J Am Board Fam Pract: first published as 10.3122/jabfm.4.1.47 on 1 January 1991. Downloaded from Anxiety And Substance Use Disorders: A Primer For Primary Care Physicians MimI Landry, David E. Smith, M.D., David McDuff, M.D., and Otis 1. Baughman III, M.D. Abstract: Primary care physicians encounter many patients with primary and secondary anxiety and substance use problems. Some patients have a dual diagnosis of both an anxiety and a substance use disorder. Symptoms may be overdiagnosed, underdiagnosed, and misdiagnosed. This article provides the primary care physician with an overview of the relation between psychoactive substance use disorders and anxiety symptoms. Also described are drug use patterns and diagnostic criteria for psychoactive substance use disorders. A model for understanding the role of anxiety symptoms during drug use is provided. (J Am Board Fam Pract 1991; 4:47-53.) Primary care physicians, especially rural family abuse liability, and dual or multiple diagnoses, physicians, often are the first practitioners to see all within the practical time constraints of pa­ patients who have maladaptive drug use or psy­ tient visits. chiatric problems. In particular, primary care Physicians and other professionals who focus physicians treat many patients who have anxiety their work on the treatment of addictions have disorders, the most prevalent group of psychiat­ become aware of the complex interrelations ric conditions in the United States. I Indeed, among common psychiatric syndromes, espe­ physicians in family practice, general practice, cially the forms of anxiety; substance use and internal medicine, and osteopathy write two abuse, especially alcohol, illicit drugs, and pre­ thirds (66.8 percent) of all new prescriptions for scribed medications; and ordinary medical ill­ antianxiety or anxiolytic medications.2 They pre­ nesses. These increasingly common clinical scribe anxiolytics more frequently than psychi­ problems can coexist in the same patient, mimic atrists-who prescribe more antidepressants each other, and mask or exacerbate each other. than primary care physicians-however, psychi­ Modem clinicians, especially those in primary atrists typically provide a mental illness diagnosis care specialties, must become expert in the fine http://www.jabfm.org/ for these patients while primary care physicians points of recognition, the subtleties of diagnosis, typically do not.3 Concurrently, primary care the risks and benefits of prescribing psychoactive clinicians treat large numbers of patients with medications, and the art of obtaining effective substance use disorders, whose complaints often consultations and making appropriate referrals. are anxiety, insomnia, or depression, rather than This article focuses on the subtleties of diag­ substance use. In addition, medications, such as nosis and shows how concepts from addiction on 29 September 2021 by guest. Protected copyright. the benwdiazepines, which can be particularly medicine can be integrated with current descrip­ useful and beneficial to one patient, may have tive and criterion-based psychiatric diagnosis (as adverse effects on another. in the Diagnostic and Statisticallvlanual of Mental Physicians need to be knowledgeable about Disorders [DSlvf-III-R)) in the primary care set­ differential treatment outcomes, medication ting. The care of ordinary medical patients can be improved by a clearer understanding of the meaning of symptoms and the ways by which From the Haight Ashbury Training and EduL'ation Project, prescribed or self-medication contributes to the San Francisco; Haight Ashbury Free Clinics, San Francisco; Di­ vision of Alcohol and Drug Abuse, Department of Psychiatry, alleviation or exacerbation of symptoms. University of Maryland School of Medicine, Baltimore; and the Family Medicine Residency Program, Spartanburg Regional Anxiety and Anxiety Disorders Medical Center, Spartanburg, SC. Address reprint requests to Haigbt A~hbury Training and Educdtion Project, 409 Clayton Anxiety disorders are the most common group Street, San FrandsL"O, CA 94117. of psychiatric problems (Robins, et al. reported Anxiety and Substance Abuse Disorders 47 .. --------------------------~.-.-...- ...... J Am Board Fam Pract: first published as 10.3122/jabfm.4.1.47 on 1 January 1991. Downloaded from 8.3 percent of Americans experienced clinically ing, or cold clammy hands; (8) dry mouth; (9) significant anxiety symptoms in a 6-month pe­ dizziness or lightheadedness; (10) nausea, diar­ riod, but only 23 percent received some form of rhea, or other abdominal distress; (11) flushes treatment).! However, the physician's decision to (hot flashes) or chills; (12) frequent urination; treat or how to treat must consider the severity (13) trouble swallowing or "lump in throat." of the problem and the risk-benefit ratio of the • Vigilance and scanning: (14) feeling keyed up treatment selected. Symptoms of anxiety are a or on edge; (15) exaggerated startle response; part of the human experience, but more severe (16) difficulty concentrating or "mind going anxiety creates dysfunction, and treatment deci­ blank" because of anxiety; (17) trouble falling or sions should rest upon an accurate diagnosis. It staying asleep; (18) irritability.4 p 253 is clinically useful to separate anxiety symptoms into two groups: primary and secondary. Substance Use Disorders Primary anxiety includes what patients might Substance use disorders are common in the gen­ refer to as "nervousness." In one large study, 25 eral population and the primary care setting, but percent of Americans considered themselves they are frequently undiagnosed. It is estimated "nervous."! It also includes the symptoms that that between 16 and 18 percent of family prac­ are common elements of many psychiatric dis­ tice patients have a formal diagnosis of alcohol­ orders, as well as such specific anxiety disorders ism. 5-7 Understanding the nomenclature and as generalized anxiety disorder, post-traumatic definitions of addiction medicine can provide an stress disorder, and panic. important diagnostic foothold. There are two Secrmdary anxiety includes symptoms that are particularly useful ways of describing the use of caused by some other primary problem, e.g., psychoactive drugs: drug use patterns and drug medical illness, medications, or drug abuse. The use disorders. physician should consider whether the patient has a neurological problem, endocrine disorder, Drug Use Patterns prescription or street drug problem, alcohol Drug use patterns provide data that can be use­ withdrawal, or is consuming high doses of caf­ ful to form a diagnostic impression related to feine, over-the-counter cold preparations, diet both psychiatric and substance use disorders.8,9 pills, or nicotine. These patterns of volume and frequency of drug It is also important to become familiar with use provide important but incomplete clinical the diagnostic criteria for the various anxiety dis­ descriptions. It is necessary also to understand http://www.jabfm.org/ orders (panic disorder with or without agora­ the distinctions among drug use, abuse, and ad­ phobia, agoraphobia without panic disorder, so­ diction, especially as they apply to prescribed cial phobia, obsessive compulsive disorder, medications and prescription-other drug combi­ post-traumatic stress disorder, and generalized nations. The cornerstone for understanding the anxiety disorder). distinctions among use, abuse, and addiction is The DSM-III-R, for example, describes the the concept of drug-related dysfunction. on 29 September 2021 by guest. Protected copyright. essential feature of generalized anxiety disorder Experimental use is short-term, nonpatterned (GAD) as being unrealistic or excessive anxiety trials of a drug in which the user is motivated and worry about two or more life circumstances chiefly by curiosity and a desire to experience for 6 months or longer, during which the patient the anticipated effect. Such use generally begins has been bothered by these concerns more days socially among friends. than not.4 A minimum of six of the following Social-recreational use occurs in social settings 18 symptoms would be exhibited: among friends or acquaintances who wish to share an experience perceived as acceptable and • Motor tension: (1) trembling, twitching, or pleasurable. The primary motivation is social, feeling shaky; (2) muscle tension, aches, or sore­ and use is voluntary. ness; (3) restlessness; (4) easy fatigability. Circumstantial-situational use' is a self-limited • Autonomic hyperactivity: (5) shortness of use of variable pattern, frequency, intensity, and breath or smothering sensations; (6) palpitations duration. Use is motivated by a perceived need or accelerated heart rate (tachycardia); (7) sweat- to achieve a known drug effect in order to cope 48 JABFP Jan.-Feb.1991 Vol. 4 No.1 1 J Am Board Fam Pract: first published as 10.3122/jabfm.4.1.47 on 1 January 1991. Downloaded from with a specific condition or situation or to en­ current social, occupational, psychologic, or hance the enjoyment of a specific situation. physical problems caused or exacerbated by the Intensified use is long-term patterned use oc­ use of the [drug]." 6 p 169 Alternately, there can curring at least once a day. It is motivated by a be "recurrent use in situations in which use is perceived need or desire to obtain relief from a physically hazardous." As can be seen, drug persistent problem or stressful situation. Use abuse is defined as the use of a psychoactive drug may be unrestrained