Approach to anxiety disorders: Clinical sciences

Anxiety disorders are conditions characterized by excessive fear and anxiety. Fear is an emotional reaction to a threat, either real or perceived, and is usually associated with autonomic arousal. Anxiety, on the other hand, is the anticipation of a future threat; it’s not usually associated with autonomic arousal; and it often causes maladaptive changes in thinking or behavior.

Distinguishing between the various anxiety disorders requires identifying the triggers that set them off, any related changes in thinking or behavior, and assessing the Diagnostic and Statistical Manual, or the DSM-5 criteria. Common anxiety disorders include panic disorder with or without agoraphobia, obsessive-compulsive disorder or OCD, specific phobias, social anxiety disorder, and generalized anxiety disorder or GAD.

When a patient presents with a chief concern suggesting an anxiety disorder, first perform a focused history and physical examination.

Your patient will report excessive fear or anxiety, or sometimes both. In some cases, they might also report chest discomfort.

The physical exam might show restlessness, a tense or constricted affect, tachycardia, or elevated blood pressure. With these findings, consider an anxiety disorder, and investigate further to determine the specific type.

Let’s start by assessing for a history of panic attacks. A panic attack is an abrupt period of intense fear, accompanied by an uncomfortable surge of autonomic arousal, where the heart beats faster, respirations increase, and muscles tense up.
Patients might report trembling, sweating, chest discomfort, palpitations, shortness of breath, nausea, paresthesias, or lightheadedness. Additionally, there might be associated emotional symptoms, like crying, dissociation, feeling out of control, or fear of dying. Panic attacks can be triggered by stressful situations or can occur unexpectedly.
Here’s an important clinical pearl! An acute panic attack can present like acute coronary syndrome, with symptoms such as diaphoresis, chest discomfort, and shortness of breath.

With this presentation, be sure to evaluate for cardiac causes. This is especially recommended if it’s a patient’s first episode or if there are any risk factors for cardiovascular disease.

In this case, order cardiac enzymes and a 12-lead ECG. If it’s a true panic attack, cardiac enzymes will be unremarkable, and the ECG will show no signs of ischemia.

Now, if your patient experiences recurrent panic attacks, consider panic disorder. To confirm the diagnosis, assess the DSM-5 criteria, which specify that they must have repeated, unexpected panic attacks. Also, they must experience at least one month of nearly constant worry about future episodes; or make maladaptive changes to their behavior to avoid having attacks; or both. If these criteria are met, and there’s no medical condition, substance use, or other mental disorder that could cause the symptoms, diagnose panic disorder.
Here’s a clinical pearl to keep in mind! Certain medical conditions can cause symptoms resembling panic attacks. These include hyperthyroidism, hyperparathyroidism, seizures, and pheochromocytoma. Additionally, certain medications such as steroids, stimulants, and similar drugs of abuse can trigger these symptoms. So, keep an eye out for these possibilities during your assessment!

Okay, once you’ve diagnosed panic disorder, your next step is to determine if agoraphobia is present. Agoraphobia refers to fear or anxiety about situations, such as using public transportation; being in open spaces like a parking lot; being in enclosed spaces like a theater; standing in line or being in a crowd; or being alone outside of their home.
Your patient will report avoiding situations like these or endure them with extreme anxiety due to fear that they’ll be unable to escape or that there’s no help available if something terrible happens, like visibly panicking or becoming embarrassed.

The amount of anxiety they experience will be out of proportion to the actual danger these situations pose to them, and it will impair their ability to function in important areas of life, like social or occupational contexts. If agoraphobia has been persistent for at least 6 months, and there’s no medical condition, substance use, or other mental disorder that could cause the symptoms, diagnose panic disorder with agoraphobia. Otherwise, diagnose panic disorder without agoraphobia.

Here’s another clinical pearl to keep in mind! Agoraphobia is typically diagnosed in association with panic disorder, but it can occur independently. For instance, an elderly person may develop agoraphobia associated with the fear of falling or having incontinence outside the home, but without associated episodes of panic. In this case, agoraphobia can result in problems like missing important medical appointments or becoming socially reclusive.

Now, let’s look at when your patient reports infrequent or no panic attacks. In this case, your next step is to assess for the presence of obsessions and compulsions. Obsessions are recurrent, intrusive thoughts that can manifest as images or urges that cause significant anxiety or distress.
On the other hand, compulsions are ritualized attempts aimed at alleviating the anxiety caused by obsessions. The content or subject of obsessions and compulsions can vary from patient to patient, and common themes include contamination, symmetry, or danger.

And here’s another clinical pearl! Compulsions can manifest as either mental or behavioral acts, often unrelated to the obsession in a realistic manner. Examples of compulsions include excessive handwashing, arranging or ordering items, counting, repeating words or phrases, or repeatedly checking locks.