AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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, in the ED, a similar approach can be used for both. The goal of the emergency physician is to help determine the cause of anxiety and initiate a safe and effective management plan for relief.

Pathophysiology

Heightened physiologic response and elevated catecholamine levels play an important role in the normal physiologic response of the body to stress and anxiety. It has been hypothesized that pathologic anxiety results 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. Recent advances have demonstrated the benefit of serotonin in anxiety and panic attacks.

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

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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, family illness/death, spousal conflict/abuse, illicit drug use).
• Family may be an excellent source of history for a patient with acute anxiety. Historical elements on the ED record should include any previous psychiatric illnesses as well as any active medical illnesses. Seek any agents that can cause anxiety (eg, prescribed drugs, over-the-counter medications, caffeine, weight loss pills, herbal supplements).
• The Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) classifies anxiety disorders as follows:
• • GAD
    • GAD is defined as persistent fear, worry, or tension in the absence of panic attacks. The disabling persistent worry usually is out of proportion to the impact of the feared event and typically revolves around routine life circumstances.
    • Formal diagnosis of GAD requires a clinical duration of at least 6 months. Lifetime prevalence is about 4% for the general population, although prevalence in elderly persons can be as high as 15%. GAD occurs frequently with mood disorders (eg, major depression).
    • GAD is clinically associated with tremulousness, shaking, insomnia, irritability, and restlessness. Patients often complain of somatic symptoms (eg, muscle tension, cold clammy hands, dry mouth, diaphoresis, nausea, diarrhea, urinary frequency).
  • 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).
  • Obsessive-compulsive disorder consists of an anxiety-producing obsession comprised of persistent thoughts or ideas that are intrusive and inappropriate combined with a compulsion of repetitive behaviors that reduce the anxiety of the obsession. This disorder causes significant distress to the patient and seldom produces any pleasure or gratification.
  • Phobic disorders (eg, social phobia, specific phobia, agoraphobia without panic disorder)
    • Phobic disorders are persistent fears that are usually excessive or unreasonable.
    • Social phobias are fears of situations involving possible scrutiny (eg, public speaking), and specific phobias are fears of a circumscribed stimulus (ie, object, situation)
  • Post-traumatic stress disorder (PTSD) involves recurrent experiences of a traumatic event accompanied by symptoms of increased anxiety and avoidance of stimuli associated with the trauma.
  • 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.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Neuropathies
Pheochromocytoma
Sinus tachycardia
Brugada syndrome

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• The history is the best tool available to the emergency physician in the workup of anxiety.
• If clinical suspicion exists or if a physical examination finding is abnormal, the clinician will need to perform appropriate laboratory testing to distinguish anxiety from drug-induced causes and organic illnesses (eg, systemic infections, toxins, electrolyte and endocrine disturbances).
• Useful laboratory tests may include the following:
• • Complete blood count (CBC)
  • Chemistry panels
  • Serum and/or urine drug screen
  • Thyroid-stimulating hormone level (This test is often not immediately performed or available.)

Imaging Studies

• Imaging studies are not useful in diagnosing anxiety but may be need to exclude other possibilities in the differential diagnosis.

Other Tests

• Electrocardiograms are useful for evaluating possible tachydysrhythmia and screening for adverse medication effects such as QT prolongation.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

Prehospital personnel may provide reassurance and symptomatic relief within the usual protocols of EMS. Early identification of symptoms can facilitate evaluation and therapy by the emergency physician.

Emergency Department Care

• Anxiety in its most severe form can be quite debilitating. Organic illness, medications, drug abuse, and obvious psychotic causes of an anxious state must be ruled out and documented prior to treatment of anxiety. Patients require ED treatment for anxiety when they are in an acute anxious state of such severity that they pose a danger to themselves and to others in the immediate vicinity.
• Patients with significant discomfort from their anxiety can also benefit from emergency treatment. A thorough psychosocial history should include inquiries into common instigators of anxiety including a recent death, financial or job-related crises, domestic violence, underlying depression, and illicit drug use.
• The clinician should be vigilant in addressing any abnormal vital signs. Patients who present with initial elevated blood pressure should have it repeated when they are less anxious. Initial tachycardia that resolves with reassurance is common. However, medical persistent tachycardia should not only be attributed to anxiety and organic causes (eg, dysrhythmia, pulmonary embolism, thyrotoxicosis, mitral valve prolapse) (See Differentials).
• While remaining vigilant for life-threatening illness, ED physicians should provide a reassuring encounter to patients with anxiety. Place patients in a calm quiet room where a formal evaluation can begin to identify the functional components of the patient's anxiety.
• Effective treatments for an acute anxiety attack include providing a calm environment and social support from family, friends, or the emergency staff. For patients with more severe anxiety, a short course of a fast-acting anxiolytic agent is recommended. Chronic anxiety often requires a comprehensive approach utilizing psychotherapy, counseling, and a wider spectrum of anxiolytics (eg, benzodiazepines, buspirone, antidepressants).

Consultations

• Psychiatry
• • Anxiety disorders are often chronic illnesses and require follow-up psychiatric intervention for successful treatment.
  • Any patient with anxiety who presents with homicidal or suicidal ideation requires urgent psychiatric intervention in the ED.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Short-acting benzodiazepines are most useful in the ED. Benzodiazepines should only be prescribed in motivated and cooperative individuals who have reliable follow-up arrangements.

Barbiturates are not recommended because of their high addictive potential, marked side effects, slow onset of action, and low therapeutic indices. Tricyclic antidepressants and MAOIs should not be prescribed in the acute setting. Beta-blockers do not reduce intrinsic anxiety, although they do reduce anatomic components (eg, tachycardia, diaphoresis). Serotonin reuptake inhibitors (eg, paroxetine) generally are preferred as the drug of choice for long-term treatment of panic disorders, although traditional tricyclic antidepressants also have been used.

Buspirone has a low abuse potential, and a short course can safely be prescribed in the ED. However, peak efficacy may take several weeks and, in patients with concomitant depression, buspirone alone is often not effective. Antidepressants have well-known pharmacologic profiles and could be useful in patients with concomitant depression and anxiety. They have demonstrated benefit as adjunct agents in the treatment of GAD. All patients with anxiety should follow up with their primary care provider or be referred for outpatient psychiatric counseling. Patients who express suicidal or homicidal thoughts should have an emergent psychiatric evaluation in the ED.

Drug Category: Benzodiazepines

Agents of choice due to short half-lives and high therapeutic indices. By binding to specific receptor sites, these agents appear to potentiate the effects of GABA and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters.

Drug Category: Serotonin receptor agonists

These agents stimulate 5-HT1-receptors, producing anxiolytic effects. Buspirone is a nonsedating antipsychotic drug unrelated to benzodiazepines, barbiturates, and other sedative-hypnotics. Has been found to be comparable with benzodiazepines in reducing symptoms of anxiety in double-blind placebo-controlled clinical trials and has fewer sedative or withdrawal adverse effects than benzodiazepines. Also has fewer cognitive and psychomotor adverse effects, which makes its use preferable in elderly patients. Major limitations include lack of antipanic activity and reduced anxiolytic effects in patients recently withdrawn from benzodiazepines. Also has a longer onset of action and, thus, is of fairly limited use as a sole agent in the treatment of acute anxiety in the ED.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• All anxious patients with suicidal ideation, homicidal ideation, or acute psychosis require emergent psychiatric consultation.

Complications

• Some studies report the failure rate of diagnosing anxiety disorders at as high as 50%. This can result in overuse of health care resources and increased morbidity and mortality rates for anxiety disorders and comorbid medical conditions.

Patient Education

• For excellent patient education resources, visit eMedicine's Anxiety Center. Also, see eMedicine's patient education articles, Anxiety, Panic Attacks, and Hyperventilation.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Anxiety states may be associated with increased prevalence of other physical illnesses.
• Avoid falsely attributing the somatic symptoms of anxiety to other medical conditions.
• Understand that anxiety can provoke or maintain other medical disorders. For example, the prevalence of hypertension has been found to be 13.6% in patients diagnosed with panic attacks, compared to 4.4% in controls without panic attacks.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• American Psychiatric Association. Anxiety disorders. In: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington DC: American Psychiatric Association; 1994.
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• Huffman JC, Pollack MH. Predicting panic disorder among patients with chest pain: an analysis of the literature. Psychosomatics. 44(3):222-36. [Medline].
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Article Last Updated: May 8, 2007