The Jesalva Algorithm: Principle #4 - Anxiety and wellness

Patients who are treated for depression improve with treatment.  However, there is a subset of them that are less depressed but still not able to function as well as they are expected.  They feel better but are not well.
​
Wellness is a concept that is often times elusive.  In my experience, this obstacle can most often be due to an anxiety disorder that has not been treated or has not been diagnosed. 

Anxiety has many forms.  I often categorize the symptoms into 2 categories:  physical and emotional.
Physical symptoms can be the following:

1. There are motor symptoms such as feeling fidgety, restless, "can't sit still", " always need to be on the go", being constantly need to be pre-occupied.  It could also be manifested by nail biting, picking, or jaw clenching.
2. There are gastrointestinal symptoms such as nausea, vomiting, diarrhea, feeling like you have "knots" or "butterflies" in your stomach.
3. There are cardiovascular symptoms such as chest tightness, shortness of breath, "lump in my throat", increase in heart rate, and  palpitations.
4. There are neurological symptoms such as tingling, dizziness, sweating of the hands.

Emotional symptoms of anxiety can include the following:

1. "Worrying", "overthinking", overanalyzing" ruminating, thinking about the "worst case scenario", doing the "what ifs".
2. Anxious patients are often self critical, self conscious and have a lot of self doubt.
3. Patients often describe that the anxiety interferes with their short term memory (STM) and concentration.  Thus they are more forgetful and have problems paying attention.
4. Feeling easily overwhelmed and have difficulty making decisions.
5. They were often "shy" as a child and tended to avoid school or social situations.

Many patients who have untreated anxiety disorders tend to have many of the above symptoms.  They tend to live a life of fear, dread, frustration, with constant "worry".  The cognitive impairment associated with the anxiety disorders tend to be severe enough that it prevents many from holding productive working lives and employment.  Many self medicate with drugs, alcohol and marijuana.
The Jesalva Algorithm address this as a very important issue.  Anxiety disorders need aggressive treatment in order to achieve wellness.  This can be accomplished in several ways without the use of benzodiazepines.  Using antidepressants at doses  at the upper end of the therapeutic spectrum is a way that I advocate.  Also, using gabapentin at high doses is another medication that I often use.  Finally, second generation antipsychotics could be a 3rd line choice if the others fail.
Of course, non-medication modalities are also needed.  Exercise is a tool that is most helpful especially cardio-oriented ones.