City Health Information
Volume 33 (2014) New York City Department of Health and Mental Hygiene No. 1; 1-8
 

IN THIS ISSUE

 

Diagnosing and Managing the Mental Health
Needs of Adults Exposed to Disaster
  • Educate patients about physical and emotional symptoms of normal stress reactions.
  • Ask patients about their exposure and reactions to disaster.
  • Identify patients who may have posttraumatic stress disorder, depression, generalized anxiety disorder, or a substance use disorder and use standard screening tools for further evaluation.
  • Encourage patients to take advantage of psychotherapy, pharmacotherapy, or both.

 

GENERALIZED ANXIETY DISORDER

Generalized anxiety disorder is characterized by persistent, excessive, and uncontrollable worry and anxiety about daily life and routine activities. The anxiety and worry are associated with at least 3 of the following 6 symptoms, with at least some symptoms present for more days than not during the past 6 months: feeling restless, keyed up, or on edge; being easily fatigued; having difficulty concentrating or mind going blank; irritability; muscle tension; and sleep disturbance. Patients suffering from generalized anxiety disorder may consistently expect the worst and experience physical symptoms of anxiety, including myalgias, trembling, jumpiness, headache, dysphagia, gastrointestinal discomfort, diarrhea, sweating, hot flashes, and feeling lightheaded and breathless (27,28). Patients with anxiety disorders are more likely to seek treatment from a primary care physician than from a psychiatrist, so it is important to be alert to possible manifestations of anxiety (27).

Screening

Screening includes assessing symptoms of generalized anxiety disorder, level of functional impairment, and presence of comorbid psychiatric conditions. If you suspect generalized anxiety disorder, use the GAD-7 assessment tool (29) to help confirm the diagnosis (Resources—City Health Information: World Trade Center).

Differential Diagnosis (27)

Rule out other possible causes for the symptoms before beginning any form of treatment. Anxiety may be caused by hyperthyroidism, Cushing's disease, and arrhythmias, among other disorders. Medications such as steroids, over-the-counter sympathomimetics, SSRIs, digoxin, thyroxine, and theophylline, as well as alcohol, caffeine, nicotine, and cocaine and other illicit drugs (whether during intoxication or withdrawal), can also cause or exacerbate anxiety symptoms.

Treatment

Treatment involves psychotherapy, pharmacotherapy (Box 5), or both (27). The short-term treatment goal is to rapidly reduce symptoms and overwhelming anxiety; long-term goals include full recovery, relapse prevention, and management of any comorbid disorders. Consider pharmacotherapy for patients whose anxiety affects their daily functioning (27).

Psychotherapy (28,30). Psychotherapy is most effective when used in combination with pharmacotherapy, but psychotherapy alone can be used as the initial treatment for patients with mild generalized anxiety disorder.

Treatment approaches include

  • cognitive-behavioral therapy to focus on the relationships among thoughts, feelings, and behaviors and modify unhealthy and harmful patterns and relations,
  • behavioral therapy to modify the patient's behavior,
  • cognitive therapy to change unproductive and harmful thought patterns,
  • psychodynamic therapy to identify and resolve internal conflicts,
  • relaxation therapy to develop techniques to deal effectively with stress.
BOX 5. PHARMACOTHERAPY FOR GENERALIZED ANXIETY DISORDER

Several antidepressants, escitalopram (Lexapro®), paroxetine (Paxil®), and venlafaxine (Effexor®), are approved by the FDA for the treatment of generalized anxiety disorder. If the patient needs prompt symptom relief, consider prescribing an anxiolytic (benzodiazepine)* such as prazolam (Xanax®), diazepam (Valium®), chlorazepate (Tranxene®), lorazepam (Ativan®), clonazepam (Klonopin®), or oxazepam (Serax®).


* Benzodiazepines have the potential for abuse and dependence when used for more than several weeks. Benzodiazepines are fairly well tolerated by young to middle-aged adults, but they should be prescribed with great caution for elderly patients, especially those aged 75 and older, due to adverse reactions, drug-drug interactions, potential for toxic drug levels, and greater sensitivity to drugs affecting the brain. The sedative effect on the elderly sometimes results in poor concentration, lethargy, mental clouding, and confusion, sometimes misdiagnosed as dementia.

PDF version of Box 5

 

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