Talking with your patients about anxiety

By Julie Luzarraga

Anxiety has become so common in our society that it is easier than ever to miss the signs and symptoms. Comments like “that makes me so anxious” or “I had a panic attack” can be heard in casual conversations with enough frequency it can be hard to know the degree to which the speaker is in fact clinically suffering. Unfortunately, while it may be socially acceptable to loosely use the term “anxious” or “panic,” a stigma around talking about our real mental health symptoms persists. It may be challenging to know how someone is defining anxiety, but it is clear it is a significant concern in our culture.    

According to the National Institute of Mental Health, approximately thirty-one percent of adults in the United States will experience an anxiety disorder at some time in their lives. Anxiety disorders are the most common mental health disorders in the U.S. and include generalized anxiety disorder, panic disorder, phobias, agoraphobia, social anxiety, and separation anxiety disorders. Post-traumatic stress syndromes and obsessive-compulsive disorder are related conditions included in the thirty-one percent. Anxiety disorders are ego-dystonic and distressing for the sufferer. People living with an anxiety disorder are aware that many of their anxious thoughts are not rational or realistic, yet their physical symptoms and feelings are very real. This experience can cause feelings of depression, which further complicate the clinical picture. In addition, people who suffer from anxiety may not realize it is treatable disorder. The Anxiety and Depression Association of America reports only approximately 37 percent of those diagnosed with an anxiety disorder receive treatment.

Anxiety disorders frequently manifest in the form of physical symptoms such as increased heart rate, dizziness, weight loss, insomnia, pain, and gastrointestinal problems. These types of physical concerns may be what first gets brought to the attention of a provider. Because of stigma and the shame often associated with mental illness, it is often easier for a patient to schedule an appointment for insomnia or pain versus for their excessive worry.

Many people with an anxiety disorder are high functioning. This does not mean they are not suffering. It means they can compartmentalize their anxiety and function, sometimes over-function, as a way of coping with their anxiety. This makes it easy to assume everything is okay and not ask the questions most patients want their providers to ask.

As integrative healthcare providers, asking the questions helps in making the diagnosis and referrals for anxiety disorders. To help illustrate this concept, I created a case study based on a patient care experience in my practice. Please note, names of the patient and providers have been changed or omitted for privacy purposes.   

Take Holly, a 54-year old professional woman who made an appointment with her primary care provider because she was worried something was wrong with her. She couldn’t sleep and was losing weight without trying. In addition to her physical exam and bloodwork, the relationship and dialogue with her provider were crucial to determining Holly’s presenting issue.

When the provider asked Holly how she and her family were, Holly responded that things were “great.” Within the last six months her youngest child had left for college, she received a job promotion, and she and her husband were downsizing and moving into a condo. The provider could have easily moved on from there, but she noted these were all significant life events, even though they were positive experiences. 

The provider slowed down and made sure to look at Holly when she asked, “so, how is your mood? How have you been feeling?” The patient burst into tears and explained that she seemed to worry about everything and couldn’t understand why when things were going so well. 

Using a patient-centered approach, the provider also listened for Holly’s language. She frowned when the provider used “anxiety” and said, “no, it’s not anxiety, it’s just I worry.” The provider used “worry” during the rest of their conversation in order to get an accurate understanding of Holly’s experience. Had she used the term “anxiety,” Holly may have given different answers.

The patient’s situation may not warrant a diagnosis. Having that many life events in a six-month period could create a normal stress-response and be treated with lifestyle changes and mindfulness techniques. However, as the provider and Holly talked more it was clear that she met the criteria for Generalized Anxiety Disorder. The provider asked three questions:

1. How often are you experiencing worry? Frequency and length of symptoms is an important diagnostic factor. If someone is preparing to move next week and has been having difficulty sleeping for the last few nights that does not meet the criteria for Generalized Anxiety Disorder. In Holly’s situation, when asked the question she disclosed worry at least six out of seven days each week. She could also remember when it started which was over six months ago when her daughter left for college.
2. What, if anything, helps? One of the criteria for Generalized Anxiety Disorder is feeling unable to control the worry. By asking Holly what helps her worry less, the provider could determine if Holly has coping skills that help mitigate the symptoms. Holly was able to identify that she could distract herself with work but the minute she laid down to sleep, even when she was exhausted, the worry came right back.
3. How disruptive has this been? In general, Holly seemed to be functioning very well. Her marriage was healthy, she was successful at work, and she was exercising on a regular basis. However, when the provider asked, “how is this changing your life?” Holly reported that because she was not sleeping, she had started to drink more; the fatigue was keeping her from going to her regular book club; and she knew she was missing things at work and having to work harder to catch them. Holly concluded, “I just haven’t been myself.” Her worry was clearly disrupting her life.

These three questions helped get to patient’s experience. Each patient has a unique set of life circumstances, preferences, and experiences, which influence how we diagnosis and treat. 

While anxiety disorders are uncomfortable, the use of prescriptions to treat the anxiety should be a last resort. Lifestyle changes such as relaxation techniques, breathing exercises, physical activity, and reduced caffeine intake are great places to start while making a referral to a mental health provider who can further assess and treat. 

Holly was referred to a mental health provider, who discovered that her family has a long history of anxiety disorders making it even more beneficial for her to be in therapy to learn ways to decrease her anxiety. 

How the providers made the referral was important to accessing care. The provider assured Holly that her worry was not “silly,” but it was negatively impacting how she was living her life. She explained how that worry can create patterns and that she worked with a mental health provider who could help her look at her patterns and how to decrease that anxiety. The provider would work with Holly and the mental health provider to develop a treatment plan to address the worry, insomnia, and unintentional weight loss. The provider was authentic and explained why they were making the referral. 

In integrative healthcare, the relationship with the patient creates a container to use the patient’s language, ask specific questions, and get the patient’s experience, which helps to collaborate on diagnosis and treatment planning when treating anxiety.