2002 CLINICAL PRACTICE GUIDELINES (Reviewed and Approved for 2004)

OXFORD HEALTH PLANS

2002 CLINICAL PRACTICE GUIDELINES (Reviewed and approved for 2004):
DETECTION, DIAGNOSIS, and Treatment OF ANXIETY DISORDERS
IN PRIMARY CARE
OVERVIEW

• Anxiety disorders are the most common psychiatric illnesses affecting both children and adults.
• An estimated 19 million adult Americans suffer from anxiety disorders and there is significant overlap or co-morbidity with mood and substance abuse disorders.
• These orders can be characterized by, relatively early ages of onset, chronicity, relapsing or recurrent episodes of illness, and periods of disability.
• Although anxiety disorders are highly treatable, only approximately one third of those suffering from anxiety disorders receive treatment.
• It is likely that the co-morbid anxiety in suicide is underestimated. Panic disorder and agoraphobia, in particular, may be associated with increased risk of suicide.
• Practitioners should be sensitive to the occurrence of anxiety disorders in their patient population, institute screening methods to identify anxiety disorders, and implement parameters for treatment and referral.

TYPES OF ANXIETY DISORDERS

The Anxiety Disorders include: Generalized Anxiety Disorder (GAD), Obsessive-Compulsive Disorder (OCD), Panic Disorder (with and without a history of agoraphobia), Agoraphobia (with and without a history of panic disorder), Acute Stress Disorder, Post-Traumatic Stress Disorder (PTSD), Social Anxiety Disorder (Social Phobia), and Specific Phobias, Body Dysmorphic Disorder.

WHEN TO REFER TO A MENTAL HEALTH SPECIALIST

Primary care physicians should refer a patient to a psychiatrist or experienced
Mental Health specialist under the following circumstances:
First and foremost, IF THE PATIENT PRESENTS A SUICIDE RISK.*

• The patient presents persistent reduced capacity to function.
• The patient fails to respond to an adequate trial of anti-anxiety medication.
• There is no evidence of social supports.
• The patient requires inpatient care.
• The patient has a previous history of depression or suspicion of bipolar disorder.

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• The patient is pregnant or plans to become pregnant.
• The anxiety is resistant to treatment.
• The patient has a complex medication regimen.
• The patient has certain co-morbid conditions (i.e. substance abuse, major depression, bipolar disorder, dementia).

SUICIDE RISK*

• All patients suffering from an anxiety disorder should be assessed for the risk of suicide by subtle questioning about suicidal thinking, impulses, and personal history of suicide attempts.

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• Patients are generally reassured by questions about suicidal thoughts and by education that suicidal thinking is a common symptom of the anxiety, or depression itself, and not a sign that the patient is “crazy.”

DIAGNOSING ANXIETY DISORDERS
1. USE THE CLINICAL INTERVIEW TO IDENTIFY SYMPTOMS OF ANXIETY:
It may be useful to employ a self-report questionnaire, which provides the patient with a written list of symptoms related to anxiety, and asks the patient to indicate any symptoms experienced. (See attachment)
2. BE ATTENTIVE TO COMMON PATIENT COMPLAINTS WHICH MAY INDICATE ANXIETY DISORDERS WHEN MEDICAL WORK-UPS ARE PERSISTENTLY NEGATIVE:

• Unexplained GI symptoms, heart palpitations, rapid pounding heartbeat, tightness of chest, hyperventilation, weakness all over, tremors, dizziness, dry mouth, sweaty, confusion, speeded up thoughts, muscle tension/aches, fatigue.

3. SEEK OTHER CLINICAL CLUES IN THE PATIENT HISTORY WHICH PREDISPOSE FOR ANXIETY
DISORDERS:

• Prior episodes of anxiety or depression.
• Family history of depression.
• Family history of eating disorders, substance abuse, or anxiety disorders.
• Personal or family history of suicide attempt(s).

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• Recent stressful life events.
• Concurrent general medical illnesses.
• Concurrent substance abuse.
• Lack of social supports.
• Use of Kava-Kava.

4. THOROUGHLY EVALUATE THE PATIENT’S INITIAL COMPLAINTS WITH A MEDICAL REVIEW OF SYSTEMS AND A PHYSICAL EXAMINATION
5. CONSIDER GENERAL MEDICAL CONDITIONS IN RELATION TO ANXIETY DISORDERS:

• Stroke
• MI
• Dementia
• Diabetes

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• Fibromyalgia
• Cancer
• Coronary Artery Disease Medication

• Side-Effects of Medications
• Hypothyroidism

• Parkinson's

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• Drug Interactions
• Pseudodementia
• Alzheimer's

6. IDENTIFY AND TREAT POTENTIAL KNOWN CAUSES, IF PRESENT, OF ANXIETY DISORDERS:

• Alcohol and Drug Abuse

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• Causal Non-Mood Psychiatric Disorder

• General Medical Disorder

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• Grief Reaction

7. SCREEN FOR MEDICATIONS WHICH CAN CAUSE SYMPTOMS OF ANXIETY (or PRECIPITATE ANXIETY DISORDERS):
DIAGNOSTIC CRITERIA FOR ANXIETY DISORDERS
Generalized Anxiety Disorder:
1)Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities.
2)The person finds it difficult to control the worry.
3)The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children.
a)Restlessness or feeling keyed up or on edge,
b)Being easily fatigued,
c)Difficulty concentrating or mind going blank,
d)Irritability,
e)Muscle tension,
f)Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep).
4)The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.
5)The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
6)The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., Hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.
Obsessive-Compulsive Disorder:
1)Either obsessions or compulsions: Obsessions as defined by a, b, c, and d, and compulsions as defined by e, and f:
a)Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress,
b)The thoughts, impulses, or images are not simply excessive worries about real-life problems,
c)The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action,
d)The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion),
e)Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly,
f)The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.
2)At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.
3)The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.
4)If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia’; or guilty ruminations in the presence of Major Depressive Disorder).
5)The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Panic Disorder:
1)Recurrent unexpected Panic Attacks. Criteria for Panic Attack:
a)A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:
i)Palpitations, pounding heart, or accelerated heart rate,
ii)Sweating,
iii)Trembling or shaking,
iv)Sensations of shortness of breath or smothering,
v)Feeling of choking,
vi)Chest pain or discomfort,
vii)Nausea or abdominal distress,
viii)Feeling dizzy, unsteady, lightheaded, or faint,
ix)Derealization (feelings of unreality) or depersonalization (being detached from oneself),
x)Fear of losing control or going crazy,
xi)Fear of dying,
xii)Paresthesias (numbness or tingling sensations),
xiii)Chills or hot flushes.
2)At least one of the attacks has been followed by 1 month (or more) of one (or more) of the following:
a)Persistent concern about having additional attacks,
b)Worry about the implications of the attack or it’s consequences (e.g., losing control, having a heart attack, “going crazy”),
c)A significant change in behavior related to the attacks.
3)The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a dug of abuse, a medication condition (e.g., hyperthyroidism).
4)The Panic Attacks are not better accounted for by another mental disorder, such as Social Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., in response to stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response to being away from home or close relatives.
Panic Disorder WITH Agoraphobia:
1)Meets the criteria for Panic Disorder.
2)The Presence of Agoraphobia (see criteria below).
Panic Disorder WITHOUT Agoraphobia:
1)Meets the criteria for Panic Disorder.
2)Absence of Agoraphobia.
Agoraphobia WITHOUT History of Panic Disorder:
1)The Presence of Agoraphobia related to fear of developing panic-like symptoms (e.g., dizziness or diarrhea). Criteria for Agoraphobia:
a)Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or automobile.
Note: Consider the diagnosis of Specific Phobia if the avoidance is limited to one or only a few specific situations, or Social Phobia if the avoidance is limited to social situations.
b)The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion.
c)The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as Social Phobia (e.g., avoidance limited to social situations because of fear of embarrassment), Specific Phobia (e.g., avoidance limited to a single situation like elevators), Obsessive-Compulsive Disorder (e.g., avoidance of dirt in someone with an obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated with a severe stressor), or Separation Anxiety Disorder (e/g/, avoidance of leaving home or relatives).
2)Criteria have never been met for Panic Disorder.
3)The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
4)If an associated general medical condition is present, the fear described in first criterion is clearly in excess of that usually associated with the condition.
Acute Stress Disorder:
1)The person has been exposed to a traumatic event in which both of the following were present:
a)The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others,
b)The person’s response involved intense fear, helplessness, or horror.
2)Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:
a)A subjective sense of numbing, detachment, or absence of emotional responsiveness,
b)A reduction in awareness of his or her surroundings (e.g., “being in a daze”)
c)Derealization,
d)Depersonalization,
e)Dissociative amnesia (i.e., inability to recall an important aspect of the trauma).
3)The traumatic event is persistently re-experienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.
4)Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).
5)Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hyper vigilance, exaggerated startle response, motor restlessness).
6)The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual’s ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.
7)The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.
8)The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by Brief Psychotic Disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.
Posttraumatic Stress Disorder:
1)The person has been exposed to a traumatic event in which both of the following were present:
a)The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others,
b)The person’s response involved intense fear, helplessness, or horror.
2)The Traumatic event is persistently re-experienced in one (or more) of the following ways:
a)Recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.
b)Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content.
c)Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In young children, trauma-specific reenactment may occur.
d)Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
e)Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
3)Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following:
a)Efforts to avoid thoughts, feelings, or conversations associated with the trauma,
b)Efforts to avoid activities, places, or people that arouse recollections of the trauma,
c)Inability to recall an important aspect of the trauma,
d)Markedly diminished interest or participation in significant activities,
e)Feeling of detachment or estrangement from others,
f)Restricted range of affect (e.g., unable to have loving feelings),
g)Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or a normal life span).
4)Persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following:
a)Difficulty falling or staying asleep,
b)Irritability or outbursts of anger,
c)Difficulty concentrating,
d)Hypervigilance,
e)Exaggerated startle response.
5)Duration of the disturbance (symptoms in 2, 3, and 4) is more than 1 month.
6)The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:

• Acute: if duration of symptoms is less than 3 months,
• Chronic: if duration of symptoms is 3 months or more.

Specify if:

• With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.

Social Phobia:
1)A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in poor settings, not just in interactions with adults.
2)Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
3)The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
4)The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
5)The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
6)In individuals under age 18 years, the duration is at least 6 months.
7)The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic disorder With or Without Agoraphobia, separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).
8)If a general medical condition or another mental disorder is present, the fear in Criterion 1 is unrelated to it, e.g., the fear is not of Stuttering, trembling, Parkinson’s disease, or exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.
Specify if:

• Generalized: if the fears include most social situations (also consider the additional diagnosis of Avoidant Personality Disorder).

Specific Phobia:
1)Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation (e.g., flying, heights, animals, receiving and injection, seeing blood).
2)Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.