History
To rule out anxiety disorders secondary to general medical or substance abuse conditions, a detailed history and review of symptoms is essential. Review use of caffeine-containing beverages (coffee, tea, colas), over-the-counter medications (aspirin with caffeine, sympathomimetics), herbal “medications,” or street drugs. Ask the patient’s sleep partner about apneic episodes or myoclonic limb jerks. Concurrent depressive symptoms are common in all of the anxiety disorders. Severe anxiety disorders may produce agitation, suicidal ideation, and increased risk of completed suicide. Always ask about suicidal ideation or suicidal intent. (See Mental Status Examination)
Panic disorder
Patients with panic disorder frequently present to the emergency department (ED) with chest pain or dyspnea, fearing that they are dying of myocardial infarction. They commonly report a sudden unexpected and spontaneous onset of fear or discomfort, typically reaching a peak within 10 minutes. DSM-5 criteria for panic disorder include the experiencing of recurrent panic attacks, with 1 or more attacks followed by at least 1 month of fear of another panic attack or significant maladaptive behavior related to the attacks. A panic attack is an abrupt period of intense fear or discomfort accompanied by 4 or more of the following 13 systemic symptoms:
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Palpitations, pounding heart, or accelerated heart rate
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Sweating
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Trembling or shaking
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Shortness of breath or feeling of smothering
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Feelings of choking
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Chest pain or discomfort
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Nausea or abdominal distress
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Feeling dizzy, unsteady, lightheaded, or faint
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Chills or heat sensations
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Paresthesias (ie, numbness or tingling sensations)
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Derealization (ie, feeling of unreality) or depersonalization (ie, being detached from oneself)
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Fear of losing control or going crazy
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Fear of dying
During the episode, patients have the urge to flee or escape and have a sense of impending doom (as though they are dying from a heart attack or suffocation). Other symptoms may include headache, cold hands, diarrhea, insomnia, fatigue, intrusive thoughts, and ruminations.
Patients with panic disorder have recurring episodes of panic, with the fear of recurrent attack resulting in significant behavioral changes (eg, avoiding situations or locations) and worry about the implications of the attack or its consequences (eg, losing control, going crazy, dying).
Panic disorder may result in changes in personality traits, characterized by the patient becoming more passive, dependent, or withdrawn.
Assess precipitating events, suicidal ideation or plan, phobias, agoraphobia, and obsessive-compulsive behavior. Exclude involvement of alcohol, illicit drugs (eg, cocaine, amphetamine, phencyclidine, amyl nitrate, lysergic acid diethylamide [LSD], yohimbine, 3,4-methylenedioxymethamphetamine [MDMA, or ecstasy]), cannabis, and medications (eg, caffeine, theophylline, sympathomimetics, anticholinergics).
Consider symptomatology of other medical disorders, which may manifest with anxiety as a primary symptom.
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Angina and myocardial infarction (eg, dyspnea, chest pain, palpitations, diaphoresis)
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Cardiac dysrhythmias (eg, palpitations, dyspnea, syncope)
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Mitral valve prolapse
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Pulmonary embolus (eg, dyspnea, hyperpnea, chest pain)
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Asthma (eg, dyspnea, wheezing)
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Hyperthyroidism (eg, palpitations, diaphoresis, tachycardia, heat intolerance)
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Hypoglycemia
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Pheochromocytoma (eg, headache, diaphoresis, hypertension)
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Hypoparathyroidism (eg, muscle cramps, paresthesias)
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Transient ischemic attacks (TIAs)
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Seizure disorders
Consider other mental illnesses that may result in panic attacks, including schizophrenia, manic disorder, depressive disorder, posttraumatic stress disorder, phobic disorders, and somatization disorder. Assess family history of panic or other psychiatric illness.
Generalized anxiety disorder
This disorder is characterized by excessive anxiety and worry about a number of events and activities. Worrying is difficult to control. Anxiety and worry are associated with at least 3 of the following 6 symptoms occurring more days than not for at least 6 months:
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Restlessness or feeling keyed-up or on edge
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Being easily fatigued
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Difficulty concentrating or mind going blank
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Irritability
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Muscle tension
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Sleep disturbance
Although not a diagnostic feature, suicidal ideation and completed suicide have been associated with generalized anxiety disorder
Social anxiety disorder (social phobia)
A person with social phobia will typically report a marked and persistent fear of social or performance situations in which the individual is exposed to possible scrutiny by others, to the extent that his or her ability to function at work or in school is impaired. The individual fears that they may act in a way that will show their anxiety symptoms and result in humiliation or embarassment. Exposure to social or performance situations almost always produce fear or anxiety. These situations are avoided or endured with intense anxiety. Avoidance behavior, anticipation, or distress in the feared social or performance setting produces significant impairment in functioning.
Ask the patient about any difficulties in social situations, such as speaking in public, eating in a restaurant, or using public washrooms. Fear of scrutiny by others or of being embarrassed or humiliated is described commonly by people with social phobia.
Agoraphobia
Inquire about any intense anxiety reactions that occur when the patient is exposed to specific situations such as heights, animals, small spaces, or storms. Other areas of inquiry should include fear of being trapped without escape (eg, being outside the home and alone; in a crowd of unfamiliar people; on a bridge, in a tunnel, in a moving vehicle).
Specific (simple) phobia
If specific phobias are suspected, specific questions need to be asked about irrational and out of proportion fear to specific situations (eg, animals, insects, blood, needles, flying, heights). Phobias can be disabling and cause severe emotional distress, leading to other anxiety disorders, depression, suicidal ideation, and substance-related disorders, especially alcohol abuse or dependence. The physician must inquire about these areas as well.
Mental Status Examination
A complete mental status examination should be obtained for each patient with anxiety symptoms, assessing appearance, behavior, ability to cooperate with the exam, level of activity, speech, mood and affect, thought processes and content, insight, and judgment. Patients may exhibit physical signs of anxiety such as sweaty palms, restlessness, and distractibility. Patients are generally oriented times 3 and cooperative. Mood may be normal or depressed. Affect is often preserved. Psychotic symptoms are not typical of uncomplicated anxiety disorders. Suicidal ideation should be assessed by asking about passive thoughts of death, desires to be dead, thoughts of harming self, or plans or acts to harm self. Homicidal ideation is uncommon. Cognition is typically intact with no impairment in memory, language, or speech. Insight and judgment are typically intact.
Generalized anxiety disorder
Two main elements of the mental status examination should be assessed in generalized anxiety disorder. The first involves asking about suicidal/homicidal ideation or plan, such as the following:
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Have you ever wished you were never born, thought you would be better off dead, wish to harm yourself or others, have a plan to harm yourself or others, or ever tried to kill yourself or seriously injure yourself or others?
The second involves formal testing of orientation/recall, such as the following:
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Does the patient respond when you call them by name (oriented to person)?
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Is the patient oriented to place and time? When you ask what place, season, day, month, year is it, does the patient respond appropriately?
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Does the patient have intact short- or long-term recall? Ask the patient to spell the word WORLD forward and backward, count backward from 100 by 7s, recall what he or she did to celebrate his or her birthday last year and the name of his or her first-grade teacher.
Panic disorder
Mental status screening is essential for diagnosis. Standardized examinations include the Primary Care Evaluation of Mental Disorders (PRIME-MD), the Mobility Inventory for Agoraphobia (MIA), the Agoraphobia Cognitions Questionnaire (ACA), and the Body Sensations Questionnaire (BSQ).
No signs on mental status examination are specific for panic disorder. While the patient may or may not appear anxious at the time of interview, their Mini-Mental Status Examination, including cognitive performance, memory, serial-7, and proverb interpretation, should appear intact and consistent with the patient’s educational level and apparent baseline intellectual functioning.
The mental status examination may reveal an anxious-appearing person, although this is not required for diagnosis. Speech may reflect anxiety or urgency, or it may sound normal. Mood may be described as similar to “anxious,” with congruent affect. Incongruent affect should raise consideration for other diagnostic possibilities. Thought processes should be logical, linear, and goal directed. Thought content is particularly important to specifically assess in order to ensure a patient has no suicidal or homicidal thoughts. Acute anxiety, as a form of acute mental anguish, can lead to unsafe or self-injurious behavior. Abnormalities in thought process or thought content (aside from impulsive suicidal thoughts) should prompt reconsideration of other etiologies. Insight and judgment are usually present and intact.
Phobic disorders (including social anxiety disorder [social phobia], specific phobia, and agoraphobia
In a situation where the patient is acutely confronted with the object of his or her phobia, the patient’s mental status examination is significant for an anxious affect, with a restricted range. Neurovegetative signs (such as tremor or diaphoresis) might be present. The patient also reports feeling anxious (mood) and can clearly identify the reason for his/her anxiety (thought content). The thought content is significant for phobic ideation (unrealistic and out of proportion fears). Insight might be impaired, especially during exposure, but most times the patient has preserved insight and while reporting that they cannot control their feelings, they also acknowledge that the severity of their fears is not justified.
At any other time, a patient with phobic disorder has a mental status within normal limits, with the exception of thought content positive for phobic ideation. Of note, phobic ideas might remain undisclosed unless questions about phobias are specifically asked. Phobias do not present with suicidal or homicidal ideation, but comorbid conditions commonly associated with phobias, including depression and other anxiety disorders, do present with suicidal or homicidal ideation. If comorbid conditions exist, a specific assessment of the suicidal and homicidal risk should also be completed.
Physical Examination
Because anxiety manifests with a number of physical symptoms, any patient who presents with a de novo complaint of physical symptoms suggesting an anxiety disorder should have a physical examination and basic laboratory workup to rule out medical conditions that might present with anxiety like symptoms (see Differentials).
For a patient who presents for a repeat visit with similar complaints, after medical contributors have been ruled out, a careful mental status examination might be better suited than repeat physical examination and laboratory investigations. (See Mental Status Examination.) While considering anxiety as the primary suspect, the physician should always remember that over time patients with anxiety do develop medical conditions at the same rate as other patients. In other words, a diagnosis of anxiety, while changing the threshold for investigation of physical symptoms, should not deprive the patient of regular follow-up examinations as otherwise indicated.
Panic disorder
No signs on physical examination are specific for panic disorder. The diagnosis is made primarily by history.
The patient may have an anxious appearance. A patient presenting in an acute state of panic can physically manifest any anticipated sign of an increased sympathetic state. Tachycardia and tachypnea are common; blood pressure and temperature may be within the reference range, though hypertension may occur as well. Tremors may be noted. Cool clammy skin may be observed. Hyperventilation may be difficult to detect by observing breathing because respiratory rate and tidal volume may appear normal. Patients may have frequent sighs or difficulty with breath holding. Reproduction of symptoms with overbreathing is unreliable. Chvostek sign, Trousseau sign, or overt carpopedal spasm may be present.
The remaining examination findings are typically normal in panic disorder. However, remember that panic disorder is largely a diagnosis of exclusion, and attention should be focused on the exclusion of other disorders.
A panic attack generally lasts 20-30 minutes from onset-rarely more than an hour. Somatic concerns of death from cardiac or respiratory problems may be a major focus of patients during an attack. Patients may end up in the ED.
Generalized anxiety disorder
Common physical signs of generalized anxiety disorder include tremor, tachycardia, tachypnea, sweaty palms, and restlessness. Typically, children and adults with generalized anxiety disorder also experience uncomfortable physical symptoms including rapid heartbeat, feeling short of breath, increased sweating, stomach cramping, a feeling of a lump in the throat or inability to swallow, frequent need to urinate, dry mouth, nausea, diarrhea, cold and/or clammy hands, headaches, or neck or backaches. A feeling of nervous tension is often accompanied by a feeling of shaking, trembling, twitching, or body aches. Often, children especially are not diagnosed or receive incorrect treatment and they may undergo unnecessary, invasive, or dangerous medical testing and inappropriate medication treatment for supposed presence of physical illnesses and, as a result, experience an increase in the intensity of fear and worry about their health status. [37, 38, 39]
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Anxiety. Chart showing the female-to-male sex ratio for anxiety disorders. Adapted from Kessler et al, 1994.
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Anxiety. Age of onset for anxiety disorders based on specific anxiety disorder type.
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Brain structures involved in dealing with fear and stress.
