans suffer at some point in their lives with anxiety and potentially an anxiety disorder,” Dr. Fletcher said. “There are about 12% to 15% of people who have been diagnosed with anxiety, but then at the top end of that we’re looking at 25% or more people who have been diagnosed with an anxiety disorder.”

“When we start talking about different age groups, that’s where we start breaking down the different types of anxiety disorders,” he said. “We think of separation anxiety usually with infants and toddlers, but if you’re a 10-year-old who can’t stand to be away from Mom or Dad and have these physical symptoms of acting out or feeling threatened because they’re no longer close to mom and dad, that’s something you want to look at as an anxiety disorder.”

“You can also have social anxiety at 14 or 15. Obsessive-compulsive disorder—another anxiety disorder—usually starts to come out around young adulthood because people start to leave the nest and now you’re looking for some type of way to control your environment that you may have had when you were at home—which was stable—but now all of a sudden you’re on your own and you’re trying to figure out how to do that,” Dr. Fletcher said.

Additionally, as another type of anxiety disorder, “panic disorders usually come around as well in young adulthood and then you have generalized anxiety usually around your 30s as well,” he said. “These are all average ages, so there’s overlap too.”

“If you are irritable as the result of the anxiety and that irritability is affecting important relationships either at home or work, that’s a target to treat because it’s interfering,” Dr. Swantek said. “There are many people who don’t recognize that significant worry, irritability, emotional liability, and procrastination are symptoms of an anxiety disorder that is treatable.”

“These traits or characteristics can severely inhibit a person’s relationships or career and limit the anxious person’s personal happiness and success,” she added.

“An anxiety disorder often is not just an anxiety disorder. When untreated, it may progress to depression,” Dr. Swantek said. “Untreated anxiety has also been associated with elevated levels of cardiovascular disease, elevated blood pressure—and other medical conditions.”

Additionally, “pain is worsened in the presence of anxiety,” she said. It’s important for people with chronic medical problems and anxiety to receive proper treatment because without treatment, the concurrent medical problems can get worse.”

“The other risk for untreated anxiety is that people find unhealthy ways to manage their anxiety. That might be through tobacco use or cannabis use, alcohol, opiates, overuse of pain medicines,” Dr. Swantek said. “And when sleeplessness is one of the symptoms of the anxiety disorder, that can lead to people seeking benzodiazepines and other sleep medications that are not helpful for long-term use.”

“Benzodiazepines or the ‘Z’ drugs such as zolpidem may be acceptable treatments for a few nights, but these drugs lose efficacy over time and come with risk factors for dependency and for older adults, increase the risk of fall, delirium and confusion,” she said.

“There are a number of different ways to diagnose anxiety,” Dr. Swantek noted. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), published by the American Psychiatric Association “lists diagnostic criteria” and is often consulted by psychiatrists.

Primary care physicians are most likely to use the Generalized Anxiety Disorder Scale (GAD-7), which is a seven-item survey and “a very easy tool to implement.”

Additionally, with the USPSTF now “recommending screening adults 19 to 65 for anxiety disorders, it is suggested that the GAD-7 be done on an annual basis,” she said. And while “the recommendation is ages 19 to 65, older adults develop anxiety as well. Some have it from childhood or adulthood, and some are developing it for the first time later in life.”

For adults 66 or older, “there are several tools that may be used to assess anxiety. There’s an abbreviated Penn State Worry Questionnaire, the Geriatric Anxiety inventory and the Adult Manifest Anxiety Scale or the Geriatric Anxiety Scale,” Dr. Swantek said. “All of these are self-administered.”

“First and foremost, before the symptoms even occur, patients should try to think about what situations are bringing on the symptoms,” Dr. Fletcher said. “For instance, on the GAD-7 evaluation you ask: Are you nervous, anxious or on edge?

“But a better question is: Do you find yourself avoiding certain situations? Do you find yourself avoiding going places?” he added. “That can tell you if it is specifically that you don’t want to go to the store or if it’s because you’re afraid of spiders or something like that.”

“Anxiety is normal. Anxiety is a part of getting ready for an intense situation sometimes,” Dr. Fletcher said. “But when you find yourself avoiding situations, it’s impacting your relationships with people and you’re avoiding things that you need to do to be functional and successful and move through life in a positive way—all these things are signs that it’s probably time for you to get some help.”

“Ultimately, we do the best we can to protect ourselves. It doesn’t matter what it is, whether it’s anxiety or depression or anything else, we do the best with what we have and sometimes it’s not enough and that’s when you need to ask for help,” he said.

“Before a person seeks medication, I strongly encourage them to try nonpharmacologic interventions. What I regularly teach in my office—is deep breathing,” Dr. Swantek said. “There are a number of different methods, but it is basically deep, slow breath in through the nose in a five-three-eight pattern.

“So, a deep breath in for five counts, holding that breath for three and then exhaling for at least eight counts,” she added, noting that she encourages patients with anxiety disorder to do this at least three times daily—and even more often during an anxiety episode or “if they’re having trouble going to sleep.”

“That’s the simplest intervention possible and activates the parasympathetic nervous system, which is essentially our own personal chill pill,” Dr. Swantek said. “That’s why it’s such a good intervention—you’re literally mustering up your own body’s calming reflex.”

“Rhythmic, aerobic exercise of moderate to low intensity, such as walking or jogging for 15 to 30 minutes at least three times weekly is associated with reduced anxiety,” Dr. Swantek said. “Other activities such as tai chi, yoga or meditation regularly accomplished can also help control anxiety."

“Really, just about any regular physical activity—whether it’s bike riding, dancing, running or just walking—help reduce anxiety,” she said.

“When anxiety is truly interfering with daily activities or what you need to do, it’s time to seek professional help,” Dr. Swantek said. “Professional help does not always involve medication. In fact, I encourage people to avoid medication until they’ve made a good trial of cognitive behavioral therapy, which is our No. 1 psychotherapeutic tool for managing anxiety.”

“If that is still not successful, then we think about using medications like a serotonin reuptake inhibitor. Notice I’m not saying benzodiazepine,” she said. “A serotonin reuptake inhibitor is the psychiatrist’s No. 1 choice for treating anxiety as well as depression because they have fewer side effects and no risk of the misuse and dependency associated with benzodiazepines.

“For older adults, those risks are compounded by the increased risk of confusion, fall and delirium with benzodiazepines,” Dr. Swantek added.

“You didn’t get here overnight. Whatever you’ve been going through is something you’ve probably been dealing with for quite some time and it’s only now that you’re here,” Dr. Fletcher said. “With that in mind, I don’t have a pill or anything that’s going to fix it overnight.”

In fact, “there are some studies that show even with medication, it can take anywhere from six months to two years before you’re able to really be able to live a better life with your anxiety,” he said. “Because what has happened is over that time period you have learned what it is about the anxiety that leads it into a disorder. You’re essentially getting a better understanding of yourself and what your triggers are.”