Anxiety
W. Ali H. MD Medicine (I), Roberta A. Lee, MD
Overview: Anxiety
Anxiety disorders are one of the most commonly encountered medical conditions in primary care.
According to the National Institute of Mental Health, the 1-year prevalence rate is 18.1% of the population, or 40 million people.
Underdiagnosis is common; the average patient with an anxiety disorder consults 10 health care professionals before a definitive diagnosis is made.
Furthermore, patients who carry the diagnosis use primary care services three times as often as other patients.
In the past, when underdiagnosis was more common, patients received elaborate medical workups, but the definitive diagnosis remained elusive.
These patients became categorized as the “worried well.”
Nevertheless, because anxiety can be masked in numerous psychosomatic ways, practitioners must maintain a high index of suspicion for this disorder.
Important Points to Consider
Contrary to common belief, valerian is not suitable for acute treatment of anxiety or insomnia. A beneficial effect may take several weeks.
Although the pathophysiology of generalized anxiety disorder is multifactorial, the amygdala in the brain appears to be a focus for stressful memories that stimulate the autonomic nervous system when the body and mind perceive danger.
Both the length of the exercise session and the duration of the physical activity program seem important in maximizing the beneficial effect of exercise on anxiety reduction.
Medical Conditions Often Associated With Symptoms of Anxiety
Supplement and Drug Recommendations for Treatment of Anxiety
Prevention Prescription
Maximize nutrition to include foods rich in omega 3-fatty acids, B vitamins, and folic acid.
Follow a regular exercise routine (even walking and tracking use with a pedometer).
Institute a daily mind-body exercise program to enhance the relaxation response.
Keep a journal; take a “feeling inventory,” and enhance self-awareness.
Limit your use of personal digital assistants, cellphones, and BlackBerry devices. Do not access these devices during meals and special times with family and friends. Turn to “off ” at 10 am and “on” at 6 to 7 am, and do not recharge these devices right next to your bed!
Get enough sleep to feel refreshed.
Therapeutic Review
The following steps are recommended for initial management of patients with generalized anxiety disorder (GAD).
Remove exacerbating factors. Review current medications and supplements that could contribute to anxiety (especially botanical supplements such as ephedra and over-the-counter preparations that are stimulants). Supplements that are unnecessary should be discontinued.
Screen for diseases that mimic anxiety. Screening should be performed for underlying medical conditions that produce anxiety, for instance, hyperthyroidism or a withdrawal syndrome.
Improve nutrition. Nutritional support such as with omega-3 fatty acid supplementation (two to three servings of cold water fish per week, or flaxseed oil 2 tablespoons a day or 1000 mg of flaxseed oil in a capsule) is recommended. In addition, caffeine and alcohol consumption should be avoided.
Institute physical activity. Physical activity (aerobic or anaerobic) at least 5 days out of 7 should be encouraged. To ensure long-term compliance, an activity that is enjoyable to the patient is important.
Furthermore, adherence to a regular exercise regimen and setting realistic short-term goals may need emphasis.Increases in exercise level and intensity should be gradual.
Supplements
Vitamin B, included in a vitamin B 100 complex preparation.
Folic acid (400 mcg daily) should be considered.
5-Hydroxytryptophan (150 to 300 mg daily) could be considered as a serotonin boosting alternative, but close monitoring should be undertaken to screen for eosinophilia myalgia syndrome.
Botanicals
Kava, 50 to 70 mg three times a day (of the purified kava lactones), can be given.
Choose a standardized product with either a 30% or a 50% to 55% kava lactone concentration.
If no improvement is observed over 4 to 6 weeks, consider valerian or a valerian combination or a pharmaceutical anxiolytic (use for at least 6 weeks before evaluating efficacy).
Concurrent psychotherapy is highly recommended if this approach is acceptable to the patient.
Mind-Body Therapy Psychotherapy
The combination of psychotherapy in conjunction with supplements, botanicals, or a pharmaceutical anxiolytic or antidepressant is highly recommended, especially in GAD.
An integrative therapeutic approach is associated with higher success rates in cases of severe anxiety. Often, psychotherapy can provide the patient with skills for coping with anxiety, as opposed to extinguishing the symptoms.
Primary care physicians can monitor lifestyle modification, dietary and supplement interventions, and drug therapy.However, referral to a psychotherapist is advised.
Relaxation training: Educate the patient in relaxation techniques that will empower him or her to bring anxiety symptoms under control when needed.
Traditional Medical SystemsUse of traditional medicine systems (TMSs) is problematic in that TMSs have historically been used to provide primary care for a variety of medical ailments (including anxiety).
Allopathic physicians generally designate the use of TMSs as an adjunctive modality. However, for those patients who have strong feelings about the use of singular botanical preparations (mostly as being insufficient for treatment) or whose medical conditions appear mild, we are more than willing to be a medical partner and consider the use of a TMS (e.g., Chinese medicine or Ayurvedic medicine) as a primary therapeutic option, as long as the well-being of the patient is not in jeopardy.
PharmaceuticalsIf no improvement is obtained with lifestyle measures, dietary measures, and supplement interventions in conjunction with botanical supplements, use of a pharmaceutical anxiolytic or antidepressant should be considered.
Depending on the severity of the anxiety and the degree of lifestyle impairment, I often use a conventional prescriptive option with dietary and lifestyle interventions in combination with complementary therapy (e.g., acupuncture, mind-body therapy) to induce a sense of relaxation before the patient is weaned off the prescriptive treatment (often a couple of months later).
Depending on the severity of the disorder, I may introduce a botanical supplement (e.g., kava).Obviously, different clinical responses will be obtained with the various anxiolytics (and selective serotonin reuptake inhibitors).
Optimal management may require a change of medication, depending on the patient's symptoms. For long-term therapy, I refrain from the use of benzodiazepines because tolerance can be problematic.Consider referral to a psychiatrist if the patient remains refractory to treatment, is suicidal or psychotic, or requires psychiatric stabilization in a hospital unit.
Key Web Sources
Benson-Henry Institute for Mind Body Medicine. http://www. massgeneral.org/bhi/.
Mind and Life Institute. www.MindandLife.com.
Mindfulness-Based Stress Reduction (MBSR). www.umassmed.edu/ cfm.
Continuum Center for Health and Healing: Preparing for Surgery/ Learning Mind/Body Techniques. http://www.preparingforyour surgery.org/.
Shambhala. www.shambhala.org/.
Transcendental Meditation (TM) Program. www.tm.org/.
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