anxiety pada orang dengan hiv/aids

8/10/2019 Anxiety pada Orang dengan HIV/AIDS

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CHAPTER 8:ANXIETY DISORDERS IN PATIENTS WITH HIV/AIDS

Anxiety is a common symptom in HIV-infected patients. When anxiety symptoms are

severe or persistent, patients may have an anxiety disorder. These disorders include panic

disorder, generalized anxiety disorder, obsessive-compulsive disorder, and post-traumaticstress disorder (PTSD) (see Chapter 9:Trauma and Post-Traumatic Stress Disorder inPatients With HIV/AIDS). A recent study has shown that among HIV-infected patientsreceiving medical care, 20.3% have an anxiety disorder, with 12.3% meeting the criteria

for panic disorder, 10.4% for PTSD, and 2.8% having generalized anxiety disorder.1

Patients with other psychiatric disorders, such as adjustment disorders, major depression,

psychosis, or substance use disorders, can also present with significant anxiety. To helppatients receive optimal care, clinicians need to be aware of the differences among these

specific disorders. Furthermore, patients with histories of anxiety or mood disorders are

susceptible to recurrence of anxiety symptoms during the course of HIV illness.

Key Point:

Patients with limited social support may be particularly susceptible to developing

anxiety symptoms.

I. CLINICAL PRESENTATION

RECOMMENDATION:

Clinicians should consider the diagnosis of an anxiety disorder when a patient

presents with common somatic symptoms, such as chest pain, diaphoresis, dizziness,gastrointestinal disturbances, and/or headache, for which no underlying medical

etiology can be established.

Anxiety can present with a wide range of physiological manifestations, such as shortnessof breath, chest pain, racing/pounding heart, dizziness, diaphoresis, numbness or tingling,

nausea, or the sensation of choking. When patients present with these somatic symptoms,

for which no underlying medical etiology can be established, clinicians should consideran anxiety disorder as the cause. In addition to somatic complaints, patients with anxiety

disorders often present with fear, worry, insomnia, impaired concentration and memory,

diminished appetite, ruminations, compulsive rituals, and avoidance of situations that

make them anxious.

The following questions may help clinicians determine whether anxiety is present:

Are you anxious?

Are you fearful or afraid?

Do you worry a lot?

Are you tense or irritable?

Are you restless?

Do you have difficulty sleeping?


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II. DIAGNOSIS

A. Diagnosis

Anxiety symptoms such as worry, nervousness, fear, and tension are commonly

experienced by people with HIV during periods of their illness and may be a response tostressful situations. An anxiety disorder occurs when symptoms:

Interfere with a patients daily function (e.g., the patient is unable to work, leave

home, attend to medical care)

Interfere with personal relationships

Cause marked subjective distress

Even brief episodes of anxiety, such as those occurring during a panic attack, may

interfere markedly in a patients life andmay warrant a diagnosis of an anxiety disorder.

B. Differential Diagnosis

1. Other Mental Health Disorders and Medical Conditions

RECOMMENDATIONS:

Clinicians should exclude other mental health disorders in patients who present

with anxiety.

Clinicians should exclude medical conditions, including HIV-related central nervous

system disease, in patients who present with anxiety.

Clinicians should review medication regimens and substance use history in patients

with anxiety.

Anxiety-like symptoms may also be caused by mental health disorders other than anxietydisorders. For example, it may be difficult to distinguish depression with agitation from an

adjustment disorder with anxious mood. In general, adjustment reactions follow a stressfulevent, which is often not true in clinical depression, and are less likely to present with the

entire vegetative symptom complex seen in depression, which is characterized by insomnia,diminished appetite, diurnal variation in mood, loss of pleasure/interest, feelings of guilt,fatigue, and attention and concentration problems.

Underlying medical conditions may also cause anxiety-like symptoms. Clinicians should

exclude medical etiologies when evaluating patients who present with these symptoms.Patients can present with anxiety-like symptoms due to any one of the following conditions:

CNS pathologies:HIV-related infections, neoplasms, dementia, or delirium

Systemic or metabolic illness: hypoxia, sepsis, electrolyte imbalance

Endocrinopathies: thyroid disease, hypoglycemia, pheochromocytoma, Cushings

syndrome

Respiratory conditions:pneumonia

Cardiovascular conditions: arrhythmias, pulmonary embolus

Substance intoxication/withdrawal:from alcohol, nicotine, caffeine, cocaine, and

amphetamines


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In addition, psychotropic medications and other commonly prescribed medications may

cause anxiety-like symptoms (see Table 1). Intoxication or withdrawal from substancessuch as alcohol, nicotine, caffeine, cocaine, and amphetamines can also cause anxiety.

Table 1Medications That May Cause Anxiety-Like Symptoms in HIV-Infected Patients

Category Medication

Antihypertensives ReserpineHydralazine

Antituberculous agents IsoniazidCycloserine

Psychotropics Most antipsychotic and antidepressant medications.

Bupropion, an antidepressant that is also given for

smoking cessation, makes some patients extremely

anxious.

Sympathomimetics Ephedrine

EpinephrineDopamine

Phenylephrine

PhenylpropanolaminePseudoephedrine

Antiretrovirals See the Adult HIV Guidelines, Chapter 4A:

Antiretroviral Therapy, Appendix A

Other Amphetamine and methylphenidate

DigitalisLidocaine

Monosodium glutamate

Nicotinic acidProcarbazine

Steroids

Theophylline and aminophyllineThyroid preparations

2. Anxiety Disorders

Once an underlying medical etiology or substance/medication-induced cause has been

excluded, a structured approach is helpful in distinguishing among the anxiety disorders(see Figure 1).


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Underlying medical, substance, or medication etiology?

Generalizedanxiety

disorder

YesYes

Panic attacksor panic

disorder

Discrete episodes of intenseanxiety/fear with chest pain,

pounding heart, diaphoresis,shortness of breath?

Yes

Phobias

Fear/avoidance ofcertain situations,

places, or objects?

Yes

Yes

Obsessive-compulsive

disorder

Intrusive, disturbingthoughts or

compulsive rituals?

Event


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III. MANAGEMENT OF HIV-INFECTED PATIENTS WITH ANXIETY DISORDERS

RECOMMENDATION:

Clinicians should refer patients with symptoms of anxiety to a psychiatrist for

evaluation and possible ongoing treatment when:

Anxiety symptoms do not respond to standard pharmlogic treatment orbasic supportive/behavioral interventions

The diagnosis of an anxiety disorder is difficult to establish

Anxiety is persistent or severe

Patients with obsessive-compulsive disorder have intrusive or disturbing

thoughts or compulsive rituals that are poorly controlled with the current

medication or that cause the patient marked subjective distress

Anxiety occurs in patients with a significant substance use history or in those

who are actively using substances

A. Psychological/Supportive Intervention in the Primary Care Setting

Certain anxiety symptoms can be effectively managed without the use of medication.

There are also patients who prefer to avoid the use of psychotropic medication. Patientswith mild anxiety symptoms that do not interfere with function may respond to

supportive or behavioral interventions. Clinicians may find the following strategies

helpful in such situations:

Expressing empathy

Educating patients about anxiety

Reassuring patients that anxiety is the cause of somatic symptoms experienced

during panic attacks

Identifying the psychological factors that contribute to anxiety Preparing patients for stressful situations and assisting in development of coping

mechanisms

Teaching patients simple relaxation exercises. Slow, deep breathing with focus oninspiration and expiration of air can be helpful. Such exercises can be useful when

patients practice for 1 minute three times a day, increasing to 5 minutes, ifpossible.

Key Point:

Basic supportive and behavioral interventions are sufficient to alleviate anxiety in certainpatients.

For patients with more severe anxiety, psychotherapy, specialized behavioral treatments

such as cognitive-behavioral therapy, and/or medication may be required.

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B. Pharmlogic Intervention in the Primary Care Setting

RECOMMENDATION:

Clinicians should be familiar with the safety profiles of medications used to treat

anxiety and how these medications may interact with those used in the treatment of

HIV disease (Appendix I).

HIV-infected patients, especially those who are symptomatic, are more sensitive to

medication side effects and may respond to lower dosages of anxiolytics. For thesereasons, it is generally best to start low and go slow when prescribing medication.

Furthermore, because patients are often receiving multiple medications, the potential for

drug-drug interactions is great. Clinicians should be familiar with the safety profiles ofmedications used to treat anxiety and how these medications may interact with those used

in the treatment of HIV disease (Appendix I).

1. General Principles in the Pharmlogic Treatment of Anxiety Disorders and Their

Symptoms

No single medication will treat the spectrum of symptoms seen in patients with anxietydisorders. The following general principles will help determine the pharmlogic intervention

that is most likely to be helpful (see Table 2).

Panic Attacks/Panic DisorderIn general, while symptomatic relief for patientsexperiencing panic attacks can usually be accomplished with the short-term use of

benzodiazepines, selective serotonin reuptake inhibitors (SSRIs) are the treatment ofchoice because they effectively prevent panic attacks from recurring. Given the

morbidity associated with ongoing panic attacks, it is important to give prophylaxis toprevent recurrence. Venlafaxine is also effective in preventing panic attacks, as well

as the tricyclic antidepressants, but the latter are limited in their usage due to theirside-effect profiles and potential for drug-drug interactions.

Generalized Anxiety DisorderPatients with chronic anxiety, consistent with

generalized anxiety disorder, may require long-term therapy with medication.Buspirone should be considered because it is an effective anxiolytic that has no

potential for abuse, which is particularly important for patients with a history ofsubstance use. The SSRIs and venlafaxine can also be effective in some patients with

persistent anxiety. Although some patients may experience relief sooner, the onset ofaction of buspirone (3-6 weeks) and SSRIs (2-4 weeks) may necessitate the short-

term use of benzodiazepines; however, these should be used with caution, because ofthe potential for dependence in some patients.

Adjustment DisorderShort-term symptomatic relief may be helpful in somepatients. A time-limited use (2-4 weeks) of benzodiazepines prescribed on a daily oras-needed basis can be effective.

Post-Traumatic Stress DisorderSee Chapter 9:Trauma and Post-TraumaticStress Disorder in Patients With HIV/AIDS.

InsomniaInsomnia is an important symptom to treat because it often causesimpaired daily function. If an underlying medical etiology or chemical cause has been

excluded, insomnia should almost always be considered a symptom of an underlyingpsychiatric disorder (major depression, adjustment disorder, generalized anxiety

disorder, PTSD). Diagnosis and treatment of the underlying condition is essential and

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often results in resolution of the insomnia. Nonpharmlogic approaches to treating

insomnia should be tried before prescribing medications. See Chapter SomaticSymptomsfor recommendations on treating insomnia.

Table 2

Commonly Used Psychotropic Medications in the Treatment of Anxiety Disorders and

Anxiety Symptoms

Disorder or Symptom Medication or Medication Class

Panic disorder SSRIs

Citalopram Paroxetine

Escitalopram Fluoxetine

Sertraline

Tricyclics

Nortriptyline Doxepin

Desipramine Imipramine

Benzodiazepines Lorazepam Clonazepam

Alprazolam

Other

Venlafaxine

Generalized anxiety disorder Buspirone

SSRIs (listed above)

Obsessive-compulsive disorder SSRIs (listed above)

Other

Fluvoxamine Venlafaxine

Clomipramine

Adjustment disorder with anxious

mood

Benzodiazepines (listed above)

Insomnia* Zolpidem

Benzodiazepines (listed above) and temazepam

Other

Trazodone

Doxepin

PTSD SSRIs (listed above)

Major depression with significant

anxiety

SSRIs (listed above)

Benzodiazepines (listed above)Other

Venlafaxine

Tricyclics (listed above)

* Nonpharmlogic approaches should be attempted before treatment with medication. See Chapter Somatic

Symptoms.

Sertraline and paroxetine are the only FDA-approved medications for PTSD. However, all SSRIs (in thesame doses used for depression) are helpful in treating symptoms of depression and anxiety. See Chapter 9:

Trauma and Post-Traumatic Stress Disorder in Patients With HIV/AIDS.

See Chapter 6:Depression and Mania in Patients With HIV/AIDS.

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2.Treatment of Anxiety Disorders in Substance Users

RECOMMENDATIONS:

Primary care clinicians should coordinate with a psychiatrist and/or addiction

specialist when managing anxiety disorders among patients with substance usedisorders. A psychiatric evaluation of these patients should be performed.

Clinicians should discuss the long-term risks of dependence, withdrawal, and abuse,

as well as the intended course of treatment, with patients with substance use

disorders or a history of substance use disorders before benzodiazepines or other

controlled substances are used to treat an anxiety disorder.

Clinicians should make the decision to withhold benzodiazepines on a case-by-case

basis, weighing the risks and benefits for patients with substance use disorders.

The treatment of patients with anxiety who have a substance use history or who areactively using substances poses a challenge for clinicians. Such patients are most

effectively managed when treatment is coordinated with a psychiatrist/addictionspecialist. Psychiatric evaluation should be recommended for such patients. In some

cases, clinicians should defer initiating treatment until the evaluation is completed.

Although most clinicians attempt to avoid the use of medications with potential for abuse,such as benzodiazepines and other controlled substances, such treatment is indicated in

some clinical situations. In these cases, discussions about the long-term risks of

dependence, withdrawal, and abuse and the intended course of treatment are necessaryprior to initiation of medication. The decision to withhold benzodiazepines shouldbe

made on a case-by-case basis, weighing the risks and benefits. Furthermore, the risk ofdiscontinuing or withholding benzodiazepines may have serious medical complications.

Documentation in the medical record of the decision-making process is essential to

ensure consistency and continuity of care. (See Chapter Substance Use and MentalHealth in HIV-Infected Patients.)

REFERENCE

1. Vitiello B, Burnam MA, Bing EG, et al. Use of psychotropic medications among

HIV-infected patients in the United States.Am J Psychiatry2003;160:547-554.

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