James A. Comes, Douglas A. Rund, and Basheer Lotfi-Fard
Anxiety is a common complaint of patients who present to emergency departments (ED). It is a nonspecific symptom that has diverse causes and clinical manifestations. Anxiety can be the chief complaint of a patient with a primary anxiety disorder, but often it accompanies a comorbid medical disorder. It is important for the emergency medicine physician to recognize an underlying emergent medical disorder in the anxious patient and be able to diagnose those patients in whom anxiety has become a pathologic condition (1).
CLINICAL PRESENTATION
Subjectively, the anxious patient feels a sense of worry, apprehension, and nervousness often accompanied by physical symptoms that reflect sympathetic activity (e.g., palpitations, sweating, dry mouth, dizziness, paresthesia, and faintness). Anxiety is a pathologic condition when the patient’s physical and emotional responses surpass the normal response to a perceived threat and interfere with optimal functioning (2).
Clinically significant anxiety that is not associated with general medical illness, substance use, or substance withdrawal may warrant diagnosis of a primary anxiety disorder. Anxiety may be a feature of almost any psychiatric condition and is often prominent in schizophrenia, other psychotic disorders, depression, and bipolar disorders. The emergency physician should have a general understanding of the clinical characteristics of all major psychiatric disorders, their chronic modes of treatment, and the ED assessment and management of acute presentations.
Panic attacks are extremely distressing experiences that often lead to ED visits. As many as 20% to 44% of patients with chest pain who come to the ED have a panic disorder (3,4). Recent surveys of the adult US population report an annual prevalence rate of 1% to 2% and a morbid risk (lifetime risk) of 2% to 4%. These episodes are abrupt, almost paroxysmal, in onset and progress rapidly to a degree of anxiety grossly disproportionate to any perceived threat or danger. The total duration is usually 10 minutes or less and almost never as long as 30 minutes. Following cessation of the acute episode, patients typically experience considerable residual anxiety centered on concerns about possibly having a life-threatening illness. Some patients describe their first panic attack as the worst experience of their lives.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of panic attacks depends on the specific circumstances in which they occur. Situational or cued panic attacks occur in association with particular experiences or stimuli, which may be internal or external, recognized or unrecognized. Uncued panic attacks are experienced as occurring “out of the blue” and are especially frightening because of the assumption that they are a symptom of life-threatening illness. The only psychiatric condition in which uncued panic attacks occur is panic disorder.
Most medical conditions are associated with some degree of anxiety, but certain conditions can be present with anxiety as a predominant feature. Examples include asthma exacerbation, hypoglycemia, pulmonary embolism, myocardial infarction, mitral valve prolapse, paroxysmal atrial tachycardia, thyrotoxicosis, pheochromocytoma, and carcinoid syndrome (5). In addition, anxiety itself may exacerbate a medical comorbidity because its associated symptomatic responses create demands on previously impaired organ systems (6). Panic attacks may also be associated with substance use (caffeine or stimulants) and withdrawal (alcohol, barbiturates, or benzodiazepines). After these conditions have been ruled out, psychiatric diagnoses should be considered.
In phobic disorders, panic attacks may occur in connection with the unreasonable degree of fear associated with a particular stimulus or situation that the person makes effort to avoid. In acute and posttraumatic stress disorders, panic attacks may be triggered by environmental reminders, distressing memories, or flashbacks of the traumatic experience. In obsessive-compulsive disorder, panic attacks may be caused by situations in which the person fears being overwhelmed by the obsessional concern (7).
ED EVALUATION
It is critical to exclude a primary or comorbid medical disorder in the initial and ongoing assessment of patients with anxiety (8). Anxiety and depressive disorders are common among patients presenting with chest pain. However, the prevalence of anxiety and depressive disorders may be similar in patients with chest pain of cardiac and noncardiac origin (9).
Because of their inherently short duration, most panic attacks are clinically evaluated only retrospectively. Patients commonly seek emergency medical care following these upsetting experiences, especially if the attack was uncued. By the time they are examined, vital signs usually have returned to baseline. Even during the actual attacks, objective physiologic changes may be far less impressive than the degree of distress suggests. Panic attacks are brain events, and any peripheral changes are secondary manifestations. They are clinically recognized from the description of the person’s internal experience, not from externally observable characteristics.
ED MANAGEMENT
Reassurance is the first-line intervention in patients with anxiety disorders. Patients should be assured that they are safe and will receive help. A firm, direct approach in a quiet, comfortable environment helps the patient feel secure and in better control (10).
If a supportive interview is unsuccessful, pharmacologic intervention may be considered. Benzodiazepines can be used to treat acute anxiety. Collectively, benzodiazepines are similar in their clinical effect, although they differ in pharmacokinetic properties. Short-acting benzodiazepines with a rapid onset (half-life: 5 to 20 hours) include lorazepam (Ativan) and alprazolam (Xanax). For patients with history of substance abuse, hydroxyzine (Atarax, Vistaril) may be considered a useful alternative over benzodiazepines (11).
Once a diagnosis of panic attack is established, the patient should be reassured the panic attack is not imminently life-threatening. There may be serious long-term consequences if left untreated, and treatment options as an outpatient should be discussed (e.g., cognitive behavioral therapy or use of selective serotonin reuptake inhibitors).
CRITICAL INTERVENTIONS
• Assess patients with panic attacks for suicidal ideation, because there is a high rate of depression in these patients (12).
• Administer short-acting benzodiazepines for acute anxiety.
DISPOSITION
Most patients with anxiety disorders can be discharged from the ED with primary care or psychiatric follow-up. Patients who are actively suicidal, violent, or significantly disabled by their anxiety should be admitted to the hospital. Likewise, when the cause of acute anxiety is unclear, short-term admission for further medical and psychiatric evaluation should be considered. If benzodiazepines are prescribed, only a small quantity should be given, and close follow-up and subsequent psychiatric evaluation should be arranged.
Common Pitfalls
• Assuming that an acutely anxious patient, even one known to suffer from an anxiety disorder, has no medical problem. Patients presenting with anxiety must be presumed to have a medical condition as the cause until it is ruled out by an appropriate evaluation.
REFERENCES
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