Anxiety
Jagoda Pasic
Paul Zarkowski
PRESENTING CLINICAL FEATURES
Anxiety is a symptom of many clinical syndromes of diverse etiology and manifestations. The symptoms may be relatively constant or develop quickly over minutes. Patients subjectively experience anxiety as a diffuse, unpleasant, vague sense of apprehension and uneasiness (psychological symptoms; Table 19.1). These symptoms are often accompanied by a varying degree of autonomic symptoms ranging from mild headache, perspiration, and palpitations to severe chest pain and shortness of breath (physical symptoms; Table 19.1). Anxiety can be an intensely negative experience, and it may cause extreme subjective distress. Recurrent anxiety can become disabling, and the person may avoid places where attacks occurred or restrict his or her normal activities and become housebound (behavioral symptoms). Anxiety symptoms can result from many physical, medical, and psychiatric disorders.
TABLE 19.1 Physical and Psychological Symptoms of Anxiety | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Depending on the severity of symptoms, patients with anxiety present in different care settings. Only 26% of panic attack patients initially seek care in a mental health setting. Patients with predominantly somatic symptoms seek help from nonpsychiatric physicians, most often in primary care settings (35%)(1). Thirty-two percent of patients with a severe anxiety attack present in the emergency department (ED) with chest pain, shortness of breath, tachycardia, and fear of a myocardial infarction (MI) or death. Twenty-five percent of patients who present to an ED with chest pain meet criteria for panic disorder, although 98% are undiagnosed on arrival (2). Many patients with an acute anxiety attack will have resolution of their symptoms before arrival at the ED. However, some patients may continue to have anxiety symptoms that persist for hours.
IMMEDIATE INTERVENTIONS FOR ACUTE PRESENTATIONS
The first intervention for an anxious patient should be to demonstrate genuine concern and to assess patient safety. The physician must consider the risks of serious medical events, such as MI or hypoxia. Immediate interventions include monitoring vital signs and evaluating the need for oxygen. If the vital signs and initial physical exam do not indicate a life-threatening event, the physician can offer reassurance while proceeding with the evaluation. A calming, reassuring approach may be effective in decreasing discomfort and anxiety level. Patients may require pretreatment with medications before the clinician finishes the evaluation or obtains a complete history.
EVALUATION
The initial evaluation begins with the current complaint, including the course, intensity, and duration of symptoms. The patient needs to be asked about environmental triggers, such as stressful life events and sleep deprivation. Associated cognitive elements, including obsessions, ruminations, worries, and in particular, suicidal ideations, need to be assessed (see “Criteria for Hospitalization” later in this chapter).
The important elements of history include age of onset of anxiety, family history of anxiety, childhood antecedents, resultant avoidance, and traumatic events. The medical history should focus on conditions associated with anxiety and frequent ED visits, such as exacerbation of asthma and chronic obstructive pulmonary disease (COPD). All medications need to be reviewed, including over-the-counter (OTC) medications. Cold remedies may cause acute
anxiety symptoms in a vulnerable patient. Previous medication trials should be reviewed to establish whether acute anxiety symptoms are secondary to initiation or discontinuation of a selective serotonin reuptake inhibitor (SSRI), side effects of current treatment, or a poor treatment response. Recreational drug use, particularly stimulants and alcohol, caffeine consumption, and smoking all need to be carefully ascertained in the history because of the high incidence of substance use in the ED population.
anxiety symptoms in a vulnerable patient. Previous medication trials should be reviewed to establish whether acute anxiety symptoms are secondary to initiation or discontinuation of a selective serotonin reuptake inhibitor (SSRI), side effects of current treatment, or a poor treatment response. Recreational drug use, particularly stimulants and alcohol, caffeine consumption, and smoking all need to be carefully ascertained in the history because of the high incidence of substance use in the ED population.
A thorough physical exam should be performed in all patients presenting with acute anxiety symptoms. There is a considerable overlap between physical symptoms of acute anxiety and serious medical conditions (Table 19.2).
TABLE 19.2 Medical Illnesses, Medications, and Substances in the Differential Diagnosis of Acute Anxiety Attack | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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A number of laboratory tests should be performed, depending on the symptom presentation and associated physical symptoms. The following laboratory tests are recommended: toxicology screen, complete blood count, electrolytes, glucose level, blood urea nitrogen/creatinine ratio, thyroid-stimulating hormone, free thyroxine, triiodothyronine (T3) and T3 uptake, and an electrocardiogram if the patient has cardiac symptoms or is older than 40 years. Other tests should be directed by clinical suspicion. For example, patients with cardiac symptoms should have serial cardiac enzymes taken to rule out MI, and echocardiography for suspected mitral valve prolapse. Patients with prominent respiratory symptoms may need to have a chest radiograph, blood gases,
and ventilation/perfusion scan to rule out pulmonary embolism; for suspected seizures, an electroencephalogram would be indicated.
and ventilation/perfusion scan to rule out pulmonary embolism; for suspected seizures, an electroencephalogram would be indicated.
DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS
Medical Disorders
Diagnosis of primary anxiety requires differentiation from medical disorders. The difficulty with the differential diagnosis of acute anxiety is that patients typically have symptoms across multiple organ systems (Table 19.1); hence, it can be a complex differential. Factors suggesting a medical etiology include onset late in life, absence of an initial life event or precipitating event, absence of avoidance or fear, and absence of childhood antecedents or family history. Poor response to trials of antipanic or antidepressant medications may be suggestive of an underlying medical disorder. Table 19.2 lists relevant medical conditions in the differential diagnosis of an acute anxiety episode.
Psychiatric Disorders
PRIMARY ANXIETY DISORDERS
Panic attacks, or intense anxiety, develop suddenly and can occur at any time, even during sleep. Classically, a panic attack is associated with fear of
impending doom or loss of control, with symptoms of autonomic arousal and intense need to flee from the situation in which the attack occurred. An attack usually peaks within 10 minutes, but some symptoms may last much longer. Although panic attack is not a separate DSM disorder, it is prerequisite to a diagnosis of panic disorder. Ninety percent of patients with panic disorder believe that they suffer from a serious physical disorder, so they seek help in the general medical system. Such patients often undergo expensive cardiac workups, but they receive neither a diagnosis of panic disorder nor treatment for the disorder. An additional challenge in making the right diagnosis is that patients with chest pain that is significant enough to warrant testing for coronary artery disease (CAD) are as likely to have panic disorder and no CAD (22%) as they are to have CAD and no panic disorder (18%)(3).
impending doom or loss of control, with symptoms of autonomic arousal and intense need to flee from the situation in which the attack occurred. An attack usually peaks within 10 minutes, but some symptoms may last much longer. Although panic attack is not a separate DSM disorder, it is prerequisite to a diagnosis of panic disorder. Ninety percent of patients with panic disorder believe that they suffer from a serious physical disorder, so they seek help in the general medical system. Such patients often undergo expensive cardiac workups, but they receive neither a diagnosis of panic disorder nor treatment for the disorder. An additional challenge in making the right diagnosis is that patients with chest pain that is significant enough to warrant testing for coronary artery disease (CAD) are as likely to have panic disorder and no CAD (22%) as they are to have CAD and no panic disorder (18%)(3).
Patients with prominent psychological or behavioral components of anxiety in addition to physical symptoms are more likely to be referred for a psychiatric evaluation. Such patients typically present with intense irritability, sense of impending doom or loss of control, uncontrolled worrying, or limited functioning due to avoidance. In addition, patients with repeated, unresolved attacks clinically present with a sense of hopelessness, dysphoria, and ultimately, with suicidal ideation.
Patients with specific phobia fear and avoid specific situations (e.g., airplanes, heights) or objects (e.g., snakes, dogs). Exposure to the feared stimuli consistently induces intense anxiety with a panic attack–like reaction. Patients rarely seek care in the ED because they have relatively intact insight into the origin of their anxiety symptoms.
Patients with social phobia are fearful of social or performance situations, such as public speaking, in which humiliation or embarrassment might occur. Exposure to such situations almost invariably provokes anxiety, which may take the form of panic attacks, but unlike patients with panic disorder, patients with social phobia recognize that the fear is excessive or unreasonable. Although patients with social phobia may present often in the ED with panic attacks (23%), they are almost three times less likely than panic disorder patients to present in cardiology clinics (46% vs. 16%) or undergo excessive medical workup (4).
Patients with obsessive-compulsive disorder (OCD) suffer from recurrent, intrusive, senseless, distressing thoughts (obsessions) or the need to repeat certain stereotypical behaviors or rituals to reduce anxiety and distress (compulsions). Patients with uncomplicated OCD generally do not pre-sent in the ED. However, with their underlying susceptibility to anxiety, an ED visit can be precipitated by exaggerated anxiety due to OTC medications (cold remedies), medical conditions (asthma), excessive caffeine and nicotine use, and other substance use. Of all anxiety disorders, OCD has the lowest rate of seeking medical care through the ED (16%)(4).
Patients with posttraumatic stress disorder (PTSD) and acute stress disorder develop anxiety symptoms with intense fear, helplessness, or horror after a person has experienced or witnessed a serious, life-threatening, or violent event. These patients may startle easily, become emotionally numb, lose interest in things they used to enjoy, have trouble feeling affectionate, be irritable, angry, and hypervigilant, and reexperience the traumatic event in recurrent intrusive recollections, dreams, or flashbacks. PTSD and acute stress disorder differ by the duration of symptoms (1 month vs. 2 days to 4 weeks). PTSD was initially associated with war veterans, but it can result from a variety of traumatic events, such as natural disasters due to floods or earthquakes, bombing, child abuse, rape, mugging, shooting, and car, plane, or train accidents. Victims of recent trauma may present in the ED in a crisislike state of anxiety and agitation. There is evidence that panic attacks occur in 53% to 90% of trauma survivors during the traumatic experience, and half of them report recurrent panic attacks after the trauma (5
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