Anxiety & Traumatic Stress

What does it look like?

Anxiety symptoms, such as those noted in the table below, can be normal responses to major stressors such as the COVID-19 pandemic and quarantine. However, if these symptoms persist and/or become functionally impairing they may represent the onset and/or exacerbation of an anxiety disorder such as Post-Traumatic Stress Disorder, Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Panic Attack Disorder and Agoraphobia.

Normal vs. pathological reactions to intense stress/trauma

Generalized anxiety disorder

Generalized anxiety disorder is characterized by a variety of worries that are difficult to control, produce distress, and are often associated with physical symptoms. Most often patients describe muscle tension or GI upset. These patients often describe themselves as lifelong “worriers” or “worry warts.”

PTSD

Adult Trauma Vignette

Jane is a 56 year old woman with a history of asthma. She works as a grocery store manager and has been required to wear a mask when at work due to the COVID-19 pandemic. Two months ago, she started experiencing shortness of breath and chest pain while at work and was rushed to the emergency room fearing she was having a heart attack. Due to the COVID-19 pandemic, the hospital was overcrowded. She waited on a bed in the hallway for 6 hours, because there were not enough rooms. While she was waiting, she witnessed a “code blue” and the patient didn’t make it. When she was finally worked up, she was found to be in good health and had not had a heart attack. It was determined that she was experiencing an exacerbation of her asthma. She was given an inhaler and sent home. She is here today to follow up with her PCP after her emergency room visit to discuss her asthma treatment and continue difficulty tolerating wearing a mask at work. Upon further questioning, she also describes trouble sleeping. She has been waking up almost every night due to nightmares about her experience in the hospital. In her nightmares, she relives the scenario she witnessed when the patient didn’t make it, and experiences the fear she felt when she thought she was having a heart attack and no one would be able to help her in time. She wakes up in a cold sweat and sometimes can’t get back to sleep. Any time she feels short of breath, she is reminded of the hospital all over again. She used to love running, and found it to be a helpful stress reliever, but she hasn’t gone running since, as she doesn’t want to feel shortness of breath. Her husband has tried to talk to her about what happened, but she will abruptly change the subject- it’s too painful to have to relive what happened. Her main goals for this appointment are to improve her sleep and control her asthma so that she can tolerate wearing a mask at work and can resume running.

You talk with Jane about her asthma and work with her to determine how to best use her inhaler to manage her symptoms. Given the other information Jane shared, you also suspect she may be experiencing post-traumatic stress disorder (PTSD) and have her fill out the PTSD Checklist (PCL).  She has an elevated score, so you give her some information about common reactions to trauma and refer her to mental health services to follow up.

How do I screen for it?

To screen for general anxiety symptoms, use the Generalized Anxiety Disorder Questionnaire (GAD-7):

Scoring for the GAD-7
0-4: minimal anxiety
5-9: mild anxiety
10-14: moderate anxiety
15-21: severe anxiety

For scores between 5-14, offer self-help resources and continue to screen at each visit; for scores between 10-14 you may also consider a consultation with Behavioral Health Collaborative Care.

Scores > 14 warrant consultation with Behavioral Health Collaborative Care, or consideration of referral for psychotherapy. If you are a Michigan Medicine provider, and would like access to our lists of behavioral health resources, you may contact Michele Brown at resoho@med.umich.edu.

To screen for post-traumatic stress disorder, consider the following instruments:

PCL5: Posttraumatic Stress Disorder Checklist  
Assesses symptoms of PTSD.
  Frequency: every 84 days
  Age Range: 18+
  Interpretation: 38+: Suggestive of PTSD
  MiChart Name: UM AMB POSTTRAUMATIC STRESS DISORDER CHECKLIST (PCL5)

PCPTSD: Primary Care PTSD Questionnaire  
Assessment of symptoms of PTSD.
  Frequency: every 175 days
  Age Range: 18+
  Interpretation: 3+: Suggestive of PTSD
  MiChart Name: UM AMB PRIMARY CARE PTSD SCREEN (PCPTSD)

 

For scores suggestive of PTSD, consult with Behavioral Health Collaborative Care. In clinics without access to BHCC, consider referral for psychotherapy. If you are a Michigan Medicine provider, and would like access to our lists of behavioral health resources, you may contact Michele Brown at resoho@med.umich.edu. Medication treatment considerations can be found here [insert link]. In addition, consider providing information on the PTSD Coach app to provide the patient with initial psychoeducation. Medication treatment considerations can be found here [insert link to that section]. {{ still to do!}}

What are the treatment options?

Psychotherapy is considered first-line treatment for many anxiety disorders. It is also reasonable to start and/or augment with medication for severe symptoms, comorbid depression and/or if there are significant delays/hurdles to starting psychotherapy. SSRI and SNRI medications are safe and appropriate first-line pharmacological options for treating anxiety disorders.

Self-Help Resources

Self-Help for Anxiety

Care Guide Handouts


 

Managing Anxiety During the COVID-19 Pandemic

 


Michigan Medicine Depression Center Toolkit

For: Adults, adolescents
Cost: Free
Description:
Provides information, tools, support, and resources for people who are experiencing problems with mood, stress/anxiety, those who have been recently diagnosed with depression or bipolar disorder, and those receiving treatment for mood disorders.
Also offers help to family members and caregivers of those who suffer from mood disorders
Created by experts from the University of Michigan Depression Center, with the help of individuals with lived experience of mood and anxiety disorders and a group of external professionals.


Mood Gym

For: Adults
Cost: $27 for 12-month access
Description:
Moodgym is like an interactive self-help book which helps you to learn and practice skills which can help to prevent and manage symptoms of depression and anxiety.
Studies of use in primary care settings demonstrate effectiveness in reducing depression and anxiety symptoms.


 

Self-Help for PTSD

PTSD Coach - Download app at Apple App store or Google Play

For: Adults
Cost: Free
Description:
PTSD Coach was designed for those who have, or may have, posttraumatic stress disorder (PTSD). This app provides education about PTSD, information about professional care, a self-assessment for PTSD, opportunities to find support, and tools that can help you manage the stresses of daily life with PTSD. Tools range from relaxation skills and positive self-talk to anger management and other common self-help strategies. This app can be used by people who are in treatment as well as those who are not.

Additional Resources