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Disappointing article in NEJM on anxiety

MeSci

ME/CFS since 1995; activity level 6?
Messages
8,231
Location
Cornwall, UK
Generalized Anxiety Disorder
Murray B. Stein, M.D., M.P.H., and Jitender Sareen, M.D.

N Engl J Med 2015; 373:2059-2068November 19, 2015

I think that this piece is related to a recent diagnostic quiz in the journal, which alarmed but did not entirely surprise me in that it offered a list of psychiatric diagnoses but not a single physiological one.

It makes several claims for 'evidence', based on research that I suspect is of poor quality as it sounds oh-so-familiar.

This conflict of interest is given at the end:
Dr. Stein reports receiving consulting fees from Janssen, Pfizer, and Tonix Pharmaceuticals, and from Care Management Technologies for providing a review of health service protocols.

Some other quotes that cause me to question the validity of the claims and general psychiatric gist of the piece are:
In primary care, patients with this disorder often present with physical symptoms such as headaches, muscle tension, gastrointestinal symptoms, back pain, and insomnia.

another peak of new-onset cases occurs in older adulthood, often in the context of chronic physical health conditions.

The predominant presentation in primary care (rather than mental health) settings is physical symptoms such as headaches or gastrointestinal distress.5 In children, generalized anxiety disorder often manifests as recurrent abdominal pain and other somatic symptoms6 that may cause them to stay out of school.

Patients with generalized anxiety disorder have increased risks of other mental and physical health conditions (e.g., chronic pain syndromes, asthma or chronic obstructive pulmonary disease, and inflammatory bowel disease).9
Er, where are the mental illnesses in that lot?
A psychological construct known as intolerance of uncertainty — the tendency to react negatively to situations that are uncertain — has been shown to be a relatively specific characteristic of persons with generalized anxiety disorder.15
Actually this seems to me to be more of a typical issue with doctors, who are unable to say "I don't know." Perhaps they project this onto their patients - this is claimed to be a common psychological problem - mistaking your psychological problems/fears as being someone else's!
Patients with generalized anxiety disorder generally have an affirmative response to the question “Do you worry excessively about minor matters?” That question is worth asking of patients with insomnia, a depressed mood, chronic gastrointestinal and other pain symptoms, or other unexplained recurrent health concerns.

Isn't worrying excessively the definition of GAD? The reference to chronic gastrointestinal symptoms is a big clue IMO, which is not adequately addressed in this article. Having personally reduced my anxiety levels dramatically through diet and supplements, and read of others who have done the same, it seems extremely remiss for the authors not to mention this. Has it not yet filtered through to such a respected journal as the NEJM? Instead they are allowing an article that promotes the usual dubious 'evidence' and the usual treatments, which have very limited efficacy IME and IMO, and some can be dangerous.
Since insomnia is a prominent symptom of generalized anxiety disorder, the patient should be encouraged to practice positive sleep-hygiene behaviors (i.e., to maintain a regular sleep schedule, avoid smoking or the use of nicotine during the evening, and avoid alcohol and the prolonged use of devices with light-emitting screens, such as smartphones, laptops, and television, before bedtime). However, randomized trials are lacking to support specific benefits of sleep hygiene for patients with generalized anxiety disorder.

So why should it be encouraged? Shades of PACE here...

When I was an anxiety-ridden child there were no computers and very little on TV. My time was spent making my own entertainment, which included country walks. I did, however, have gastrointestinal problems and a diet full of sugar and starch. Did children only start getting GAD when computers and smartphones were invented? I don't think so.
Selective serotonin-reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) are generally considered to be first-line pharmacotherapies for generalized anxiety disorder, with response rates in the range of 30 to 50%.23,32 A recent meta-analysis suggested the possibility of publication and reporting biases in clinical trials of these agents for the treatment of anxiety, but the authors concluded that these biases probably did not lead to a systematic inflation of effect sizes.33

The authors say it's OK. So that's all right then. :rolleyes:
The evidence base is growing for the use of SSRIs and SNRIs for the treatment of anxiety disorders, including generalized anxiety disorder, in children and adolescents.35

Really? I haven't heard about this, but have heard about increasing evidence for SSRIs increasing suicidality, amid withholding of data about this risk. I think it involves unpublished studies.
 
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whodathunkit

Senior Member
Messages
1,160
An organ can be a "mouthpiece" or a way of disseminating information.

An organ can also be a...well, you know. A "tool".

Little un-PC play on words there.
 

MeSci

ME/CFS since 1995; activity level 6?
Messages
8,231
Location
Cornwall, UK
An organ can be a "mouthpiece" or a way of disseminating information.

An organ can also be a...well, you know. A "tool".

Little un-PC play on words there.
Oh, I see. I thought perhaps you were referring to an author called Organ (there are several scientific authors with that name!).
 

MeSci

ME/CFS since 1995; activity level 6?
Messages
8,231
Location
Cornwall, UK
you betcha! over-the-top physiological anxiety. Greatly exacerbated by that other non-significant fad, gluten. Brain inflammation anyone???
No no no - you are just imagining that gluten is a problem. You are clearly worrying too much. Non-coeliac gluten sensitivity is just a fad...:D
 
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3,263
@MeSci, sorry I'm bit late posting, I know, but I just read the NEJM paper.

The actual content of the paper didn't sound as bad as the opening couple of paragraphs. They did make it clear later that their idea of generalised anxiety disorder definitely had psychological features as it core (that the somatic complaints were just an alert to doctors to at least ask questions about worry).

But in general, I am concerned about the inclusion of somatic complaints in any psychiatric diagnosis or in any psychological construct for that matter. The core idea underlying depression, anxiety etc., is that these are about certain patterns of thinking and/or kinds of feelings. That's what makes them psychological. Somatic complaints are often included in diagnoses or in self-report scales because they seem to frequently accompany those thoughts and feelings. But by including them in definitions and scales, we risk losing the integrity of the original concept - which was psychological - and contaminating them with a measure of something very different. Especially when we cannot ascertain to what extent the somatic complaints are caused by the thoughts/feelings.

Not sure that makes any sense at all. But thanks for posting, interesting.
 

jimells

Senior Member
Messages
2,009
Location
northern Maine
One big problem with all these diagnoses is that "anybody" and "everybody" are now qualified to make them. Where I live, all it takes is a masters degree in psychotherapy - maybe even less. And of course there's no time to bother with excluding possible well-known biomedical causes of the symptoms, which the psychotherapy people are completely unqualified to do.

The primary care people are just as bad, since they don't have or take the time to actually find out about the patient's background and social history. I have a new primary care physician. She never asked about what I did before getting so sick, or what I would do if I wasn't sick, or even the extent of my impairments. I explained how without medication my pulse goes from 60 supine to 120 standing in less than ten minutes. She could see my hyperadrenergic state (cold & clammy hands and feet, blue & red feet, etc) and still proclaimed my illness is primarily psychological as she sent me to the ER for a liter of saline. :bang-head::bang-head:

Meanwhile we have all these official publications promoting psychobabble and pills to family physicians and telling them that treating symptoms somehow magically perpetuates them.

How can we possibly get through to our doctors?
 

MeSci

ME/CFS since 1995; activity level 6?
Messages
8,231
Location
Cornwall, UK
She could see my hyperadrenergic state (cold & clammy hands and feet, blue & red feet, etc) and still proclaimed my illness is primarily psychological as she sent me to the ER for a liter of saline. :bang-head::bang-head:
Why would saline be used for a psychological condition? A number of PwME have found that saline helps with physical symptoms, which makes sense, as many - perhaps most - of us seem to be deficient in salt and fluids.
 

jimells

Senior Member
Messages
2,009
Location
northern Maine
Why would saline be used for a psychological condition? A number of PwME have found that saline helps with physical symptoms, which makes sense, as many - perhaps most - of us seem to be deficient in salt and fluids.

I've been trying to get an order to receive a saline IV at home for the last month. I've been to the ER three times now in the past six weeks. I think the only reason the primary care doctor agreed to it after her exam is that she talked to the ER doctor, who actually looked up POTS after I showed up in his ER and asked for a saline IV. (It's a tiny hospital so the doctors all know each other)

Thank God there are some doctors willing to listen to patients. Around here they mostly seem to be ER docs, for some reason.
 

MeSci

ME/CFS since 1995; activity level 6?
Messages
8,231
Location
Cornwall, UK
I've been trying to get an order to receive a saline IV at home for the last month. I've been to the ER three times now in the past six weeks. I think the only reason the primary care doctor agreed to it after her exam is that she talked to the ER doctor, who actually looked up POTS after I showed up in his ER and asked for a saline IV. (It's a tiny hospital so the doctors all know each other)

Thank God there are some doctors willing to listen to patients. Around here they mostly seem to be ER docs, for some reason.
That's a problem @taniaaust1 has been battling with too - getting saline at home instead of waiting to collapse, being rushed to hospital, asking for saline there (sometimes in vain) and then struggling to get home again. :(
 

barbc56

Senior Member
Messages
3,657
and "everybody" are now qualified to make them. Where I live, all it takes is a masters degree in psychotherapy
In the US, each state requires that you are licensed to be able to (legally? medically?) diagnose anyone with a psychiatric disorder. This not only requires you to take specific courses at an accredited institution but also includes, among other things, one or morr internships and clinical hours.There are also requirements to remain certified. These may differ by state. It's a lot of work.

Of course all this is meaningless if the diagnostic guidelines are crap.

http://www.counselor-license.com/articles/counselor-license.html#context/api/listings/prefilter

Barb
 
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Messages
3,263
MSci said:
A psychological construct known as intolerance of uncertainty — the tendency to react negatively to situations that are uncertain — has been shown to be a relatively specific characteristic of persons with generalized anxiety disorder.
Actually this seems to me to be more of a typical issue with doctors, who are unable to say "I don't know."
Perhaps they project this onto their patients - this is claimed to be a common psychological problem - mistaking your psychological problems/fears as being someone else's!

This is funny = and ironic!
 

jimells

Senior Member
Messages
2,009
Location
northern Maine
one or morr internships and clinical hours.There are also requirements to remain certified. These may differ by state. It's a lot of work.

And the internships are unpaid - basically slave labor. I understand all that. But it doesn't require the therapists to be able to differentiate biomedical illness from psychological behaviors - a major hole, in my opinion.
 

barbc56

Senior Member
Messages
3,657
And the internships are unpaid - basically slave labor. I understand all that. But it doesn't require the therapists to be able to differentiate biomedical illness from psychological behaviors - a major hole, in my opinion.

Definitely. It's really a matter of the whole system being biased.

Barb.
 

Hip

Senior Member
Messages
17,795
Er, where are the mental illnesses in that lot?

Generalized anxiety disorder (GAD), like other mental disorders, often comes with physical symptoms. This fact should make people realize that many mental disorders are likely underpinned by an organic physical dysfunction of the body which causes both mental and physical symptoms, rather than the mental disorder being caused by psychological factors.



A psychological construct known as intolerance of uncertainty — the tendency to react negatively to situations that are uncertain — has been shown to be a relatively specific characteristic of persons with generalized anxiety disorder.

Actually this seems to me to be more of a typical issue with doctors, who are unable to say "I don't know." Perhaps they project this onto their patients

I don't think it has got anything to do with doctors; this intolerance of uncertainty was probably first observed by psychologists, and it makes perfect intuitive sense if you think about it: since the primary mental symptoms of GAD are excessive worry and/or excessive mental tension, then clearly uncertain situations, which tend to raise mental tension and worry even in healthy people, are very likely going to cause lots of problems for someone with GAD, who has a much higher baseline level of tension and worry. So intuitively you would expect someone with GAD to be less able to tolerate uncertain or precarious situations.

When I first developed GAD, I changed from being a person happy to take risks, to becoming wary of any situations of uncertainty.

If you have GAD, which I think may be an organic physical dysfunction that turns up your volume control on your brain's risk and uncertainty amplifier (otherwise known as the amygdala), then even small inputs of uncertainty into this amplifier are going come out as very loud sounds of tension and worry. Stands to reason.


I have elsewhere speculated that a full nervous breakdown may occur when: (a) someone develops GAD (via some organic physical causes), and then (b) when that personal, who now has a major intolerance of uncertainty, gets forced (perhaps though their job or their life circumstances) to encounter situations of high stress, high risk and high uncertainly. Then the combination of a high baseline of tension and worry from an organic disease of GAD, plus the situations of high stress and uncertainly, will lead to a full nervous breakdown.



Selective serotonin-reuptake inhibitors (SSRIs) and serotonin–norepinephrine reuptake inhibitors (SNRIs) are generally considered to be first-line pharmacotherapies for generalized anxiety disorder, with response rates in the range of 30 to 50%.
The authors say it's OK. So that's all right then.

For me personally, SSRIs dramatically and severely worsened my depression, and induced intense suicidal ideation within hours of taking a pill (not surprising then that SSRIs are known to lead suicide in some cases — and now carry a black box warning about this). So I unfortunately could not use SSRI drugs to treat my GAD. But one friend of mine who also suffered from GAD found SSRIs very effective as a GAD treatment.



I am concerned about the inclusion of somatic complaints in any psychiatric diagnosis or in any psychological construct for that matter. The core idea underlying depression, anxiety etc., is that these are about certain patterns of thinking and/or kinds of feelings. That's what makes them psychological.

Some psychologists and the general public might think that, but others (myself included) assume that many mental health conditions have a physical organic cause, and a physical pathophysiology.



Somatic complaints are often included in diagnoses or in self-report scales because they seem to frequently accompany those thoughts and feelings.

But by including them in definitions and scales, we risk losing the integrity of the original concept - which was psychological - and contaminating them with a measure of something very different. Especially when we cannot ascertain to what extent the somatic complaints are caused by the thoughts/feelings.

Lots of mental health disorders come with physical symptoms, and likewise, quite a few physical health disorders come with mental symptoms.

If we assume that a mental disorder primary has an organic cause and pathophysiology (as opposed to the mental disorder having a psychological cause), then you might expect that pathophysiology to manifest both physically and mentally.


You are starting with different assumptions: that the mental disorder is caused by psychological factors, and that the mental disorder then spills over to the body to create somatic symptoms. A lot of psychologists see it this way, but I think this is likely the wrong way to look at it.

As mentioned, I think most mental disorders will turn out to have primarily organic physical causes. Those physical causes then trigger both the mental symptoms, and also trigger some physical symptoms at the same time.
 
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3,263
As mentioned, I think most mental disorders will turn out to have primarily organic physical causes.... You are starting with different assumptions: that the mental disorder is caused by psychological factors, and that the mental disorder then spills over to the body to create somatic symptoms. A lot of psychologists see it this way, but I think this is likely the wrong way to look at.
I think we all agree here, @Hip. If you read back over the posts, that is exactly what I and the others were saying.