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The many faces of anxiety

For health professionals 17 Jan 2022
Pensive woman in front of window

Anxiety commonly impacts the lives of women in Australia, and the burden has only been exacerbated by the pandemic. Recognising the physical manifestations of anxiety, in the absence of obvious psychological symptoms, can sometimes be challenging for health professionals. Here we look at the many faces of anxiety, how to distinguish the more subtle presentations and how to best manage this multi-faceted condition.

Long before the arrival of COVID-19, anxiety was the most common women’s mental health condition in Australia, with one in three women experiencing the condition at some point in her life, according to Beyond Blue. The virus just made things a whole lot worse.

The psychological fallout of the pandemic is evident in healthcare settings. A recent newsGP poll suggested mental health was the number one reason female patients were presenting to GPs.

Identifying anxiety in women can typically be easy. “As a GP, I find in general that women are more attuned to their own thinking and psychological issues than men are,” says Dr Grant Blashki, Lead Clinical Adviser to Beyond Blue.

But sometimes making the diagnosis can be more vexing because the condition manifests itself in physical symptoms.

The psychological as physical

Somatisation, where psychological distress presents as physical symptoms, can occur for a number of reasons.

Dr Blashki says some patients may be less aware of anxiety conditions because of poor mental health literacy. Others might hold strong views or feel stigma about having a mental health condition sometimes arising from cultural or family beliefs. Others may simply be in denial.

So how does a health professional better understand what is going on?

“A few clues to me as a GP that I might be dealing with somatisation are multiple unexplainable symptoms – usually the tests are normal, and the specialist assessments unremarkable – and I ask myself, ‘could this be anxiety?’,” says Dr Blashki.

I use a technique called ‘reattribution’, where we ask people to reflect on the fact that their physical symptoms seem to get stirred up at a particular time of stress, and whether or not this could be related."

Dr Grant Blashki, Lead Clinical Adviser to Beyond Blue

“So, for example, ‘I’ve noticed that you had the headache and the stomach problems last year around exams [as well], could it be connected?’

“It requires a thorough assessment to make sure you’ve ruled out the common physical problems that can manifest as anxiety such as thyroid problems, hormone problems, heart problems and many other conditions. Sometimes I suggest an empirical trial with some of the anti-anxiety approaches.”

The causes of anxiety

The causes of anxiety are complex and often attributed to a mix of genetics and life experiences. In some cases, symptoms of anxiety can be a red flag for an underlying medical illness such as thyroid disease, heart disease, diabetes, and other conditions. It’s also worthwhile noting that anxiety can be a normal response to dealing with any severe illness or stressor.

One of the reasons the GP is most well-positioned to assess someone with anxiety is that they are one of the few professionals who can straddle physical and mental conditions.”

Dr Grant Blashki, Lead Clinical Adviser to Beyond Blue

In practice, he notes, anxiety can often but not always be a diagnosis of exclusion.

Dr Tessa King, a Jean Hailes GP with a special interest in mental health, says it can be difficult for a health professional to quantify a patient’s internal experience of anxiety.

To evaluate the level of anxiety, she will consider questions to establish its severity by asking if the patient feels constantly nervous? Does she feel helpless or hopeless? How is it affecting her quality of life?

“Each person has a unique and subjective experience,” she explains. “I just listen to what their experience of anxiety is.”

If a patient is continually presenting with physical symptoms, she suggests that anxiety as a cause – or exacerbator of these conditions – cannot be discounted.

When it comes to raising a possible diagnosis of anxiety with patients, Dr King recommends a gentle approach. “They are experiencing physical symptoms so you have to be sensitive in suggesting it might be related to anxiety.

In relation to women of reproductive age, she says, “It can be helpful with some patients to ask if anxiety worsens around the second half of the cycle to rule out PMDD [premenstrual dysphoric disorder].

Anxiety is part of the human experience, but we draw the line on where it becomes a problem, a medical condition. There’s a spectrum there. I think it’s good we’re talking about anxiety and treating it.”

Dr Tessa King, Jean Hailes specialist women's health GP

Anxiety conditions: a quick explainer

There are four common types of anxiety disorders.

A person with generalised anxiety disorder (GAD) feels anxious on most days for a period of six months or more. Their worries are intense, persistent and affect their day-to-day lives.

Social anxiety has a number of presentations including a fear of being judged, criticised, or laughed at in front of others. People with a social anxiety disorder can be uncomfortable in social situations where they have to make small talk, or in work situations where they might need to assert themselves.

Panic disorder is usually characterised by uncontrollable feelings of anxiety combined with a range of physical symptoms that might include shortness of breath, chest pains, dizziness, and excessive perspiration.

Phobias centre on a specific concern or fear about a particular situation, activity, animal or object. The feelings of panic or fear are out of proportion to the actual threat.

The COVID factor

Pre-pandemic, anxiety commonly affected the lives of women in Australia – with potential impacts on their relationships, work, sense of identity and ability to engage in opportunities in their lives – and the past two years have only exacerbated the situation.

“COVID had a gendered impact,” says Dr Blashki. “And we know there was a troubling spike in the number of girls and young women presenting to hospitals with self-harm injuries.”

Women were stretched to their limits with work, a greater workload at home, and increased childcare duties. “There was also the complexity around relationships, a lot of loneliness as well as spikes in domestic violence,” he says. “A lot of women lost their jobs and their self-esteem.”

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Treatment: a three-step approach

In treating anxiety, Dr Blashki talks about a three-step approach.

“Look at lifestyle and ensure that the patient is eating well, getting adequate sleep and some regular exercise,” he says. “Encourage them to turn down the stressors in their lives, to pause on big decisions. They might consider meditation. CBT [cognitive behavioural therapy] has also shown promising results.

“The GP can do a physical check-up and blood tests to rule out other medical issues. A Mental Health Plan might be considered, and Medicare still provides subsidies for up to 20 sessions with a psychologist. The psychologist can help the patient to unpack what has been going on with their thinking and provide them with strategies to deal with it.”

Medication can also be considered. “It’s always worth a discussion with the patient to discuss risks”, he says. “But some antidepressants can be a game changer.”

Additionally, Dr Blashki believes it’s important for a doctor to ask the patient about suicidality. It can be raised sensitively, and patients often appreciate the opportunity to talk about it.

Useful screening tools

The best way to distinguish between general stress and anxiety, says Dr Blashki, is to look at the impact on the patient’s life – the severity of the anxiety, its pervasiveness and its duration. The Kessler Psychological Distress Scale (K10) can be a useful tool to measure levels of distress.

The GAD-7 is also a helpful screening tool. It asks patients to evaluate their level of symptoms over the last two weeks. Using a cut-off score of 10, the GAD-7 can be used to screen for panic disorder, social anxiety disorder and post-traumatic stress disorder (PTSD).

Practice points

  • Anxiety, loneliness and sadness are normal responses to a pandemic and are not necessarily reflective of a mental illness.
  • Physical manifestations of anxiety can present without mental symptoms because of lower health literacy, strong views or stigma towards mental health issues, or denial.
  • A thorough assessment of physical symptoms is crucial to rule out other causes such as thyroid, hormonal and cardiovascular conditions.
  • In raising a possible diagnosis of anxiety in someone with physical symptoms, it’s important to take a sensitive approach.
  • Lifestyle recommendations for patients with anxiety include physical activity, healthy eating, stress reduction, limiting alcohol and strengthening social supports.
  • For some women with anxiety, additional treatment with a Mental Health Plan and/or medication can be crucial to quality of life.

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