eMedicine Specialties > Emergency Medicine > Psychosocial

Anxiety

Author: Lemeneh Tefera, MD, FAAEM, Attending Physician, Department of Emergency Medicine, Beth Israel Medical Center
Coauthor(s): Lauren Claire Tomao, MD, JD, Resident, Department of Emergency Medicine, Albert Einstein College of Medicine, Beth Israel Medical Center
Contributor Information and Disclosures

Updated: Nov 20, 2008

Introduction

Background

Anxiety is a complex feeling of apprehension, fear, and worry often accompanied by pulmonary, cardiac, and other physical sensations. It is a common condition that can be a self-limited physiologic response to a stressor, or it can persist and result in debilitating emotions. When pathologic, it can exist as a primary disorder, or it can be associated with a medical illness or other primary psychiatric illnesses (eg, depression, psychosis).

Mental health disorders account for approximately 5.5% of emergency department (ED) visits and, among these mental health visits, 21% are due to anxiety. Because generalized anxiety disorder (GAD) and panic attacks present with a similar constellation of symptoms, a similar approach can be used for both.

The goal of the emergency physician (EP) is to differentiate whether the anxiety is due to an acute medical condition or is the primary diagnosis. This differentiation can be difficult since many anxiety symptoms are indistinguishable from common cardiopulmonary and neurological complaints. Unfortunately, a chaotic emergency department is not the best environment to take a detailed history of the symptoms or to comfort an anxious patient. In addition, because of the high volume of ED’s nationally, EPs are under great pressure to see patients faster. Anxiety, like other psychiatric diagnoses, requires more time to take a history and engage the patient about the underlying cause of the symptoms.

Pathophysiology

Heightened physiologic response and elevated catecholamine levels play an important role in the normal physiologic response of the body to stress and anxiety. Pathologic anxiety has been hypothesized to result from disturbances in the cerebral cortex, specifically the limbic system.

The neurotransmitters primarily associated with anxiety in these regions are norepinephrine, gamma-aminobutyric acid (GABA), and serotonin. The efficacy of benzodiazepines in treating anxiety has implicated GABA in the pathophysiology of anxiety disorders. Drugs that affect norepinephrine (eg, tricyclic antidepressants, monoamine oxidase inhibitors [MAOIs]) are also efficacious in the treatment of several anxiety disorders.

Frequency

United States

The 1-year prevalence of GAD is approximately 3%, with a lifetime prevalence of 5%. Panic disorder has a lifetime prevalence of 1.5-3.5%. One third to one half of these individuals also have agoraphobia. Major depressive disorder occurs frequently (50-65%) in individuals with panic disorder. In contrast, phobic disorders have a lifetime prevalence as high as 10-13%, but they encompass several subcategories of anxiety conditions. Many of these are underreported due to mild subclinical presentations.

Mortality/Morbidity

Approximately 20-30% of individuals with panic disorders have persistent symptoms up to 10 years from the time of initial diagnosis and treatment. Such statistics are startling and reflect the ever-growing concern regarding the appropriate use of current health care resources.

Race

• In some Far East cultures, individuals with social phobia may develop fears of being offensive to others rather than fears of being embarrassed.
• Some cultural groups restrict the participation of women in public life. Treating physicians must distinguish this kind of taboo from agoraphobia.

Sex

• The female-to-male ratio of GAD is 2:1.
• Obsessive-compulsive disorders usually occur earlier in males (6-15 y) than in females (20-29 y).

Age

• Panic disorders have a bimodal distribution; one peak occurs in late adolescence and a second, smaller peak occurs in the mid-fourth decade of life.
• Phobic disorders, obsessive-compulsive disorders, and GAD tend to occur in late adolescence or early in the third decade of life.

Clinical

History

• The initial assessment must include a complete history with a focus on the patient's social history and a discussion of possible recent stressors (eg, problems with employment, financial stress, recent family illness/death, spousal conflict/abuse, illicit drug use). In addition, a detailed dietary history is critical. Caffeine, nicotine, chocolate, over-the-counter "exercise" or weight loss pills, and other natural supplements are often implicated as causes of an acute anxiety attack. Patients often do not realize that these agents are stimulants and can cause pronounced palpitations and other signs of anxiety.
• The family is an excellent source of history for a patient with acute anxiety and may be able to provide information that the patient is reluctant to discuss or does not feel is relevant to the presentation.
• The Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) classifies anxiety disorders as follows¹ :
  • Global anxiety disorder (GAD) requires a clinical duration of at least 6 months. GAD occurs frequently with mood disorders (eg, major depression).
  • Panic disorder with or without agoraphobia: Panic attacks are recurrent episodes of spontaneous, intense periods of anxiety, usually lasting less than 1 hour. Panic attacks accompany complications of agoraphobia within the first year. (Agoraphobia is a condition involving anxiety about being in places or situations where escape might be difficult.). Patients with panic attacks are often in significant distress and seek medical attention in the ED. A patient with a classic panic attack experiences at least 4 of the following symptoms: palpitations, diaphoresis, tremulousness, shortness of breath, chest pain, dizziness, nausea, abdominal discomfort, fear of injury or going crazy, derealization (perception of altered reality), and depersonalization (perception that one's body is surreal).
  • Anxiety disorder due to a general medical condition is itself a unique diagnosis, but the emergency practitioner must thoroughly evaluate the known medical problem before making this diagnosis.
  • Substance-induced anxiety disorder and anxiety disorder not otherwise specified are characterized by symptoms of anxiety that occur as a direct consequence of drug abuse, medications, or toxins.

Physical

• While the physical examination of patients with anxiety is often normal, a great deal can be learned from observing the patient during the ED visit. The general demeanor, appropriateness, insight, hygiene, mood, cognitive capacity, and ability to engage the clinician in a discussion of the symptoms. However, a good physical examination allows the emergency physician to identify any potential life-threatening illnesses. The clinician should focus on the signs and symptoms of anxiety. Examination results may guide laboratory and imaging studies needed to evaluate cardiopulmonary causes of anxiety.
• As can be expected, comorbid diseases have their own characteristic examination findings.
• Mental status examination
  • A mental status examination can be especially helpful in distinguishing functional from organic disorders. Differentiating among the numerous psychiatric illnesses is essential, as many share symptoms similar to those of anxiety disorders.
  • The examination should focus on the following:
    • Affect
    • Behavioral observation
    • Speech pattern
    • Level of attention
    • Language comprehension
    • Memory, calculation, and judgment

Causes

• Comorbid diseases have been known to cause intrinsic anxiety. Many abused drugs (eg, alcohol, amphetamines, narcotics) raise anxiety levels.
• Panic attacks in patients who are susceptible to them can be precipitated by caffeine or iatrogenic agents, such as inhaled beta2-agonists.
• Many anxiety disorders demonstrate a familial pattern. First-degree biological relatives of patients with panic disorders have up to a 7-fold increased probability, as compared to the general population, of presenting with the same illness.

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