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Sophiya Benjamin, MBBS, discusses the clinical examination for generalized anxiety or panic disorder.
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Sophiya Benjamin, MBBS, discusses the clinical examination for generalized anxiety or panic disorder.
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Language: EN.
Segment:0 .
[ Music ] >> Hello and welcome to JAMAevidence, our monthly podcast focused on core issues in evidence-based medicine. I'm David Simel, the Editor of the Rational Clinical Examination series, and a Professor of Medicine at the Durham Veterans' Affairs Medical Center in Duke University in Durham, North Carolina.
Today, we're talking about generalized anxiety disorders and panic disorders. Joining me on the program is Dr. Sophiya Benjamin who is an Assistant Clinical Professor of Psychiatry at McMaster University and the Grand River Hospital in Waterloo, Ontario. So, Dr. Benjamin, to begin with, can you please describe the symptoms of generalized anxiety and panic disorder for our listeners? >> Sure. So, the main symptom of generalized anxiety disorder is excessive anxiety and worry.
And, in general, the criteria state that the anxiety symptoms have to be present on more days than not for at least six months. And what's important among these individuals is that they also find it difficult to control the worry. And besides feeling anxious and worried, they also have three or more of the following symptoms, which are physical symptoms. So, they can be restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating, or their mind going blank, irritability, muscle tension, and sleep disturbance.
So, panic disorder is a little different in that these individuals have recurrent and unexpected panic attacks. So, recurrent meaning multiple, unexpected meaning coming out of the blue. And what a panic attack is, it's an abrupt surge of intense fear or intense discomfort and it reaches a peak within minutes. And during this time, the person has a lot of autonomic symptoms like palpitations, sweating, trembling, shortness of breath, feelings of choking, chest pain, feeling dizzy, paresthesias; they can sometimes feel like they're losing control, going crazy, or feel like they're going to die.
So, it can be a terrifying experience. But a panic attack can be present in more than one psychiatric disorder. So, what makes it a panic disorder is when an individual starts worrying about having another panic attack. So, this becomes a persistent concern for at least a month. And besides that, they also start developing a maladaptive change in behavior. For example, they might avoid a situation because they're afraid that they're going to have a panic attack and may not be able to get help.
So, these are the features that identify someone with a panic disorder. >> Now, when you describe the patient with an anxiety disorder, you use the word on edge and that seems like a great term because every primary care clinician has the experience of seeing a new patient who seems on edge and just wants to tell you everything about themselves all at once. Their speech may be circumstantial. And it feels like if you don't cut them off, you'll never finish your evaluation.
And you might feel anxious yourself. So, you know the patient seems to have an anxious personality. But is that the same thing as a generalized anxiety disorder? >> And that is a very common clinical question. So, anxiety symptoms like worry or physical tension are experienced almost universally in response to a stressful situation. And for some patients with an anxious personality, even being in a doctor's appointment can be anxiety-provoking.
But that is different from having anxiety disorder and there are several features that can help differentiate these two. So, first, patients with an anxiety disorder have worries that are excessive and typically interfere with their functioning. As an example, a student worrying about an exam they can be functional when they use that anxiety to prepare better, but when it becomes a functional impairment is when they're so anxious that they can't get themselves to even attempt the exam.
And secondly, when someone has a generalized anxiety disorder, the worry is more pervasive and is present for a longer duration and it also occurs even without any precipitant. And thirdly, patients with generalized anxiety disorder often have physical symptoms that accompany them like restlessness or feeling keyed up or on edge. So, these are some ways to help differentiate the two groups.
>> Now, for panic disorder, do I have to rule out a pathophysiological process that may have caused the symptom or be represented by the symptom? >> I think that would be important to do. For example, if a patient presents to the ER with palpitations and breathlessness, it would be important to do a targeted clinical exam and order tests that are informed by that clinical exam. So, there is no universal test that needs to be ordered for everyone but it's important to remember that patients with several physical disorders like if they have an MI or if they have COPD can also present appearing anxious so it would be important to rule them out.
>> To put this all in context, what is the prevalence of an actual generalized anxiety disorder and of a panic disorder in the general population? >> So, in the general population, the prevalence rate for generalized anxiety disorder is 5.1% and panic disorder is 3.5%. It varies if we are looking at the prevalence in a primary care population where the rates are slightly higher.
So, for generalized anxiety disorder, it's 8%, and for panic disorder, it's 6.8% in a primary care population. But it's even a little different if the person is presenting with anxiety as the concern and the rate of generalized anxiety disorder actually goes up to 22% among those individuals. >> Okay. So, your study that looked at this evaluated self-reported screening instruments for generalized anxiety and panic disorders.
So, how about walking us through what you found in that systematic review? >> Sure. We screened about 3,605 titles and we reviewed 76 articles in detail to find the best screening instruments for generalized anxiety disorder and panic disorder. We identified nine screening instruments. And based on our analysis, the best performing test for generalized anxiety disorder is the GAD 7, which is Generalized Anxiety Disorder Scale 7, and it has a positive likelihood ratio of 5.1 and a negative likelihood ratio of 0.13. The best performing test for panic disorder was the Patient Health Questionnaire with a positive likelihood ratio of 78 and a negative likelihood ratio of 0.20. I would like to mention though that we recommend further validation of these instruments because they were not replicated in more than one primary care population.
So, that is what we found in our study. >> Okay, most of our listeners probably don't have these instruments in front of them as we're carrying on this conversation, so could you describe how they're organized and the lines of inquiry that they take? >> Sure. So, both the GAD 7 and the PHQ are screening instruments that are available online freely and they're available at a website called PHQscreeners (all one word) .com.
And screeners is plural. They have been translated in multiple languages. The Patient Health Questionnaire or PHQ is a three-page instrument that addresses several disorders including depression, panic disorder, and other anxiety disorders. After completing the self-report form by the patient, the clinician can apply an abbreviated algorithm that is present at the end of the questionnaire to make the diagnostic decision. The GAD 7-- it has seven questions that address some of the symptoms that we just talked about.
And when a patient says yes or answers affirmatively to any of the questions, they then have another question that addresses the functional aspects and how the symptoms affect their work, home, or relationships. The authors also suggest that in addition to diagnosing GAD, this instrument can also be used to track the severity of symptoms and we can use cut-points of five, 10, and 15 to interpret the symptoms as mild, moderate, or severe.
So, we could also use this to track response to a treatment. >> As a self-reported screening instrument, it sounds to me like these could be given to the patient while they sit in the waiting room. Is that what you suggest? >> Yes. Because both of these instruments are self-administered and they don't require a high level of literacy to complete and they don't take a lot of time, these are instruments that can be given to the patient while they are in the waiting room.
However, depending on who we decide to give these questionnaires to, for example, if we give it to every patient, the test might perform differently because their prevalence rate is different, whereas if we gave these questionnaires to patients who presented with anxiety as a complaint then the prevalence is very different and it may result in the test performing a little differently. So, the clinician who gives the test to the patient will have to be mindful about this.
>> So, we should reserve the use of these to patients where we're suspicious that they may have a generalized anxiety disorder or a panic disorder? >> That is correct. >> Tell us about how the instruments could be used for both generalized anxiety and panic disorder in a simultaneous screen so that we wouldn't have to be using two different instruments. >> So, in our study, we did identify a screen that can be used for patients who have both either GAD or panic disorder and that is called the Beck Anxiety Inventory Primary Care and it's performed well compared to other instruments.
It had a positive likelihood ratio of 4.6 and a negative likelihood ratio of 0.19. It would be important to remember though that after they screen positive, we would have to interview the patient and understand what the primary disorder is. >> Is there anything else you'd like to tell our listeners about the clinical examination for generalized anxiety or panic disorder? >> I would like to say that anxiety disorders are very treatable conditions and at the same time they can be quite functionally impairing.
So, it would be important to identify these patients and treat them. I would also stress that the scales that we've identified in our study are screening instruments. So, if someone screens positive, then we still have to do a further clinical exam and a targeted physical exam to arrive at a definitive diagnosis. >> Well, thank you, Dr. Benjamin, for talking to us today. More information about this topic is available in the Rational Clinical Examination and on our website JAMAevidence.com where you can listen to our entire roster of podcasts.
I'm David Simel and I'll be back with you soon for another edition of JAMAevidence.
Segment:0 .
[ Music ] >> Hello and welcome to JAMAevidence, our monthly podcast focused on core issues in evidence-based medicine. I'm David Simel, the Editor of the Rational Clinical Examination series, and a Professor of Medicine at the Durham Veterans' Affairs Medical Center in Duke University in Durham, North Carolina.
Today, we're talking about generalized anxiety disorders and panic disorders. Joining me on the program is Dr. Sophiya Benjamin who is an Assistant Clinical Professor of Psychiatry at McMaster University and the Grand River Hospital in Waterloo, Ontario. So, Dr. Benjamin, to begin with, can you please describe the symptoms of generalized anxiety and panic disorder for our listeners? >> Sure. So, the main symptom of generalized anxiety disorder is excessive anxiety and worry.
And, in general, the criteria state that the anxiety symptoms have to be present on more days than not for at least six months. And what's important among these individuals is that they also find it difficult to control the worry. And besides feeling anxious and worried, they also have three or more of the following symptoms, which are physical symptoms. So, they can be restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating, or their mind going blank, irritability, muscle tension, and sleep disturbance.
So, panic disorder is a little different in that these individuals have recurrent and unexpected panic attacks. So, recurrent meaning multiple, unexpected meaning coming out of the blue. And what a panic attack is, it's an abrupt surge of intense fear or intense discomfort and it reaches a peak within minutes. And during this time, the person has a lot of autonomic symptoms like palpitations, sweating, trembling, shortness of breath, feelings of choking, chest pain, feeling dizzy, paresthesias; they can sometimes feel like they're losing control, going crazy, or feel like they're going to die.
So, it can be a terrifying experience. But a panic attack can be present in more than one psychiatric disorder. So, what makes it a panic disorder is when an individual starts worrying about having another panic attack. So, this becomes a persistent concern for at least a month. And besides that, they also start developing a maladaptive change in behavior. For example, they might avoid a situation because they're afraid that they're going to have a panic attack and may not be able to get help.
So, these are the features that identify someone with a panic disorder. >> Now, when you describe the patient with an anxiety disorder, you use the word on edge and that seems like a great term because every primary care clinician has the experience of seeing a new patient who seems on edge and just wants to tell you everything about themselves all at once. Their speech may be circumstantial. And it feels like if you don't cut them off, you'll never finish your evaluation.
And you might feel anxious yourself. So, you know the patient seems to have an anxious personality. But is that the same thing as a generalized anxiety disorder? >> And that is a very common clinical question. So, anxiety symptoms like worry or physical tension are experienced almost universally in response to a stressful situation. And for some patients with an anxious personality, even being in a doctor's appointment can be anxiety-provoking.
But that is different from having anxiety disorder and there are several features that can help differentiate these two. So, first, patients with an anxiety disorder have worries that are excessive and typically interfere with their functioning. As an example, a student worrying about an exam they can be functional when they use that anxiety to prepare better, but when it becomes a functional impairment is when they're so anxious that they can't get themselves to even attempt the exam.
And secondly, when someone has a generalized anxiety disorder, the worry is more pervasive and is present for a longer duration and it also occurs even without any precipitant. And thirdly, patients with generalized anxiety disorder often have physical symptoms that accompany them like restlessness or feeling keyed up or on edge. So, these are some ways to help differentiate the two groups.
>> Now, for panic disorder, do I have to rule out a pathophysiological process that may have caused the symptom or be represented by the symptom? >> I think that would be important to do. For example, if a patient presents to the ER with palpitations and breathlessness, it would be important to do a targeted clinical exam and order tests that are informed by that clinical exam. So, there is no universal test that needs to be ordered for everyone but it's important to remember that patients with several physical disorders like if they have an MI or if they have COPD can also present appearing anxious so it would be important to rule them out.
>> To put this all in context, what is the prevalence of an actual generalized anxiety disorder and of a panic disorder in the general population? >> So, in the general population, the prevalence rate for generalized anxiety disorder is 5.1% and panic disorder is 3.5%. It varies if we are looking at the prevalence in a primary care population where the rates are slightly higher.
So, for generalized anxiety disorder, it's 8%, and for panic disorder, it's 6.8% in a primary care population. But it's even a little different if the person is presenting with anxiety as the concern and the rate of generalized anxiety disorder actually goes up to 22% among those individuals. >> Okay. So, your study that looked at this evaluated self-reported screening instruments for generalized anxiety and panic disorders.
So, how about walking us through what you found in that systematic review? >> Sure. We screened about 3,605 titles and we reviewed 76 articles in detail to find the best screening instruments for generalized anxiety disorder and panic disorder. We identified nine screening instruments. And based on our analysis, the best performing test for generalized anxiety disorder is the GAD 7, which is Generalized Anxiety Disorder Scale 7, and it has a positive likelihood ratio of 5.1 and a negative likelihood ratio of 0.13. The best performing test for panic disorder was the Patient Health Questionnaire with a positive likelihood ratio of 78 and a negative likelihood ratio of 0.20. I would like to mention though that we recommend further validation of these instruments because they were not replicated in more than one primary care population.
So, that is what we found in our study. >> Okay, most of our listeners probably don't have these instruments in front of them as we're carrying on this conversation, so could you describe how they're organized and the lines of inquiry that they take? >> Sure. So, both the GAD 7 and the PHQ are screening instruments that are available online freely and they're available at a website called PHQscreeners (all one word) .com.
And screeners is plural. They have been translated in multiple languages. The Patient Health Questionnaire or PHQ is a three-page instrument that addresses several disorders including depression, panic disorder, and other anxiety disorders. After completing the self-report form by the patient, the clinician can apply an abbreviated algorithm that is present at the end of the questionnaire to make the diagnostic decision. The GAD 7-- it has seven questions that address some of the symptoms that we just talked about.
And when a patient says yes or answers affirmatively to any of the questions, they then have another question that addresses the functional aspects and how the symptoms affect their work, home, or relationships. The authors also suggest that in addition to diagnosing GAD, this instrument can also be used to track the severity of symptoms and we can use cut-points of five, 10, and 15 to interpret the symptoms as mild, moderate, or severe.
So, we could also use this to track response to a treatment. >> As a self-reported screening instrument, it sounds to me like these could be given to the patient while they sit in the waiting room. Is that what you suggest? >> Yes. Because both of these instruments are self-administered and they don't require a high level of literacy to complete and they don't take a lot of time, these are instruments that can be given to the patient while they are in the waiting room.
However, depending on who we decide to give these questionnaires to, for example, if we give it to every patient, the test might perform differently because their prevalence rate is different, whereas if we gave these questionnaires to patients who presented with anxiety as a complaint then the prevalence is very different and it may result in the test performing a little differently. So, the clinician who gives the test to the patient will have to be mindful about this.
>> So, we should reserve the use of these to patients where we're suspicious that they may have a generalized anxiety disorder or a panic disorder? >> That is correct. >> Tell us about how the instruments could be used for both generalized anxiety and panic disorder in a simultaneous screen so that we wouldn't have to be using two different instruments. >> So, in our study, we did identify a screen that can be used for patients who have both either GAD or panic disorder and that is called the Beck Anxiety Inventory Primary Care and it's performed well compared to other instruments.
It had a positive likelihood ratio of 4.6 and a negative likelihood ratio of 0.19. It would be important to remember though that after they screen positive, we would have to interview the patient and understand what the primary disorder is. >> Is there anything else you'd like to tell our listeners about the clinical examination for generalized anxiety or panic disorder? >> I would like to say that anxiety disorders are very treatable conditions and at the same time they can be quite functionally impairing.
So, it would be important to identify these patients and treat them. I would also stress that the scales that we've identified in our study are screening instruments. So, if someone screens positive, then we still have to do a further clinical exam and a targeted physical exam to arrive at a definitive diagnosis. >> Well, thank you, Dr. Benjamin, for talking to us today. More information about this topic is available in the Rational Clinical Examination and on our website JAMAevidence.com where you can listen to our entire roster of podcasts.
I'm David Simel and I'll be back with you soon for another edition of JAMAevidence.
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