Clinical Manual for Management of the HIV-Infected Adult
2006 Edition

Section 8: Neuropsychiatric Disorders

Anxiety Disorders

Background

Anxiety symptoms can develop because of a patient's uncertainty about HIV infection and treatment or because of issues unrelated to HIV. Symptoms can include mild distress, full-blown panic attacks, generalized anxiety disorder, or other disorders. The criteria for a diagnosis of generalized anxiety disorder include unrealistic or excessive worry about 2 or more life circumstances for more than 6 months, and at least 6 of the subjective complaints listed below.

It is important to differentiate between anxiety with and without panic attacks. Symptoms of anxiety can mimic symptoms of physical illness, and an appropriate workup should be performed to rule out other illnesses. (For more information about panic disorders, see chapter Panic Disorder.)

S: Subjective

The patient complains of the following:

• Difficulty concentrating
• Dizziness or lightheadedness
• Dry mouth
• Easy fatigability
• Exaggerated startle response
• Feeling anxious or on edge
• Flushes or chills
• Frequent urination
• Irritability
• Muscle tension, aches, or soreness
• Nausea, diarrhea, or other abdominal distress
• Palpitations or accelerated heart rate
• Restlessness
• Shortness of breath or smothering sensations
• Skin rashes
• Sweating or cold, clammy hands
• Trembling, twitching, or feeling shaky
• Trouble falling or staying asleep
• Trouble swallowing or "lump in the throat"

History

Obtain the following information during the history:

• Anxiety patterns (eg, constant or intermittent; timing)
• Caffeine intake
• Concomitant illnesses
• Family history of similar problems
• Medications, supplements, and herbal preparations
• New or recurrence of previous episodes
• Onset: sudden or gradual
• Recent stressors
• Recreational drugs or alcohol use (current or recent)
• Sleep disturbances
• Other physical symptoms

O: Objective

Perform a physical examination, including mental status and neurologic examination. Note heart rate, respiratory rate (shortness of breath, hyperventilation), tremor, rashes.

A: Assessment

A partial differential diagnosis includes the following:

• Allergic reactions
• Anemia
• Central nervous system (CNS) or opportunistic infections or malignancies
• Electrolyte imbalances
• Excessive caffeine intake
• Heart disease, arrhythmias
• Hyperthyroidism
• Hypoglycemia
• Immune disorders
• Medications such as efavirenz, isoniazid, steroids, theophylline
• Respiratory disease
• Sleep disturbances or sleep deprivation
• Substance use (eg, amphetamines, cocaine)
• Substance withdrawal (eg, alcohol, benzodiazepines)
• Systemic or other infections
• Vitamin B12 deficiency

P: Plan

Laboratory and Diagnostic Evaluation

Perform the following tests:

• Electrocardiogram (EKG)
• Thyroid studies
• Blood glucose
• Arterial blood gases (if frank difficulty breathing is not self-limited)
• Other tests as indicated based on symptoms and physical examination

Treatment

Once other diagnoses have been ruled out and the diagnosis of anxiety disorder is established, several options are available:

Cognitive-behavioral therapy interventions

Options include individual cognitive-behavioral therapy, a stress-management group, relaxation therapy, visualization, and guided imagery. Refer the patient to available community-based support.

Psychotherapy

Psychotherapy may be indicated if experienced professionals are available and the patient is capable of forming an ongoing relationship. If possible, refer to an HIV-experienced therapist.

Pharmacotherapy

Patients with advanced HIV disease, like geriatric patients, may become more vulnerable to the CNS effects of certain medications. Medications that affect the CNS should be started at low dosage and titrated slowly. Similar precautions should apply to patients with liver dysfunction.

Interactions may occur between selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, and HIV medications. Consult with an HIV expert or pharmacist before prescribing.

• SSRI-type antidepressants, including fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro) may be effective. Venlafaxine timed-release formulation (Effexor XR), at dosages of 75-225 mg/d, has been approved for the treatment of generalized anxiety disorder. Note: There is a risk of hypertension at the higher dosages of venlafaxine; monitor blood pressure.
• Buspirone (BuSpar) is a nonaddictive anxiolytic. Start at 5 mg orally 3 times per day. If symptoms persist, the dosage can be increased by 5 mg per dose each week to a maximum of 10-15 mg orally 3 times per day (for a total daily dosage of 30-45 mg). It will take several weeks for patients to notice a decrease in anxiety; low-dose benzodiazepines may be used during this interval. The major potential adverse effects of buspirone are dizziness and lightheadedness.
• Treatment may include intermediate half-life benzodiazepines such as oxazepam (Serax) 10 mg orally every 6 hours or lorazepam (Ativan) 0.5 mg orally every 8 hours, if buspirone is not tolerated or to alleviate anxiety symptoms until buspirone takes effect. Longer-acting benzodiazepines such as clonazepam (Klonopin) also may be useful at dosages of 0.25-0.5 mg orally twice a day.
• Benzodiazepines should be used only for acute, short-term management because of the risk of tolerance and physiologic dependence. These risks are even more problematic in patients with a history of addiction.
• Note that protease inhibitors and nonnucleoside reverse transcriptase inhibitors may raise blood concentrations of many benzodiazepines. If benzodiazepines are used, they should be started at low dosages, and other CNS depressants should be avoided. Consult with a clinical pharmacist before prescribing.
• Midazolam (Versed) and triazolam (Halcion) are contraindicated with all protease inhibitors and with delavirdine and efavirenz.
• Some sedating antidepressants are effective, nonaddictive anxiolytic agents. These include trazodone (Desyrel) 25-100 mg at bedtime or imipramine (Tofranil) 25 mg at bedtime. Note that imipramine is contraindicated with ritonavir or in advanced HIV disease. Neurontin 200-400 mg 2 times daily or 4 times daily can also be used.

Patient Education

• Behavioral interventions can help to reduce anxiety, but may take practice. Patients should seek help from a therapist, an experienced source, or a friend.
• Some patients develop problems with sexual function because of antianxiety medications. Patients should report any problems to their prescribers.

References

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington: American Psychiatric Association; 1994.
• New York State Department of Health AIDS Institute. Mental Health Care for People with HIV Infection: Clinical Guidelines for the Primary Care Practitioner. 2001. Available online at www.hivguidelines.org/. Accessed February 7, 2006.
• U.S. Department of Health and Human Services. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. May 4, 2006. Available online at aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?GuidelineID=7. Accessed May 19, 2006.