What would you teach MDs about anxiety disorders?

[cbrons]

What is the single most valuable thing you would teach MDs, particularly primary care physicians about an anxiety disorder (any of them)?

One I have heard is - in patients with hypochondriasis/illness anxiety disorder, ordering medical tests for the sole reason of allaying patient fears about some horrid illness is always a terrible idea.

---

Members don't see this ad.

 

[erg923]

What is the single most valuable thing you would teach MDs, particularly primary care physicians about an anxiety disorder (any of them)?

One I have heard is - in patients with hypochondriasis/illness anxiety disorder, ordering medical tests for the sole reason of allaying patient fears about some horrid illness is always a terrible idea.

To calm the **** down- don't panic. Not every problem/complaint needs treatment... or even a referral. It is my experience that primary care physicians want to "treat" EVERYTHING. There is "indicative" anxiety and pathological anxiety. Half the patients I see simply have "indicative" anxiety. It's an unfortunate part of living in the real world. Sometimes it's just people aknowledging the human experience.

True Anxiety disorders are probably the most treatable psychiatric disorder in the entire manual.

"Anxiety"never killed anybody, so let's not Overreact or catastrophize the situation. Use common sense and advise your patient accordingly.

Don't do benzo's unless there's some very particular circumstances. Preferably, don't start an anxiolytic medication of any kind until the patient has had some kind of mental health/psychiatric consultation.

Refer to a psychologist or other mental health practitioner that uses evidence based treatments if it's not simply "indicative" anxiety/worry.

 

[PsyDr]

What is the single most valuable thing you would teach MDs, particularly primary care physicians about an anxiety disorder (any of them)?

One I have heard is - in patients with hypochondriasis/illness anxiety disorder, ordering medical tests for the sole reason of allaying patient fears about some horrid illness is always a terrible idea.

Think about a scared child. You don't freak out, you don't feed into their fears. You act like a grown up and act calm, which calms them.

And using double bind communication is good in somatization: "the great news is that if this is physical, it should get better. If it's psychological it will get worse.".

 

[cbrons]

And using double bind communication is good in somatization: "the great news is that if this is physical, it should get better. If it's psychological it will get worse.".

Can you expand on this?
There is a sizeable # of patients these days (especially with the internet glossary of symptoms) that complain of an array of vague symptoms for which a hugely expensive workup is performed, only to realize several months or even years down the road that the entire constellation was likely a result of anxiety.

 

[Fan_of_Meehl]

What is the single most valuable thing you would teach MDs, particularly primary care physicians about an anxiety disorder (any of them)?

One I have heard is - in patients with hypochondriasis/illness anxiety disorder, ordering medical tests for the sole reason of allaying patient fears about some horrid illness is always a terrible idea.

That--at least for behavioral treatments--determining the specific stimulus that the patient fears is critical to designing effective treatment. All anxiety is not created equal. Cognitive and behavioral interventions for panic disorder (where, typically, the core fear is dying or going crazy due to specific internal sensations) vs. social phobia (where fear is embarrassment) vs. health anxiety (where fear is having a serious medical condition) are going to be quite different and--if you don't really determine what the specific fear is about--you can't develop effective behavioral interventions.

Simply determining what thoughts/beliefs and behaviors are typical when the person is feeling anxious will go a long way toward effective differential diagnosis and treatment planning.

Also that avoidance and 'safety behaviors' make the anxiety worse in the long run (though they may make the patient feel better in the short term).

 

[EmotRegulation]

I was basically going to say "stop throwing anxiolytic medication at people!" Sure, Xanax and the like have their place, but meds for anxiety are band-aids and reinforce the feeling that people can't handle their emotions...which can perpetuate anxiety over time. Anxiety issues are SO treatable with psychosocial treatments. Hell, I'd probably recommend a couple of self help-books for MDs to show/recommend to clients if they are unwilliing to seek therapy.

 

[WisNeuro]

I second EmotRegulation. The single, most important thing I would do is show them the research on how benzos just make things worse. Still happening with frightening frequency.

 

[Istilldontknow]

Agree with everyone regarding the use of Benzos.

Also, as someone with Panic D/o and Agoraphobia, PLEASE refer to a MH clinician. When I was a child and not diagnosed yet, my mom took me to several PCP's because she didn't know what was wrong. I was told to take sea-weed pills from GNC. I was literally housebound and given crushed up sea-weed. Also, be aware that someone with a legit anxiety d/o will likely not even take a pill you prescribe them. Please, just refer them to a psychologist.

 

[Therapist4Chnge]

1. Definitely try and tease out the WHEN & HOW of the anxiety, and if possible the WHY. Much like evaluating pain, type, frequency, et al. are all important pieces of data.

2. Refer for psychotherapy, as med only is often insufficient. Often times it can be a time-limited experience (4-8 sessions) to get a patient setup w. strategies and tools to better manage their anxiety.

3. Benzos are great in very specific circumstances. They should be a 2nd/3rd line option in most cases and non-pharma interventions shoukd be trialed prior to bringing a benzo into the mix.

 

[PsychPhDone]

I second EmotRegulation. The single, most important thing I would do is show them the research on how benzos just make things worse. Still happening with frightening frequency.

Yup. Benzos have their place, but if someone's acute distress is becoming chronic, please refer to a mental health professional. Same deal for Ambien and insomnia.

 

[cbrons]

I was basically going to say "stop throwing anxiolytic medication at people!" Sure, Xanax and the like have their place, but meds for anxiety are band-aids and reinforce the feeling that people can't handle their emotions...which can perpetuate anxiety over time. Anxiety issues are SO treatable with psychosocial treatments. Hell, I'd probably recommend a couple of self help-books for MDs to show/recommend to clients if they are unwilliing to seek therapy.

Which Ones do you recommend?

Yup. Benzos have their place, but if someone's acute distress is becoming chronic, please refer to a mental health professional. Same deal for Ambien and insomnia.

Insomnia is one of the worst issues to deal with in primary care (and oddly enough, in sleep medicine clinics). Patients are always thoroughly convinced that they've "tried everything" and the only thing that will work is a benzo or a z-drug. Of course, patients who are put on these drugs and instructed to use them PRN will ~6/10 times use them every single night and then half the time become nightmare patients who call the office several times per day requesting refills. They can be as bad as opioid dependents.

 

[DynamicDidactic]

3. Benzos are great in very specific circumstances.

In what type of specific circumstances? As a last resort?

 

[smalltownpsych]

In what type of specific circumstances? As a last resort?

When a patient is very uncomfortable about taking psychotropic medications in general and is highly motivated to change through psychotherapy and does not have a history of substance use, but in the meantime their anxiety can be preventing them from functioning. I have had a couple of patients over the years who met that criteria. For the vast majority of patients, benzos will make everything worse.

 

[bmedclinic]

Which Ones do you recommend?

Insomnia is one of the worst issues to deal with in primary care (and oddly enough, in sleep medicine clinics). Patients are always thoroughly convinced that they've "tried everything" and the only thing that will work is a benzo or a z-drug. Of course, patients who are put on these drugs and instructed to use them PRN will ~6/10 times use them every single night and then half the time become nightmare patients who call the office several times per day requesting refills. They can be as bad as opioid dependents.

tbh that's what its relatively easy to sell pts on CBT-I.
You're right, they've tried everything. And its been X years. And darn it, they're still not sleeping. And that's the opportunity to sell behavior change. Med free (sometimes) behavior change. Add in a dash of psychoed, some sleep restriction, and behavior mod and you're set.

 

[bmedclinic]

loved @erg923 's post above. The only thing I'd add based on my time in primary care is, get this: there's more than Anxiety Dx NOS. Dont just call it anxiety and write a rx. Get a freaking history, and dx/refer for tx based on that.

 

[Therapist4Chnge]

In what type of specific circumstances? As a last resort?

1. To give a speech (Xanax) or fly if you truly have panic attacks but need to fly (Ativan or Xanax). These are stopgap Rxs, not ongoing, with the expectation of doing therapy.

2. If someone has crippling anxiety/panic attacks and it is cross-titrated w. an SSRI. 60-90day supply with the understanding it is a temporary fix while the SSRI gets to a therapeutic level.

3. ETOH taper. Or benzo taper.

4. In acute emergency circumstances (high agitation in ED)...B52 or similar.

5. In cases where a person has a consistent psychologist and psychiatrist and is actively participating in ongoing therapy and it makes clinical sense; no substance abuse history and with the understanding that it isn't a forever plan.

There are other scenarios, but these popped up first. I've seen it with patients who have anxiety and a significant history of seizures, but those cases are zebras and not horses.

 

[PsychPhDone]

tbh that's what its relatively easy to sell pts on CBT-I.
You're right, they've tried everything. And its been X years. And darn it, they're still not sleeping. And that's the opportunity to sell behavior change. Med free (sometimes) behavior change. Add in a dash of psychoed, some sleep restriction, and behavior mod and you're set.

Yup! Definitely love being able to provide a solution for this situation. OP: get some psychologists in your sleep med program!

 

[singasongofjoy]

Yup! Definitely love being able to provide a solution for this situation. OP: get some psychologists in your sleep med program!

YESSSSSS. Patients may SAY they have tried everything, but what they often mean is they tried a few things they heard about on Dr. Oz, once or twice each, half-heartedly, and in isolation of other approaches when they really need to be applying several strategies at once, consistently. So basically they've tried nothing but are convinced there's no hope for them. CBT-I is generally pretty time-limited and very effective. Have them try that before ambien because otherwise they haven't really tried everything!

Also based on ppl I know who have been rx Ambien a little too liberally, try some (repeated) education about exactly how it screws your sleep cycle up. Explain WHY it's bad to take a PRN every. single. night. Have that conversation repeatedly to make sure it sinks in. I've often been surprised at how totally unaware many actually are about why taking it every night makes things so much worse but then are willing to reconsider their habits once they know the physiology part of it. But by the time they hear that message they've already been taking it every night for weeks or months- so much harder to change bad habits than try to prevent them at the outset. I think some patients come away with the message that "of course my Dr says don't take this regularly because they're afraid I'll get addicted. But I'm not the type to get addicted to things, so that doesn't apply to me." Maybe I'm over-simplifying their thought process, but that's what it sometimes seems like to me. Sure, pills are easier than making behavior change, but sometimes emphasizing the negative side effects motivates people to actually try behavior change.

 

[DynamicDidactic]

1. To give a speech (Xanax) or fly if you truly have panic attacks but need to fly (Ativan or Xanax). These are stopgap Rxs, not ongoing, with the expectation of doing therapy.

wouldn't a beta-blocker be as effective with less disadvantage for speech?

2. If someone has crippling anxiety/panic attacks and it is cross-titrated w. an SSRI. 60-90day supply with the understanding it is a temporary fix while the SSRI gets to a therapeutic level.

makes sense.

3. ETOH taper. Or benzo taper.

makes sense

4. In acute emergency circumstances (high agitation in ED)...B52 or similar.

seems like a last resort. What is a B52?

5. In cases where a person has a consistent psychologist and psychiatrist and is actively participating in ongoing therapy and it makes clinical sense; no substance abuse history and with the understanding that it isn't a forever plan.

makes sense

 

[Ollie123]

Patients think "addicted" means robbing liquor stores to buy Ambien on the street. I actually think one hugely critical point for all of these things is to change the language used to describe them and be very explicit. I have yet to hear a doctor do this well, though I'm sure many do. "These are habit forming and can cause dependence. That doesn't mean you are going to start robbing people to get more. It does mean that the more you take them, the more you will need them. It's very common for people who take them regularly to have even more troubles sleeping than they used to on nights they don't take them. Once you do stop taking them, it can sometimes take weeks for your sleep to get back to normal. For that reason, we really discourage people from taking them more than a couple times a week and it's really important that we get to the bottom of why you aren't sleeping."

CBT-I for primary insomnia is arguably the single most effective behavioral treatment we have for anything (save possibly specific phobias). I have yet to have a compliant patient not recover, except when it turned out another sleep disorder was present that needed treatment (e.g. apnea). I cannot say the same for any of the bajillion other things that MDs are much more likely to send us a referral for.

 

[Therapist4Chnge]

wouldn't a beta-blocker be as effective with less disadvantage for speech?

It depends on the case.

seems like a last resort. What is a B52?

50mg Benadryl
5mg Haldol
2mg Ativan

 

[bmedclinic]

YESSSSSS. Patients may SAY they have tried everything, but what they often mean is they tried a few things they heard about on Dr. Oz, once or twice each, half-heartedly, and in isolation of other approaches when they really need to be applying several strategies at once, consistently. So basically they've tried nothing but are convinced there's no hope for them. CBT-I is generally pretty time-limited and very effective. Have them try that before ambien because otherwise they haven't really tried everything!

this might be the most extreme example of this, but last week a patient told me they tried melatonin. When I followed up to ask how that went, they told me they bought melatonin, but had not actually tried it.

Clearly the melatonin was not effective, as it was unable to jump out of the package and into their body without their aid.

 

[Doctor Eliza]

Also, Wellbutrin as a monotherapy is a terrible choice for someone with an anxiety disorder. I can't tell you how many times I've seen this rx'd specifically in order to treat anxiety. Never ends well. I think some docs view it as interchangeable with SSRIs or something.

 

[deleted343839]

5. In cases where a person has a consistent psychologist and psychiatrist and is actively participating in ongoing therapy and it makes clinical sense; no substance abuse history and with the understanding that it isn't a forever plan.

Take everything about this description, reverse it, add chronic pain, and you get my new patient who was put on Xanax t.i.d. a few weeks before being referred to me.