The patient is a 23-year-old woman who comes to her primary care physician's office concerned about periodic difficulty in breathing. She thinks she may have asthma.
She first experienced an attack of dyspnea while she was attending a special 2-week educational program for the state's top high school students; it was held about 2 hours from her home. During her stay, she experienced an episode in which she suddenly felt she was unable to breathe. School health officials thought she was having an asthma attack and sent her home. She was subsequently evaluated by her pediatrician. He detected minor wheezing on deep inspiration but ruled out asthma and attributed the attack to a possible allergy.
The patient experienced no further attacks for several years, until she left her parents' home for the first time to attend law school. She began to have repeated attacks of dyspnea and sought the advice of her primary physician.
During an attack, the patient feels as though she cannot breathe and that she is about to faint or die. Her heart races and she trembles. She worries that the episodes are a manifestation of an undiagnosed and perhaps life-threatening illness. The patient is embarrassed by these attacks and has not told anyone about them. However, dread of the next episode is now dominating her life and she fears she is "going crazy."
At his parent's insistence, a 22-year-old man seeks medical attention from his primary physician. He has just flunked out of college a second time. The parents want to understand the reasons behind their son's academic failure, and they fear that he may be abusing drugs. This fear was fueled, in part, by another physician who had previously evaluated the patient: the clinician had told the parents that their son was probably a "doper" and a "bad kid."
The patient had been popular and a good student in high school. He was an outstanding athlete. His parents reported that they had enjoyed living with him and that he had always been helpful around the house.
The patient reports that although he loves to coach sports, he is unable to get up in front of a group and teach. He finds it similarly difficult to speak in the classroom. He describes himself as "very shy" and reports that he is afraid people are laughing at him. Friends seek out his company, but he never pursues these relationships.
He reports that drinking was a "regular" part of daily campus life and that he had been using alcohol almost every day to the point of intoxication to cover up his shyness. His alcohol dependence led to his expulsion from school.
The patient is a 54-year-old man who has been worrying excessively about activities of daily living in general and his health in particular for several years. He recently read about leukemia and asked his primary physician to perform a bone marrow aspiration to rule out the disease. A hypochondriac, he fears that his minor physical ailments (such as headaches, coughing, and sneezing) are masking a deadly disease. He is also convinced that his 33-year-old son, who is mildly overweight, is going to die soon of heart disease, and he is doing his utmost to convince his son to lose his excess weight.
The patient is a successful businessman, husband, and father of several children as well as an athlete, a painter-even a decorated war veteran. Despite his achievements, however, the patient feels "miserable" and "tortured" by his persistent worries. He anticipates and dreads poor outcomes of even routine activities. He feels he cannot go to the movies because he might be unable to get a parking spot. He is convinced that people disregard him because he is short. He believes his wife is entirely unsympathetic to his plight. He now seeks your medical advice.
Each of the patients in these case histories is suffering from an anxiety disorder. The young law student has panic disorder-a condition that has repeatedly caused autonomic hyperarousal and anticipatory anxiety but that went undiagnosed for a long period. The 22-year-old college dropout has developed an alcohol addiction secondary to social anxiety disorder (SAD). The 54-year-old patient's persistent worries are a manifestation of generalized anxiety disorder (GAD). In each case, an anxiety disorder has interfered with activities of daily living to the point that none of these patients are able to function normally.
Psychiatric disorders affect an estimated 44 million persons in this country, more than a third of whom have at least 1 anxiety disorder.1 The burden of anxiety disorders is high-both personally, as reflected in a loss of the patient's ability to carry on normally at home and on the job-and in economic terms. The estimated price of anxiety disorders (including the direct costs of drug therapy and psychiatric and nonpsychiatric treatment, and the indirect costs of lost work time and mortality) totaled $63.1 billion in 1998 dollars.1
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines 6 distinct subcategories of anxiety disorder.2 Three of these-specific phobia, obsessive-compulsive disorder, and post-traumatic stress disorder-are usually outside the realm of primary care. However, persons with panic disorder, SAD, and GAD typically present to their primary physician with their emotional distress-and are thus the focus of this review.3-5 It is critical that primary care clinicians recognize these chronic disorders in their many somatic guises-and understand their debilitating impact on a patient's life. Knowledge of the various therapeutic options (medications, lifestyle measures, and cognitive behavioral therapy) and the ability to formulate an effective treatment plan are equally crucial.
My intent here is not to reiterate the details of diagnosis of these anxiety disorders, which have been elegantly described elsewhere.1-4,6,7 Nor is my goal to describe the details of psychotherapy, which, in the context of busy primary care, is usually the domain of the psychiatrist. Instead, the focus is on treatment-in particular, on pharmacotherapy that can be successfully employed in a primary care setting.