Magazine article Clinical Psychiatry News

Practical Psychopharmacology: Anxiety in Schizophrenia. (Psychopharmacology)

Magazine article Clinical Psychiatry News

Practical Psychopharmacology: Anxiety in Schizophrenia. (Psychopharmacology)

Article excerpt

Historically, anxiety has gone undiagnosed and untreated in schizophrenia. "Because the primary disorder is so severe, all symptoms manifested by patients were regarded as part and parcel of the psychotic process, said Dr. Michael Y Hwang, director of schizophrenia research at the New Jersey Veterans Administration Medical Center, East Orange.

But that appears to be changing. There are signs that anxiety is joining depression and substance abuse, for example, as targets for treatment.

This change in part reflects the raised expectations that have come with newer medications, said Dr. Robert C. Stern of Robert Wood Johnson Medical School, Piscataway, NJ. "Until recently, treating schizophrenia meant doing the basics to keep patients out of the hospital. Now, it's no longer a luxury to think about rehabilitation, reintegration, and quality of life." Indeed, it is becoming clear that anxiety symptoms and disorders are highly prevalent in schizophrenia and that they have a profound effect on life satisfaction and functional capacity. For example, recent studies found obsessive-compulsive disorder (OCD) rates of 8%-23% among hospitalized patients and "clinically significant" social phobia symptoms in half of a series of outpatients.

"Anxiety clearly relates to subjective quality of life," said Jonathan Huppert, Ph.D., of the Center for the Research and Treatment of Anxiety at the University of Pennsylvania, Philadelphia. His research linked elevated anxiety on the Brief Psychiatric Rating Scale with lower satisfaction with life, in general and in specific areas, in recently stabilized outpatients. Over the course of a year, changes in anxiety related more strongly with life satisfaction than with positive symptoms, negative symptoms, or depression, he said.

The same applies to specific anxiety syndromes. Schizophrenic patients with substantial OCD symptoms function more poorly, spend more time in the hospital, and generally follow a rockier clinical course than do those without such symptoms, according to Dr. Hwang.

Dr. Stern said social phobia symptoms "can have a substantial impact on the social functioning and quality of life of individuals whose social activities, employment options, and ability to benefit from group-oriented treatment are ... severely restricted."

But anxiety is not often assessed in the context of schizophrenia, either in general or in specific syndromes. Dr. Huppert observed that when he interviewed patients about anxiety, a high proportion "said that no one had asked these questions before. Chart diagnoses were absent, but more than half met anxiety disorder criteria."

Dr. Hwang advocates screening for current and prior anxiety comorbidity at the time of evaluation.. "Once you've identified OC or panic symptoms, go into detail. Examine their severity and assess how they affect functional abilities." Because anxiety may arise or worsen at any point, screening should be ongoing.

"It's as simple as diagnosing anxiety in any other patient population," Dr. Stern said. A standard instrument, the Leibowitz Social Anxiety Scale, can be used as accurately with schizophrenic as with other patients, although avoidance may be a particularly prominent feature.

With regard to anxiety, a complicating factor is the possible role of antipsychotics.

Dr. …

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