Anxiety: Hiding in Plain Sight?

Anxiety is one of the most common mental health disorders. In any given year it affects over 18 percent of adults and 25 percent of children in the United States. Despite those staggering numbers, only about 36 percent of individuals with clinical anxiety receive treatment. It is important for all providers to work together to better identify patients with anxiety symptoms, integrate collaborative care and empower individuals to manage their anxiety.

Common Barriers to Diagnosis and Treatment

There are a number of barriers for people receiving appropriate care. Most individuals go to their primary care practice for symptoms of anxiety. In fact, people with an anxiety disorder are three to five times more likely to go to the doctor than those who don’t.

Anxiety disorders, particularly panic disorder, occur more frequently in patients with chronic medical illnesses (e.g., hypertension, chronic obstructive pulmonary disease, irritable bowel syndrome, diabetes) than in the general population. Conversely, patients with anxiety disorders are more likely than others to develop a medical illness, and the presence of an anxiety disorder may prolong the course of a medical illness.

Unfortunately, only 14-35 percent of cases are recognized by their physician. Only 25 percent of patients receive pharmacologic treatment and less than 25 percent of patients receive therapeutic treatment. About half of the patients screened receive no treatment at all.

Anxiety often goes unnoticed because of cultural, gender and age differences.

The language the individual uses to describe their anxiety may be different than what the DSM 5 has outlined.

Some cultures will describe their symptoms more somatically and physiologically because mental stress is either taboo or not a construct. In Puerto Rico, many identify anxiety as an attack on the nerves.

Men are less likely to acknowledge or talk about anxiety symptoms because of male enculturation and gender norms. In an appointment, they may talk about the somatic and physiological symptoms. Also, instead of typical emotional signs they may exhibit irritability, hypervigilance and anger.

Recognizing an anxiety disorder in an older adult can be challenging. Along with age comes an increased number of medical ailments, more physical limitations and more frequent use of prescription medications. Diagnosing anxiety in people with dementia can also be extremely difficult. Impaired memory may be interpreted as a sign of either anxiety or dementia and the fear they are experiencing may be excessive or realistic. As a result, separating a medical condition from symptoms of an anxiety disorder is more complicated.

The reasons why an individual is experiencing anxiety can also differ. In Japan, eye contact and blushing are bigger fears. Remember to listen to the individual’s language of distress.

Access to resources.

Many groups do not have access to appropriate resources – whether it is a primary care physician, healthy food, active living, finances, job opportunities, or community resources. Lack of access to any or all of these factors contribute to and exacerbate anxiety symptoms.

Improving Screening

Simple and short screening tools can help identify clinical anxiety and refer individuals to appropriate care.

Screening questions.

• Do you consider yourself a worrier?
• Do you have thoughts that occur over and over again that bother you?
• Does your body get tense and tired persistently?
• Do you get waves of nervousness that seem to come out of the blue?

Screening measures.

• Measures such as GAD-2 and GAD-7 are brief and validated.

Improving Therapeutic Interventions

Many therapeutic interventions have decreased clinical anxiety. The strongest research is for Cognitive Behavioral Therapy (CBT). Mental health counselors can help individuals identify triggers, re-frame distorted and distressing thoughts, and practice soothing and coping skills.

The cognitive triangle is a tool that can help individuals identify their thoughts, behaviors, and emotions, and break the cycle in which they get stuck. Having an alternative thought (“It is okay to be nervous, this situation will pass,” versus, “I’m never going to make it! What is wrong with me?”) or changing the behavior (taking deep slow breathes versus running around panicking) can help change our patterns.

Improving Pharmacological Interventions

Pharmacological interventions can be an integral part of treatment. Understanding implications, indications for appropriate treatment can greatly improve outcomes. First line medications are Selective Serotonin Reuptake Inhibitors (SSRIs), but there are numerous other modalities that can be utilized.

Let’s Work Together

Clinical anxiety is a pervasive and stubborn disorder. Although we cannot control all the stressful circumstances and surprises life will throw at us, we can be prepared with good tools and supports. It is important for all providers to work together to better integrate collaborative care and empower individuals to manage their anxiety.