Diagnosis Crucial to Anxiety Disorder

Roxanne Bachowski spent 15 years convinced she was deathly ill. The mother of two regularly experienced frightening episodes of shortness of breath and dizziness, with her heart pounding and eyes dilated. She made hundreds of trips to doctors and was given countless tests, but medical science could find nothing wrong with her. Once, she recalled, she sneaked into a morgue to be among the dead, whom she longed to join.

Almost two years ago, after being rushed to Suburban Hospital in Bethesda, Md., by ambulance, she found her diagnosis: She had been suffering for years from panic attacks.

“I had five MRIs, was on the treadmill a dozen times--there wasn’t a test I didn’t have,” said Bachowski, who lives in Potomac, Md. “The symptoms I was getting were real, but it took years to learn the cause, that I have a panic disorder.”

Once diagnosed, she began behavioral therapy--a treatment that included confronting the situations that trigger attacks (in her case, seeing a snake, for one), taking medications and making a pledge of “no more tests!” Bachowski, who is in her 30s, says she has now reclaimed some, though not yet all, of her former active life.

Bachowski’s experience is not uncommon. According to estimates from a national survey of people age 15 to 54, more than 27 million Americans in that age group suffer from some form of anxiety disorder, ranging from panic attacks and phobias to obsessive-compulsive and post-traumatic stress disorders. Most involve the brain’s inappropriate release of the fight-or-flight chemicals such as cortisol and adrenaline. This response, which evolved over eons to help people escape from danger, now makes millions of people feel seriously endangered when they are not.

What’s more, anxiety disorders are often interwoven with depression, and a heated debate continues over which comes first in patients with dual diagnoses.

Studies estimate that 12 million Americans experience their anxiety disorders coupled with depression or another psychiatric ailment. Yet until recently, anxiety disorders have largely been an orphan among mental illnesses. The symptoms of anxiety disorders are generally not taught in medical school, experts complain, and diagnoses are made by exclusion--only after everything else has been ruled out. As Washington psychiatrist Brian Doyle recently put it, “Anxiety disorders get no respect.”

Now a major study on the economic burden of anxiety disorders, commissioned by the Anxiety Disorders Assn. of America, has documented the high cost of treating--and mistreating or not treating--these mental illnesses. The results, published in last month’s Journal of Clinical Psychiatry, put a national price tag of $63 billion on the direct costs and workplace losses from anxiety disorders each year.

The study, led by Paul E. Greenberg of the Analysis Group/Economics of Cambridge, Mass., and Ronald C. Kessler of the Harvard Medical School, found that more than half of the cost associated with anxiety disorders is paid to nonpsychiatric hospitals, doctors and medical testing services that deal with the symptoms of anxiety disorders but seldom address the illness itself.

“What we found is that anxiety disorders cost the health-care system a lot, especially to test for symptoms that mimic other illnesses,” Kessler said. “If we could find people the right treatment for their anxiety, rather than running so many tests for other diseases, it is a potential win-win situation. Doctors need to be asking, ‘Might there be an emotional problem here?’ ”

Frequently, people suffering from anxiety come into hospitals complaining of headaches, backaches, stomach trouble and what they believe are heart attacks, Kessler said.

In the study, researchers found that only about a quarter of the people with an accurate diagnosis were receiving appropriate treatment. If more people with anxiety disorders got the right treatment, the study concluded, “a substantial portion of the overall economic burden of anxiety disorders can be avoided.”

The researchers also found that in the workplace untreated anxiety among workers resulted in increased absenteeism and lower productivity. About 10% of the cost of anxiety disorders, they found, came from these workplace losses.

According to coauthor Greenberg, research into anxiety disorders is increasing now that better treatments are available. “As with depression 10 years ago, the interest and attention on anxiety awareness is growing as pharmaceutical manufacturers can offer more helpful medications,” he said. “But the amount of research going into anxiety disorders is still well below the amount for depression.”

The Anxiety Disorders Assn. study was funded by nine pharmaceutical companies.

One problem in reducing the disorder’s toll is that there is no test to detect anxiety disorders the way health professionals can monitor blood pressure or even screen for depression. In 1993, the American Psychiatric Assn. brought together 12 experts to draw up such a test; according to Doyle, a member of the panel, the group ultimately could not come up with the screen.

“Given the very different clinical presentations, it was impossible to say that every patient should have an EKG or a chest X-ray or an upper and lower GI test,” he said. “We have the protocols to define a panic disorder, but we don’t have a general tool to screen for it.”

At the National Institute of Mental Health, research is underway to find out how the information that makes up anxiety and fear is processed by the brain and transmitted through its neurological pathways. Experiments have consistently shown physical differences in the neural brain patterns of people who suffer from anxiety disorders and those who don’t.

For instance, the brain normally has two pathways for processing fearful information--a primitive one that sends threatening information quickly and another that routes the information through the more “deliberative” frontal cortex. In people suffering from post-traumatic stress disorder, researchers have found, the second pathway through the cortex is generally not activated. Researchers are hopeful this information will help with diagnosis in the future.

“Our tools aren’t refined enough yet to diagnose disorders based on our neural imaging,” said NIMH Director Steven Hyman. “But I think there’s a high likelihood we’ll be able to do this within five years.”