Anxiety

Overview

Definition

Generalized anxiety disorder recognized by DSM-IV, a chronic psychiatric condition of excessive worry or fear, is distinct from anxiety related to depression, medications, or other causes. Symptoms typically begin in the teens or twenties and, while persisting, tend to fluctuate considerably over time. The condition occurs in up to 5% to 15% of general medical outpatients, more commonly in women. Significant adjustments can be noted in motor tension, autonomic hyperactivity, and hypervigilance.

Etiology

Anxiety may result from medications or drugs, medical conditions, or specific life situations. Generalized anxiety not associated with any specific physiological cause is poorly understood. Genetic or neurochemical factors may play a role, possibly along with behavioral and developmental factors.

Risk Factors

· Traumatic early life experiences

· Anxious mother

· Stress, depression, other psychiatric conditions

· Life situations (social or financial problems)

Signs and Symptoms

· Muscle tension

· Tachycardia

· Hypervigilance

· Dyspnea

· Dizziness/near-syncope

· Palpitations

· Trembling

· Sweating

· Feelings of unreality

· Fatigue

· Impaired concentration

· Irritability

· Excessive worry/sense of impending doom

· Sighing respiration

· Sleep disturbances

Differential Diagnosis

· Situation-related anxiety

· Adjustment disorder with anxiety

· Phobic anxiety

· Panic disorder

· Depression with anxiety

· Post--traumatic stress disorder

· Medical conditions that may cause or contribute to anxiety, including angina pectoris, cardiac arrhythmias, asthma, congestive heart failure, limbic lobe epilepsy, hyperthyroidism, hypoglycemia, valvular heart disease, nutritional deficiencies

· Anxiety caused by medications, including psychostimulants, sympathomimetic agents, theophylline, and indomethacin

· Caffeine, alcohol, or cocaine use

Diagnosis

Physical Examination

The patient may appear nervous, irritable, or tense. With generalized anxiety disorder, there will be no specific findings on physical exam.

Laboratory Tests

To rule out other conditions, test thyroid function and calcium levels. Use a general laboratory screen if the patient has physical symptoms. Laboratory findings are negative in cases of generalized anxiety disorder.

Other Diagnostic Procedures

Conduct a detailed medical history, focusing on substance use, and life stresses. The DSM-IV states six diagnostic criteria, which are listed below.

· Excessive anxiety and worry occurring more often than not for months

· Patient cannot control the worry.

· Anxiety is associated with at least three of the following six symptoms for 6 months: restlessness; fatigue; difficulty concentrating; irritability; muscle tension; and sleep disturbance

· The focus of the anxiety is not confined to features of other Axis I disorders (panic disorder, social phobia, separation anxiety disorder, anorexia nervosa, etc.).

· The anxiety or symptoms cause significant distress or impairment in social, occupational, or other functioning.

· The anxiety is not due to direct effects of a substance or a medical condition and does not occur exclusively with a mood disorder, psychotic disorder, or pervasive developmental disorder.

Having the patient hyperventilate may reproduce the symptoms and differentiate the disorder from cardiac and neurologic conditions.

· Special tests: EEG for patients over 40 to rule out other conditions; EEG for patients with prominent episodic neurological symptoms

Treatment Options

Treatment Strategy

If no specific known etiology, treatment focuses on eliminating or reducing the symptoms. Except in severe cases, counseling and relaxation therapies may be tried first, with pharmacologic therapy used as needed.

· Short-term counseling can assist the patient in restoring self-esteem, problem solving, and coping with life stresses.

· Patients can be instructed in self-treating techniques to control anxiety; many patients require no pharmacological treatment and succeed with self-regulation techniques, including deep breathing.

· If symptoms of hypervigilance, autonomic hyperactivity, and muscle tension persist, a short course of therapeutics may be helpful—even necessary—while the patient undergoes counseling and learns self--control techniques.

Drug Therapies

Benzodiazepines depress subcortical levels of the CNS; side effects include dizziness or drowsiness, constipation or nausea and vomiting, EEG changes, and orthostatic hypotension; contraindicated with narrow-angle glaucoma, psychosis, or pregnancy. Some benzodiazepines, which should be used for one to two months as needed, are listed below.

· Alprazolam (Xanax), 0.25 to 1 mg

· Chlordiazepoxide (Librium), 5 to 25 mg

· Clonazepam (Klonopin), 3.75 to 22.5 mg

· Clorazepate dipotassium (Tranxene), 3.75 to 22.5 mg

· Diazepam (Valium), 2 to 15 mg

· Halazepam (Paxipam), 20 to 40 mg

· Lorazepam (Ativan), 0.5 to 2 mg

· Oxazepam (Serax), 10 to 30 mg

· Prazepam (Centrax), 5 to 10 mg

· Hydroxyzine (Vistaril, Atarax), 10 to 25 mg as needed, may be used for a patient at risk of abusing a benzodiazepine; side effects include dizziness or drowsiness, dry mouth; contraindicated in pregnancy.

· A tricyclic antidepressant may be used for a patient with persistent cognitive symptoms of apprehension. It inhibits the action of serotonin. Side effects include dizziness, headache, stimulation, insomnia, nervousness, numbness, incoordination, tremors, nausea, diarrhea, constipation, tachycardia, palpitations, sore throat, tinnitus, blurred vision, and muscle pain or weakness. Some tricyclic antidepressants are listed below.

· Buspirone (Buspar), 5 to 10 mg

· Imipramine, 10 mg

· Nortriptyline, 10 mg

Complementary and Alternative Therapies

Supporting the nervous system with mind-body techniques, nutrition, and herbs may be an effective way to minimize and resolve anxiety. Progressive muscle relaxation, diaphragmatic breathing, biofeedback, meditation, and self-hypnosis can help induce the relaxation response and alleviate anxiety.

Nutrition

Avoid caffeine, alcohol, sugar, refined foods, and all known food allergens. Fresh vegetables, whole grains, and protein nourish the nervous system. Calcium (1,000 mg/day), magnesium (400 to 600 mg/day), and B-complex (50 to 100 mg/day) help support the nervous system and minimize the effects of stress.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted. A tea (3 to 4 cups/day) or tincture (10 to 20 drops four to six times/day) from the following herbs will help to reduce anxiety and strengthen the nervous system.

· Kava kava (Piper methysticum) for mild to moderate anxiety.

· St. John's wort (Hypericum perforatum) for anxiety associated with depression.

· Passionflower (Passiflora incarnata) for anxiety with insomnia.

· Oatstraw (Avena sativa) nourishes the nervous system.

· Lemon balm (Melissa officinalis) for anxiety with depression and heart palpitations.

· Lavender (Lavandula angustifolia) for nervous exhaustion and restoring the nervous system.

· Skullcap (Scutellaria lateriflora) relaxes and revitalizes the nervous system.

Kava kava (100 to 200 mg bid to qid) and St. John's wort (300 mg bid to tid) may be taken as dried extracts to maximize effectiveness in moderate anxiety.

Essential oils of lemon balm, bergamot, and jasmine are calming and may be used as aromatherapy. Place several drops in a warm bath, atomizer, or cotton ball.

Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

· Aconite for anxiety with palpitations, shortness of breath, and fear of death

· Arsenicum album for anxiety with restlessness, especially after midnight

· Phosphorus for anxiety when alone and fear that something bad will happen

Acupuncture

Acupuncture can be very effective in reducing anxiety.

Massage

Therapeutic massage can be very effective in reducing anxiety and alleviating stress.

Patient Monitoring

Patients learning self-regulatory techniques generally require multiple training sessions and periodic follow-up to ensure the technique is successful. Patients using benzodiazepines are not likely to experience tolerance, but physical and psychological dependence may occur with higher doses used frequently. Monitor the patient for signs of dependence or abuse; discontinuation requires tapering to prevent withdrawal symptoms.

Other Considerations

Hormonal balancing for cyclic anxiety

Prevention

· Caffeine can produce or aggravate symptoms

· Avoid stimulants

· Avoid refined sugar--containing foods

· Daily exercise helps prevent or reduce anxiety symptoms

Complications/Sequelae

The condition of the patient with anxiety is often complicated with other psychiatric or behavioral problems. The treatment of underlying or associated conditions is necessary along with symptomatic relief of anxiety. Anxiety in many patients may be complicated by substance abuse or dependence.

Prognosis

Variable prognosis: milder disorders may resolve with self-regulation treatment; more severe conditions may continue and become chronic or become a relapsing-remitting pattern. Psychotherapy may be necessary if other techniques fail or as an adjunct to other therapies for symptom relief. For patients on drug therapy, attempt gradual withdrawal every three to six months; in some cases a chronic maintenance dose may be required.

Pregnancy

Care should be taken in prescribing certain drugs, listed below, for the pregnant patient.

· Benzodiazepines contraindicated (U.S. FDA safety category D)

· Hydroxyzine contraindicated (U.S. FDA safety category C)

· Buspirone with precaution (U.S. FDA safety category B)

· Imipramine and nortriptyline with precaution (U.S. FDA safety category C)

· While the herbal tea earlier described is safe in pregnancy, the dried extracts of kava kava and St. John's wort should be avoided.

---------------------------------------------------------------

References

· American Council on Collaborative Medicine. Dr. Victor Bagnall's Nutritional Therapy. Accessed at: www.nutrimed.com/anxiety.htm on December 2, 1998.

· American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

· Andreoli TE, Bennett JC, Carpenter CCJ. Cecil Essentials of Medicine. 3rd ed. Philadelphia, Pa: WB Saunders; 1993.

· Barker LR, Burton JR, Zieve PD, eds. Principles of Ambulatory Medicine. 4th ed. Baltimore, Md: Williams & Wilkins; 1995:139-154.

· Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:422, 463-464.

· Dr. Bower's Complementary and Alternative Medicine Home Page. Available at: www.avery.med.virginia.edu/~pjb3s.

· Goldberg RJ. Anxiety reduction by self-regulation: theory, practice, and evaluation. Ann Intern Med. 1982;96:483.

· Health and Healing News. Accessed at: www.hhnews.com/kava_update.htm on December 2, 1998.

· Herbal Alternatives. Accessed at: www.herbalalternatives.com/kava.htm on December 2, 1998.

· Jussofie A, Schmiz A, Hiernke C. Kavapyrone enriched extract from Piper methysticum as modulator of the GABA binding site in different regions of the rat brain. Psychopharmacology. 1994;116:469-474.

· Kinzler E, Kromer J, Lehmann E. Effect of a special kava extract in patients with anxiety-, tension-, and excitation states of non-psychotic genesis. Double blind study with placebos over four weeks [in German]. Arzneimforsch. 1991;41:584-588.

· Lehmann E, et al. Efficacy of special kava extract (Piper methysticum) in patients with states of anxiety, tension and excitedness of non-mental origin: a double blind placebo controlled study of four weeks treatment. Phytomedicine. 1996;3:113-119.

· Lindenberg Von D, Pitule-Schodel H. D, L-Kavain in comparison with oxazepam in anxiety states. Double-blind clinical trial. Forschr Med. 1990;108:50-54.

· Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993:4, 40, 293.

· Stein JH, ed. Internal Medicine. 4th ed. St. Louis, Mo: Mosby-Year Book; 1994.

· Volz HP, Kieser M. Kava kava extract WS 1490 versus placebo in anxiety disorders—a randomized placebo controlled 25 week outpatient trial. Pharmacopsychiatry. 1997;30:1-5.

Anorexia Nervosa

Overview

Definition

An emotional disorder characterized by severe and potentially life-threatening weight loss through self-induced reduction in total food intake. More than 90% of reported cases occur in women in industrialized countries where thin bodies are considered attractive, though anorexia now occurs in a growing number of men. Although seldom appearing prior to puberty, associated mental disturbances are usually more severe when it does. Mean onset is 17 years; it rarely begins after age 40; onset is often associated with a stressful event; prevalence is 0.5% to 1.0% when full diagnostic criteria are met—higher for subthreshold diagnosis (Eating Disorders Not Otherwise Specified). Death may result—usually caused by starvation, suicide, heart failure, or electrolyte imbalance.

Two subtypes:

· Restricting Type: Dieting, fasting, or excessive exercise

· Binge-Eating/Purging Type: Regular binge-eating, and/or purging by self-induced vomiting and/or misuse of laxatives, enemas, and/or diuretics. Binge-eating may not occur; purging is common even after small amounts of food have been eaten.

Full diagnostic criteria:

· Refusal to maintain minimum body weight for age and height

· Unrealistic fear of weight gain

· Distorted perception of personal body shape and/or size; denial of seriousness of low body weight

· Amenorrhea

Etiology

· Psychopathological fear of biological and psychological maturity

· Severe trauma during puberty or pre-puberty (death of a loved one; sexual abuse)

· Abnormalities with neurotransmitters (dopamine, serotonin, norepinephrine, and endogenous opioids)

Risk Factors

· Heredity in 20% of cases compared to 6% in other psychiatric illnesses. Incidence higher among first-degree relatives (2% to 10% among mothers and sisters of anorectic women); and monozygotic twins (9 of 16) as opposed to dizygotic twins (1 of 14)

· Co-morbid depression in most patients

· Obsessive-compulsive and/or sensitive-avoidant personalities more vulnerable

· Significant increase in risk among normal dieters

· Societal attitudes place some individuals at higher risk (e.g., dancers, runners, models, jockeys, wrestlers, actresses/actors)

Signs and Symptoms

· Significant weight loss, or emaciation

· Depressive symptoms (depression, social withdrawal, irritability, insomnia, diminished sex drive)

· Obsessive-compulsive behavior related to eating or other activities

· Denial

· Distorted perception of physical self

· Preoccupation with body size, image, weight control

· Preoccupation with food (collecting recipes; hoarding food)

· Reluctance to eat in public

· Feelings of ineffectiveness

· Excessive need to control personal environment

· Rigid thinking

· Limited social spontaneity

· Excessively restrained initiative and emotional expression

Differential Diagnosis

· Physical disorders

· Tumors

· Bulimia

· Superior Mesenteric Artery Syndrome

· Major Depressive Disorder

· Schizophrenia

· Social Phobia

· Obsessive-Compulsive Disorder

· Body Dysmorphic Disorder

Diagnosis

Physical Examination

· Substantial weight loss unexplainable medically

· Emaciation

· Hypothermia

· Hypotension

· Hypocaratenemia

· Constipation

· Abdominal pain

· Cold intolerance

· Lethargy

· Excess energy

· Lanugo on trunk

· Brachycardia

· Eroded tooth enamel (from vomiting)

· Scars/calluses on dorsum of hand (from teeth during induction of vomiting)

· Dry skin, thinning hair

Laboratory Tests

Abnormal findings are primarily due to starvation:

· Hematology: leukopenia, mild anemia and—rarely—thrombocytopenia

· Chemistry: dehydration, hypercholesterolemia, elevated liver function tests, metabolic alkalosis, hypochloremia, hypokalemia, metabolic acidosis, low levels of serum thyroxine and triiodothyronine, hyperadrenocorticism, and low serum estrogen/testosterone

· Electrocardiography: sinus bradycardia and arrhythmias

· Electroencephalography: abnormalities caused by fluid and electrolyte disturbances

· Resting energy expenditure: may be significantly reduced

Pathology/Pathophysiology

· Hypotension and bradycardia

· Peripheral edema

Other Diagnostic Procedures

Evaluation of signs and symptoms after eliminating depressive disorders and/or medical conditions as primary

Treatment Options

Treatment Strategy

Treatment is lengthy and challenging; relapse is common and preoccupation with dieting and weight usually continues. The greater the time between symptom onset and treatment commencement, and/or presence of personality disorders, the less likelihood of success. Controlling the fear of abnormal body weight and relieving feeding anxiety must be central and awareness of potential medical risks is important. Treatment must be tailored to the individual as integrated treatment is most beneficial. Patients are at greater risk of osteoporosis and lifelong problems with depression/anxiety. Many patients with anorexia may be quite accomplished at carrying extra weight on their bodies when being weighed and are addicted to the heightened sensations of starvation. Support groups may actually be damaging if the patient is competitive and attends groups to get ideas on deceiving care givers. Other general treatment strategies may include the following.

· Cognitive-behavioral/educational approaches—psychoeducational principles focusing on personal, inter-relational, and social conflicts; fears/misconceptions about eating; supervised exercise programs; body image therapy

· Psychodynamic, feminist, and family approaches—self-psychological methods; consultation and therapeutic engagement; family therapy

· Special issues—managing medical/comorbid medical consequences and/or substance abuse/dependence; traumas and/or sexual abuse; refusal of treatment; group psychotherapy; self-help

· Inpatient and/or partial hospitalization in severe cases

Drug Therapies

Antidepressants appear to be helpful only after intensive psychotherapy, attainment of normal weight, and development of good eating patterns.

Complementary and Alternative Therapies

Alternative therapies may be especially helpful in patients who have fixated on avoiding anything "artificial." Treatment is long with frequent setbacks. Herbs can be effective in both calming anxiety and stimulating digestion. "Systematic desensitization" through muscle relaxation with visual imagery can be helpful.

Nutrition

· Zinc (15 mg/day increased to 50 mg bid)—may improve mood and appetite, may be most useful at increasing the accuracy of body image

· Protein supplements (1 to 3 servings a day)—will help insure sufficient amino acids and prevent wasting. Some protein supplements are low in calories, which may make the patient more willing to consider this therapy.

· Multivitamin—A well-rounded multivitamin will help to compensate for dietary deficiencies. Due to ease of assimilation, a vitamin made from whole food concentrates is more effective in eating disorders.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

· Goldenseal (Hydrastis canadensis): a strong digestive stimulant, and tonic to the digestive tract, is a specific to anorexia nervosa

· Condurango (Marsdenia condurango): alterative and digestive stimulant, where there is diminished appetite or dietary abuse is a specific to anorexia nervosa

· Licorice (Glycyrrhiza glabra): antidepressant effects, heals mucous membranes of the digestive tract, regulates cortisol release, modulates estrogen effects; contraindicated in hypertension, may cause peripheral edema (pseudoaldosteronism), which resolves when licorice is discontinued

· Wild yam (Dioscorea villosa): hormone balancing, antidepressant, supports adrenals, antispasmodic

· Valerian (Valeriana officinalis): sedative, digestive bitter, and appetite stimulant

· Lemon balm (Melissa officinalis): mild sedative, spasmolytic, may gently help regulate TSH and thyroid function

· Oatstraw (Avena sativa): nerve tonic, antidepressant, demulcent, historically used for general debility with nervous exhaustion; this herb is slow to start acting but long-lasting.

· St. John's Wort (Hypericum perforatum): restorative nervous system tonic specific in use in depression or anxiety states that have led to fatigue and adrenal exhaustion

· Fenugreek (Trigonella foenum-graecum): nutritive and digestive tonic used where there is digestive debility and poor nutrition; traditionally used in muscle wasting states or where there is great weight loss; saw palmetto can be used as an alternative to fenugreek.

· Saw palmetto (Serenoa repens, Sabal serrulata): digestive tonic and connective tissue rebuilder; traditionally used to prevent muscle wasting and general debility

· Siberian ginseng (Eleutherococcus senticosus): a supportive adaptogen used to improve vitality and stamina

Homeopathy

Acute homeopathics may be helpful during acute illness. For appropriate constitutional prescribing, which can be helpful, consult a homeopath.

Acupuncture

May be helpful in restoring energy and reducing stress.

Massage

May be helpful if patient is willing to be touched. Essential oils (lavender, rosemary, verbena) can be added to the massage to increase its effect.

Patient Monitoring

· Long-term monitoring and support is necessary, particularly in severe cases. Prognosis deteriorates significantly without long-term follow-up care.

· Follow daily activity patterns, rituals

Other Considerations

· Intravenous nutritional supplements, multivitamins, and potassium may be necessary in severe cases.

· Because the disorder is primarily psychological and not simply appetite loss, psychotherapy is usually necessary to establish normal eating patterns.

· Seek professional care from specialists in eating disorders

Prevention

· Education about serious related medical problems

· Intervention programs

· Developing skills to cope with social fixation on thinness and dieting

· Sufficient zinc intake/absorption

Complications/Sequelae

· See Laboratory subhead

· Starved patients have greater sensitivity to medications in general

· Cardiac arrhythmia and arrest

· Necrotizing colitis

· Hypokalemia

Prognosis

· Prognosis is variable

· Long-term (4 to 30 years) mortality rate is more than 10%

· Manifestation in early adolescence usually indicates a more optimistic prognosis.

· Long-term studies show 50% to 70% of patients are no longer clinically anorectic but many (presumably those doing the poorest) drop out; 25% show poor outcomes and chronic illness; and, in a given 10-year period, 5% die—usually from complications, suicide, or cardiac arrest.

Pregnancy

Possible problems include:

· Difficulty conceiving/carrying to term

· Miscarriage

· Parental malnourishment as fetus grows, particularly calcium

· Exacerbation of medical complications

· Retarded, slow, weaker, and smaller offspring at risk of inheriting the disorder

· Stress of pregnancy and/or parenthood may trigger a relapse

----------------------------------------------------------------------------

References

· American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

· Balch JF, Balch PA. Prescription for Nutritional Healing. 2nd ed. Garden City Park, NY: Avery Publishing Group; 1997.

· Garner DM, Garfinkel PE, eds. Handbook of Treatment for Eating Disorders. 2nd ed. New York, NY: The Guilford Press; 1997.

· The Harvard Mental Health Letter. October & November, 1997.

· Kalasky KL, ed. The Alternative Health & Medicine Encyclopedia. 2nd ed. Detroit, Mich: Gale Research; 1998.

· Kaplan AS, Garfinkel PE, eds. Medical Issues and the Eating Disorders—The Interface. New York, NY: Brunner/Mazel Publishers; 1993.

· Shils ME, Olson JA, Shike M, ed. Modern Nutrition in Health and Disease. 8th ed. Philadelphia, Pa: Lea & Febiger; 1994:2.

· Werbach MR. Nutritional Influences on Illness. New Canaan, Conn: Keats Publishing Inc; 1987.