What is anxiety?
Anxiety consists of several disorders or symptom constellations. Individuals afflicted by anxiety may range from feelings of worry and panic or physical reactions such as palpitations, muscle tension, or shortness of breath. Anxiety is not always problematic, but in the 21st century we do not require the level of fear and apprehension needed by our ancestors. Anxiety becomes problematic when it interferes with one’s daily functioning. Patients may present with one or more anxiety disorders, the symptoms of which may arise before, during or after pregnancy.
- Generalized Anxiety Disorder is notable for feelings of inappropriate worry about ordinary situations. The patient frequently suffers from sleep disturbance, irritability, and muscle tension in addition to their emotional concerns.
- Social Anxiety Disorder causes the sufferer to be very uncomfortable in situations where others may observe or judge them.
- Panic Disorder is notable for the rapid onset and intensity of symptoms, which often result in feeling as if one is losing control, having a heart attack, or dying.
- Agoraphobia. Strictly speaking, agoraphobia is the fear of open places, but for the sufferer, it is a fear of places or circumstances where one may feel unsafe, helpless, or unable to escape. In the most severe cases, the sufferer is unwilling to leave their home.
- Phobia. Phobias are typically very specific. Common phobias include fear of heights, spiders, blood and closed spaces. Their fear causes them to avoid specific things, and anything associated with it.
What does anxiety feel like to the patient?
The variety of anxiety disorders result in a range of symptoms and presentations, but prominent among all of them is a sense of fear and discomfort. Somatic symptoms are commonly seen as part of the presentation as well. Symptoms include, but are not limited to, the following:
- Feeling nervous
- Chest tightness
- Sense of danger, panic, doom
- Nausea or diarrhea
- Poor concentration
Patient Example 1: Jan is a primipara woman, who, along with her partner, has spent significant time and expense becoming pregnant. Since learning she was expecting, she has been sleeping poorly, lying awake thinking of all the things that could go wrong with the pregnancy. Despite not suffering from morning sickness, she has lost two pounds in the 18 weeks of her pregnancy. She has called the practice’s nursing line nearly daily to ask if her symptoms are normal and has insisted that she have weekly ultrasounds to ensure the baby is growing appropriately.
Patient Example 2: Quinn is a 40-year-old multigravida patient who reports three trips to the emergency room since last month’s visit. Quinn reports being in their usual state of health when “out of nowhere” palpitations and hyperventilation started. As additional physical symptoms appeared, Quinn became convinced that they were having a heart attack. Despite thrice being reassured that the pregnancy was at no risk and their heart was healthy, Quinn remains convinced that there will soon be another episode and the next one may be deadly.
PEACE for Moms recommends that all patients are screened for anxiety throughout the pregnancy and postpartum. The GAD-7 is a brief tool that has been validated for use in clinical settings; it is over 80% sensitive and specific at diagnosing generalized anxiety disorder.
If symptoms are more difficult to delineate it may be beneficial to administer the Perinatal Anxiety Screening Scale (PASS). For the perinatal patient, the PASS may better assess the patient for social anxiety disorder, OCD or trauma. When symptoms are more difficult to define, administration of the PASS may be beneficial. This tool may help you differentiate between general or social anxiety, obsessionality and trauma related symptoms.
For clinicians who have chosen to only administer the Edinburgh Postpartum Depression Scale (EPDS), the scale may be used to determine if further screening for anxiety should be performed. A patient who provides an affirmative response to any of these three questions from the EPDS may benefit from further evaluation for an anxiety disorder:
- Question #3: I have blamed myself unnecessarily when things went wrong
- Question #4: I have been anxious or worried for no good reason
- Question #5: I have felt scared or panicky for no good reason
Patients who screen positively for this subscale may benefit from further assistance.
As with nearly all diagnoses shared with a patient, especially one who is pregnant or postpartum, the first step to alleviating symptoms is to reassure the patient, sharing with them the nature of the diagnosis and the likely course.
There is no one best medical treatment for anxiety disorders. While many of these medications listed below are used for anxiety disorders, only some have an FDA indication for the treatment of anxiety. Before prescribing a medication off label for your pregnant or postpartum patient, we encourage you to consult with PEACE for Moms.
Benzodiazepines have been used first line by many clinicians but there is no evidence that they are a superior long-term treatment for anxiety disorders. While benzodiazepines can attenuate anxiety symptoms, the risks, including addiction and falls, lead us to recommend their use only with significant caution, especially for pregnant or breastfeeding patients.
When initiating any medication, we recommend you begin at a low dose to minimize side effects (real or imagined). Medication can be increased in increments. PEACE for Moms can assist clinicians with ultra-slow medication tapers if necessary; we find this is the case in those with medication anxiety.
FDA Approved Medications for Specific Anxiety Disorders
|Medication||Generalized Anxiety Disorder||Panic Disorder||Social Anxiety Disorder||Anxiety||Dosage (mg/day)|
Frequently asked questions
My patient is really uncomfortable. She has been increasingly anxious since becoming pregnant, fearful that everyone is looking at her belly when she does sales presentations. She dreads going to work. But she is against taking anything “unnatural” while pregnant.
Patients with anxiety disorders are often reluctant to begin medication. If you feel that a patient will benefit from starting medication for their anxiety, initiating psychotherapy, especially cognitive behavioral therapy, may ease the introduction.
My G2P1 patient is having nearly daily panic attacks. They typically happen on the drive to work and as a result she is not making it to work. Her mother gave her a Xanax recently and she said it was a miracle. Now she wants more of them.
Explain to your patient that Xanax and similar medications are simply Band-Aids and are not treating the panic disorder. Antidepressants, while slower to work, are safer for her and for her unborn child.
Moses, S. (2021, October 28). Anxiety non-pharmacologic management. Family Practice Notebook. Retrieved November 4, 2021, from https://fpnotebook.com/psych/Anxiety/AnxtyNnPhrmclgcMngmnt.htm.
Garakani, A., Murrough, J. W., Freire, R. C., Thom, R. P., Larkin, K., Buono, F. D., & Iosifescu, D. V. (2020). Pharmacotherapy of Anxiety Disorders: Current and Emerging Treatment Options. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.595584