CRACKCast E112 – Anxiety Disorders

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This episode of CRACKCast covers Rosen’s Chapter 112, Anxiety Disorders. This is the third chapter in the psychiatric section of Rosen’s. Although the diagnosis of these disorders in the ED seems intuitive, it is important to have a defined approach to the patient presenting with complaints of anxiety to ensure that alternative medical and psychiatric disorders are not missed.

Shownotes – PDF Here


Rosen’s in Perspective

“Anxiety is a specific unpleasable state of tension that forewarns the presence of danger, real or imagined, known or unrecognized, and is often verbalized as an intense feeling of worry.” – Rosen’s 9th Edition, Chapter 102

[1] List 5 predictors of anxiety caused by an underlying medical issue  

Many medical conditions mimic anxiety disorders, and up to 42% of patients initially thought to have anxiety disorders are later found to have organic disease.

BOX 102.1

Predictors of Anxiety Caused by an Underlying Medical Issue

  • Onset of anxiety symptoms after 35 years old
  • Lack of personal or family history of an anxiety disorder
  • Lack of childhood history of significant anxiety, phobias, or separation anxiety
  • Lack of avoidance behavior
  • Absence of significant life events generating or exacerbating the anxiety symptoms
  • Poor response to anti-anxiety agents

[2] List 10 organic diseases that may present with anxiety

Patients with anxiety disorders may present with apparent physical disease, and many physical diseases are strongly associated with symptoms of anxiety.

Because anxiety may be the most obvious symptom of an underlying disease or condition, the patient should be evaluated for exacerbation of known pre-existing disease, as well as for the onset of new illness, because anxiety increases the risk of acute medical exacerbation of chronic illness.

Cardiac diseases:

  • Acute myocardial infarction
  • Angina
  • Dysrhythmias
  • Mitral valve prolapse

Endocrine diseases:

  • Hypoparathyroidism
  • Hyperthyroidism
  • Hypothyroidism
  • Hypoglycemia
  • Pheochromocytoma
  • Hyperadrenocorticism

Respiratory diseases:

  • COPD
  • Asthma
    • An anxiety attack can often precipitate an asthma attack
  • Pulmonary Embolism

Neurologic disorders:

  • Temporal lobe seizures
  • Brain tumours
  • Ischemia / infarction
  • Post-TBI
  • Alzheimer’s disease
  • Parkinson’s disease
  • Multiple Sclerosis
  • Huntington’s disease

Drug intoxication and withdrawal:

  • Cocaine
  • Amphetamines
  • Caffeine
  • Marijuana
  • LSD
  • PCP
  • MDMA (ecstasy)
  • Benzodiazepine withdrawal
  • Antidepressant withdrawal
  • EtOH withdrawal

[3] Name 10 characteristics of a panic attack

NOTE: This is a diagnosis of exclusion. Be sure to consider the diagnoses above before settling on the diagnosis of panic attack. Prematurely labelling the patient could lead to increased morbidity and/or mortality in the ED.

BOX 102.2

Characteristics of a Panic Attack

  • Abrupt surge of intense fear or discomfort that reaches a peak within minutes, in which four or more of the following occur:
    • Palpitations
    • Sweating
    • Trembling
    • Shortness of breath or feeling of being smothered
    • Feeling of choking
    • Chest pain or discomfort
    • Nausea or abdominal distress
    • Feeling dizzy or light-headed
    • Chills or heat sensations
    • Paresthesias
    • Derealization or depersonalization
    • Fear of losing control or going “crazy”
    • Fear of dying

[4] List characteristics of post-traumatic stress disorder (PTSD)

PTSD is caused by experiencing or witnessing a highly traumatic event. Those with PTSD manifest symptoms of re-experiencing the event, avoidance of triggers, changes in cognition and mood, and changes in arousal and reactivity.

BOX 102.3

Characteristics of Post-Traumatic Stress Disorder

  • Exposure to actual or threatened death, serious injury, or sexual violence
  • Presence of intrusion symptoms associated with the traumatic event
  • Persistent avoidance of stimuli associated with the traumatic event
  • Negative alterations in cognition and mood associated with the traumatic event
  • Marked alterations in arousal and reactivity associated with the event
  • Duration greater than 1 month
  • Disturbance causes clinically significant distress or impairment
  • Disturbance is not attributable to the physiological effects of a substance or another medical condition

[5] Define Panic Attack, OCD, and GAD:

  • Panic Attack
    • A panic attack, differentiated from the disorder, is an abrupt fear or discomfort that reaches a peak within minutes and has associated physical and cognitive symptoms
  • Obsessive-Compulsive Disorder (OCD) 
    • OCD is characterized by recurrent, obtrusive, unwanted thoughts (obsessions), such as fears of contamination, or compulsive behaviors or mental acts (compulsions) that a person feels compelled to perform, such as hand-washing or counting
  • Generalized Anxiety Disorder (GAD) 
    • GAD is defined as excessive worry that occurs most days over a 6-month period involving several events or activities. The anxiety must cause significant distress or impairment in functioning.

[6] List ED management goals for patients with anxiety

  • Avoid escalating behaviour leading to self-harm or harm to others
  • Prevent end-organ dysfunction
  • Improve patient comfort and satisfaction

[7] List 6 non-pharmacologic therapies for anxiety

  • Reduction of environmental stimulants (quiet, private room)
  • Dimming of lights, with music/aromatherapy
  • Collateral help from family, social worker
  • Breathing techniques
  • Avoidance of caffeine and EtOH
  • Psychotherapy
  • High intensity, supervised exercise

Because anxiety states cause an increase in metabolic demands, they can cause a marginally compensated organ system to fail. In a recent study, 48% of patients presenting for pain complaints were found to have moderate to severe anxiety and only 1% received anxiety treatment. So, if you’re not able to reassure the patient, add a little pharmacology into your cocktail for nausea and pain control.

Vignettes  

  1. What is the most common cause of organic anxiety, anxiety that results from a physiologic origin?
    1. Adrenal disorders
    2. Alcohol and drug use
    3. Cardiac disease
    4. Hyperthyroidism
    5. Pulmonary embolus

Answer: 2. This may be from intoxication or withdrawal states.

  1. A 52-year-old woman presents with 2 months of recurrent episodes of anxiety, mild chest pain, subjective palpitations, hand paresthesias, and occasional muscle spasms. They have occurred weekly in the past but are now increasing in frequency. Her only past history is a thyroidectomy 4 months prior. She is taking levothyroxine (Synthroid) and had normal thyroid levels 2 weeks ago. Her vital signs, physical examination, and electrocardiogram are normal. Laboratory evaluation shows sodium 141 mEq/L, potassium 4.1 mEq/L, creatinine 100 mg/L, bicarbonate 26 mEq/L, chloride 100 mEq/L, and calcium 1.77 mmol/L; a complete blood count is normal. Which of the following should be the next step in her management?
    1. Outpatient clonazepam
    2. Parathyroid hormone level
    3. Psychiatry consultation
    4. Thyroid hormone levels
    5. Urine drug screen

Answer: 2. Anxiety is the predominant symptom in 20% of patients with hypoparathyroidism. Other symptoms include paresthesias, muscle cramps, and spasms. Most cases are idiopathic or due to inadvertent parathyroid gland harvest during thyroidectomy. The diagnosis is suggested by a low serum calcium and an elevated phosphate and is confirmed by a depressed parathyroid level.

This post was uploaded and copyedited by Dillan Radomske (@DillanRadomske)

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Adam Thomas

Adam Thomas

CRACKCast Co-founder and newly minted FRCPC emergency physician from the University of British Columbia. Currently spending his days between a fellowship in critical care and making sure his toddler survives past age 5.
Adam Thomas
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Larissa Hattin

Larissa Hattin

Larissa is a medical student at McMaster University.
Larissa Hattin

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