This document provides information on anxiety disorders and their assessment and treatment in emergency departments. It notes that anxiety disorders are one of the most common psychiatric conditions but only a minority of patients require emergency psychiatric consultation. For patients presenting with anxiety, it is important to first ensure medical stability and rule out any underlying medical or substance-related causes. It then focuses on panic disorder, describing the definition, clinical presentation, epidemiology, comorbidities, workup and treatment options including pharmacological interventions and psychological therapies like CBT.

1. +
ANXIETY DISORDERS
Maria Ysabella Bondoc, MD

2. +
Anxiety Disorders
One of the most common psychiatric conditions
 36% of psychiatric diagnoses
 only a minority requires emergency psychiatric
consultation
Patients tended to be referred for emergency
psychiatric evaluation only:
 when they had comorbid depression,
 absence of medical illness,
 or when a triage nurse elicited psychiatrically
relevant information.

3. +
Anxiety Disorders
In EDs and many other settings, anxiety-
related presentations often receive lower
priority than other conditions.
Emergency physicians provide reassurance and
small amounts of benzodiazepines or
antihistamines
However, anxiety sufficient to cause an ED visit
is likely to be extremely distressing to the
patient.

4. +
EMERGENCY ASSESSMENT
Medical Stability and Safety must be ensured
BEFORE PSYCHIATRIC EVALUATION proceeds.

5. +
Suspect medical or substance-related
cause if:
 Acute or sudden onset
 First presentation (especially after age of
40)
 Any clouding of consciousness
 Fluctuation (waxing and waning) in level of
consciousness
 Presence of visual, olfactory, and gustatory
hallucinations or autonomic instability

6. +
Signs that suggest a primary medical
or substance-related condition
pinpoint or dilated pupils,
nystagmus,
stereotypic movements,
facial asymmetry,
muscle weakness, or
clouded consciousness

7. +
Clinical Indicators consistent with the
presence of PANIC ATTACKS
concern about losing control,
a positive family history of anxiety disorder,
initial onset between 18 and 45 years old,
a recent or anticipated major life event,
and presence of an agoraphobic pattern of
avoidance.

8. +
Description of Chest Pain and Dypsnea
in Patients with Panic Attacks
 Patients with Panic Attacks
 rapid or pounding heartbeat and ill-
defined chest pain (as opposed to
crushing, substernal chest pain – Pollard
and Lewis)
May complain of shortness of breath but
rarely experiences stridor or wheezing
May feel nauseated but they usually do not
vomit

9. +
In general, patients whose anxiety results from a
primary psychiatric illness are alert, clear
headed, and are able to articulate a chief
complaint and describe the nature of their
symptoms.

10. +
Any change in mental status may indicate a level
of disorganization suggestive of a psychiatric
condition of a different nature (e.g., psychosis) or
may indicate an underlying medical illness.
Substance Use
 Should be asked in ALL patients
amount, frequency, and pattern of use
Family History of Anxiety

11. +
Mental Status Examination and
Physical Examination in Patients with
Primary Anxiety Disorder
Mental Status Examination Physical Examination
Fairly unremarkable
Somewhat rapid speech,
anxious and restless
May also be depressed and
tearful
Distractible but INTACT
cognition
Typically unremarkable
Isolated sinus tachycardia
(120 bpm) with slightly
elevated BP
**if >140bpm and a lower
than expected BP, increased
respiratory rate, for further
medical workup

12. +
PRIMARY ANXIETY
DISORDERS

13. +
PANIC
DISORDE
R

14. +
Definition
 Essential feature: RECURRENT, DISCRETE
anxiety or panic attacks
 The attacks are characterized by:
 Unexpected, extreme anxiety or fear,
 accompanied by a variety of autonomically
mediated symptoms (result from excitation of
sympathetics)

15. +
DEFINITION
Sudden onset of acute anxiety is most commonly
experienced as fear.
A sudden rise in fear may well be an appropriate
response to a real threat, but it can also occur in
the absence of threat in the form of a panic attack.
Sudden-onset fear is often accompanied by
activation of the sympathetic nervous system,
which may lead to increased heart rate, dilated
pupils, and other physiological changes that
prepare the organism to respond to threat.

16. +
Definition
 It triggers a heightened vigilance to both external
cues and internal (bodily) states as the organism
scans for sources of risk that may require
immediate responses.
 This vigilance is associated with heightened
awareness of physical sensations
 NOT DUE TO substance use, general medical
condition, or other psychiatric disorder
 The relationship of attacks to situational stressors
has diagnostic importance;
 unexpected attacks occur in panic disorder,
 whereas situational attacks occur in phobias and
other anxiety disorders.

17. +
Clinical Presentation
symptoms begin suddenly and crescendo rapidly,
reaching a peak within 10 minutes.
Attacks usually last 10–30 minutes,
 rarely do they last as long as an hour.

18. +
Clinical Presentation
Presentation
Catastrophic
misinterpretations of the
danger they represent.
Typically patients fear dying,
going crazy, or collapsing.
Palpitations, chest pain, and
shortness of breath
Patients may believe they are
having a “heart attack.”
Dizziness and
depersonalization,
patients may feel as though
they are “going crazy.”
Lightheadedness, weakness,
and flushing
impending physical collapse

19. +
Patients with Panic Disorder often
present with a PRIMARY SOMATIC
COMPLAINT
CHEST PAIN
 25% meet criteria for panic disorder
 Half had a prior history of coronary artery
disease
 80% had atypical or non-anginal chest
pain, and 75% were discharged with a
“non-cardiac pain” diagnosis.

20. +
Pathogenesis of panic may be related
to respiratory physiology by several
mechanisms:
the anxiogenic effects of hyperventilation,
the catastrophic misinterpretation (by the patient)
of respiratory symptoms,
and/or a neurobiologic sensitivity to CO2, lactate,
or other signals of suffocation.
Therefore, in a patient presenting to the ED with
dyspnea, with medical causes confidently excluded,
panic disorder should be considered and

21. +
Epidemiology
Common in the general population
Twice as common in Females than in Males
Greatest in young persons aged 15–24 years
Persons with fewer than 12 years of
education are more commonly affected than
persons with 16 or more years of schooling.

22. +
Comorbidity
The most common comorbid conditions are:
other anxiety and depressive disorders,
substance use disorders.

23. +
Comorbidity
Pulmonary disease constitutes a risk factor for
the development of panic disorder.
Pharmacologic
Benzodiazepine -used with caution to avoid
respiratory depression.
Serotonergic antidepressants - effective
treatments for panic disorder in pulmonary
patients due to relatively little potential for
significant adverse effects on respiration

24. +
Work-up
Five variables were strongly related to panic
disorder in these patients:
1. absence of coronary artery disease,
2. atypical quality of chest pain,
3. female sex,
4. younger age
5. a high level of self-reported anxiety.

25. +
Work-up
First time chest pain presentations will
usually require an acute coronary syndrome
(ACS) evaluation,
But consider the standard ED differential
diagnoses for chest pain
 pulmonary embolus, pneumothorax,
pericarditis, pneumonia, perforated viscous,
and dissection

26. +
Complete Blood Count rule out infection, anemia,
polycythemia, thrombocytopenia
Comprehensive metabolic panel
• serum values of sodium, calcium, blood urea nitrogen, creatinine, liver
transaminases, albumin, magnesium, phosphorus, and thyroid
stimulating hormone.
Cardiac Enzymes
Urine Analysis
Serum and urine toxicology To screen for presence of illicit or
other substances
Monitoring of the electrocardiogram
and the cardiac status
CSF fluid analysis CNS infection, if necessary

27. + PANIC DISORDER Treatment:
 Maintaining a calm and confident demeanor, but
without false or condescending reassurance
 Hyperventilation
 helping the patient to slow his or her breathing through
attention and control can be helpful, emphasizing that the key
is slow breathing, not deep breathing, with enough tidal
volume for adequate oxygenation but not with huge breaths
that will keep pCO2 (partial pressure of carbon dioxide) low.
 Progressive muscle relaxation, with systematic
tensing and then relaxing of the various muscle
groups of the body, is useful for some patients.

28. + PANIC DISORDER Treatment:
 Reassurance that the patient does not appear to be in
acute medical danger can also help.
 Initiation of education can both calm and lay groundwork
for subsequent treatment efforts
 informing the patient that this could be a panic attack;
 that panic attacks are overwhelming and frightening but not
truly threatening; and
 that if a panic attack, it will likely pass reasonably quickly if
the patient just lets it run its course—can both calm and lay
groundwork for subsequent treatment efforts.

29. +
Treatment: Pharmacotherapy and
Psychological Therapy
Psychological Therapy
• Directly addressing the catastrophic interpretations that
patients with panic often attach to their symptoms with an
exploration of past evidence relevant to their
interpretations
• Cognitive Behavioral Therapy that focuses on relaxation,
changes in thinking, and exposure to benign anxiety
symptoms and anxiety-provoking situations has been
shown to reduce panic. (RARE IN ER SETTING)

30. +
Psychological Therapy: CBT
• Cognitive management of panic attacks is a
cornerstone of treatment
• Swinson et al. study: Patients who presented with
panic attacks were randomly assigned to receive
either reassurance alone or reassurance coupled
with exposure instruction (told to confront the
situation), all of which occurred in the ED within 48
hours
• RESULT:
• Reassurance only: frequency of panic attacks increased
• Reassurance + Exposure instruction: panic attacks
decreased in frequency and measures of distress
improved significantly

31. + PANIC DISORDER Treatment:
Pharmacotherapy and Psychological
Therapy
Pharmacotherapy
• Standard treatment of choice in ED
• Non-BDZ of choice if possible (given that there is a high
abuse potential in BDZs like Alprazolam, Diazepam, and
Lorazepam)
• Antihistamines like Diphenhydramine and Hydroxyzine
(potential role in panic symptoms by virtue of their
sedative properties)
• Selective serotonin reuptake inhibitors (SSRIs) and
tricyclic antidepressants gradually reduce the likelihood
and intensity of panic attacks, but the clinical benefit is
often not seen for at least 2–3 weeks.

32. +
Treatment: Pharmacotherapy
Pharmacotherapy
• SSRI antidepressants are the drugs of choice
• Sertraline or citalopram are good first-choice drugs for panic
patients.
• Sertraline has a very broad dosing range, so it can be started
at very low levels (12.5 mg/day) and titrated slowly to a goal
dose of 100–200 mg/day.
• Citalopram is a good alternative, because it tends to be
minimally activating, with fewer bodily sensations for the
patient to misinterpret during titration.
• It can be started at 2.5 mg/day and titrated to a goal dose of
20–40 mg/day.

33. +
Treatment: Pharmacotherapy
Pharmacotherapy
• Atypical neuroleptics like Olanzapine and Quetiapine may be
particularly helpful in patients presenting with anxiety who
have comorbid bipolar disorder.
• Balance the risk of weight gain and hyperglycemia

34. +
Generalize
d Anxiety
Disorder

35. + Definition
GAD is characterized by:
 a prolonged period of excessive worry and
anxiety manifesting as restlessness or
feeling “keyed up” or “on edge,”
 thereby leading to easy fatigability,
difficulty concentrating, irritability, increased
muscle tension, or sleep disturbance.

36. +
Clinical Presentation
Chronic, fluctuating course
Patients often present with unpleasant
overarousal and/or somatic symptoms like
 muscle aching,
 fatigue,
 tension headaches,
 rapid heart rate,
 diaphoresis,
 gastrointestinal distress, or
 frequent urination.

37. +
Epidemiology
Lifetime prevalence of ~6%.
Risk factors include:
 female sex,
 age >24 years,
 being previously married,
 being unemployed, and
 living in the Northeastern United States.

38. +
Comorbidity
 Extremely high rates of comorbidity in
persons with GAD
 Depressive disorders are the most common
comorbid diagnoses.

39. +
Differential Diagnoses
Anxiety due to GMC or substance use
The diagnosis of an adjustment disorder with
anxiety should only be made if the criteria for
generalized anxiety disorder are not met.
It should also be noted that normal worry, as
compared to GAD, is less likely to be
accompanied by physical symptoms.

40. +
Workup
 same with Panic Disorder work-up

41. +
Treatment
Medication
Benzodiazepines Treats arousal
and somatic
anxiety
Dependence
potential
Discontinuation may
be associated with
rebound anxiety
Antidepressants Useful in the
long-term
treatment
Delay in therapeutic
action limits their
usefulness
Sedating
antihistamines
Rapid anxiolytic
effect
Used in caution in
elderly patients due
to deleriogenic
properties

42. +
Obsessive
Compulsiv
e Disorder

43. +
Definition
 characterized by
intrusive, distressing thoughts, images, or
urges (obsessions) and
senseless or excessive, repetitive
behaviors (compulsions).
 obsessions and/or compulsions are
substantially distressing or interfere with
functioning

44. +
Lowest rate of treatment in ED settings
 Because the distress of OCD is typically chronic and
persistent, patients do not normally present to the
ED.
“FRAIDS” (fear of AIDS)
 Some patients with OCD have excessive concerns
that they may have HIV infection or AIDS, even
without the presence of any risk factors.

45. +
Epidemiology
 affects ~2% of the population
 OCD affects males and females equally, though onset
is generally earlier in males (childhood).
 Patients occasionally report onset or worsening of
symptoms around the time of a stressful event, such
as during pregnancy or delivery of their baby.
 Because many patients are secretive about their
symptoms, there is often a delay of 5–10 years after
onset before patients seek psychiatric assistance.

46. +
Comorbidity
 Many patients with OCD struggle with comorbid Axis I
conditions such as major depression.
 Skodol et al. found that OCD was two to three times
more likely to be diagnosed in combination with
 a Cluster C personality disorder (the fearful, anxious
cluster): dependent personality disorder, obsessive-
compulsive personality disorder, or avoidant personality
disorder.
 Others: “OCD spectrum disorders,” including tic
disorders, body dysmorphic disorder,
hypochondriasis, and grooming disorders (e.g.,
trichotillomania).

47. +
Differentials
 Obsessions of OCD should be properly distinguished from
the excessive worries seen in GAD.
 Depressive ruminations are also sometimes confused with
obsessions, but the diagnosis of OCD should not be
considered unless clear obsessions and/or compulsions
are present.
 In patients with OCD, certain stimuli sometimes provoke
anxiety about, and avoidance of, dirt or contamination;
however, the co-occurrence of typical obsessions or rituals
clarifies the diagnosis of OCD instead of specific phobia.

48. +
Differentials
 The presence of frank obsessions and ritualistic behaviors
also helps to distinguish OCD from obsessive-compulsive
personality disorder (OCPD).
 OCPD is not characterized by anguish, but rather by
perfectionism, orderliness, and control.
 Patients with OCD know that their behaviors are not
rational but are nonetheless compelled to do them, thereby
causing significant distress.

49. +
Workup
Complete mental status
 disturbance of mood and affect, hallucinations
or delusions, orientation, memory, and
insight/judgment.
Evaluate for tic disorders
Findings on neurologic and cognitive
examinations should otherwise be normal.

50. +
Workup
Focal neurologic signs or evidence of cognitive
impairment should prompt evaluation for other
diagnoses.
Dermatologic exam,
 dry, red skin from excessive washing,
 hair loss from compulsive hair pulling, or
 lesions from compulsive skin picking.
Routine laboratory tests should be performed to
rule out medical or substance-induced causes of
symptoms.

51. +
Treatment
Of the antidepressants, only SSRIs or
clomipramine are effective in OCD.
 require doses in excess of those normally
prescribed for the treatment of other anxiety or
depressive disorders.
 Response to treatment is usually quite gradual and
may take up to 8–12 weeks.
Atypical antipsychotics are often useful
augmenting agents.

52. +
Treatment
Behavioral therapy, specifically exposure and
response prevention, is highly efficacious.
Meta-analyses and clinical significance analyses
indicate that 60%–80% of patients who engage
in this treatment improve substantially.

53. +
Acute Stress
Disorder and
Posttraumatic
Stress
Disorder

54. +
Definition
Requires
 exposure to a traumatic event
involves actual or threatened death or serious
injury, or a threat to the physical integrity of self
or others.”
“the person’s response must involve intense
fear, helplessness, or horror.”
In ASD, symptoms must last at least two days but
less than four weeks, whereas in PTSD, the
symptoms last for a period of at least a month.

55. +
Clinical Presentation
 Reexperiencing (e.g., intrusive memories, flashbacks, or
nightmares)
 Reexperiencing can occur spontaneously or can be triggered by
external sensory stimuli, even though patients typically avoid situations
that remind them of the trauma.
 Avoidance of stimuli or numbing, and
 Numbness refers to a state of detachment, emotional blunting, and
relative unresponsiveness to surroundings.
 Symptoms of increased arousal
 sleep disturbance, difficulty with memory and concentration,
hypervigilance, irritability, and an exaggerated startle
response.

56. +
Epidemiology
 The lifetime prevalence of PTSD in the United States
has been estimated at 7%.
 It is important to note that many people experience
traumatic events without developing long-term
psychological symptoms or becoming disabled.
 Kessler et al.
 Men: engaging in combat and witnessing death or severe
injury,
 whereas in women, being raped or sexually molested.

57. +
 Individual vulnerability plays a crucial role in the
development of the disorder.
 Risk factors for ASD include trauma severity, female
gender, and avoidant coping style.
 Potent risk factors for PTSD include trauma severity,
female sex, pre-trauma psychiatric illness, and
family history of psychiatric illness.
 A history of psychological treatment can be a better
predictor of PTSD than the traumatic event itself.

58. +
Comorbidty
PTSD rarely occurs in the absence of other
psychopathology.
As with all anxiety disorders, comorbidity
with other anxiety and depressive disorders
is frequent, but substance use disorders are
also common comorbid conditions.

59. +
Differential Diagnosis
Not only are responses to trauma highly
variable, but trauma can also precipitate a
variety of psychiatric conditions, including
generalized anxiety disorder, depression,
somatoform disorders, or adjustment
disorders.
Evidence of an ulterior motive and the
absence of distress when a patient believes
he or she is unobserved may suggest
malingering.

60. +
Workup
 Patients may present with physical injuries from the
traumatic event (e.g., bruises in victims of domestic
abuse).
 The mental status exam may reveal motor agitation, an
increased startle response, poor concentration or impulse
control, tense mood, suicidal or homicidal thoughts, or
evidence of reexperiencing.
 Routine laboratory tests are important to evaluate for
substance-related disorders.

61. +
Treatment
 Definitive treatment of patients with PTSD is not
usually attempted in the acute setting, but
management of patients with acute symptomatology
may necessitate temporary
 Pharmacologic intervention with a non-
benzodiazepine sedative or atypical antipsychotic.
 Symptoms requiring pharmacologic treatment may include
insomnia, poor impulse con- trol, or explosive outbursts.
 CBT anxiety management techniques, including
controlled breathing, muscle relaxation, and guided
self-dialogue, are also helpful.

62. +Appropriate treatment of PTSD is essential to
reduce symptoms and increase functioning and
quality of life for the patient.
 Early intervention is crucial in order to help prevent
the development of secondary chronic comorbidity.
There are five treatment goals when treating
PTSD:
(1) reducing the core symptoms,
(2) improving stress resilience,
(3) improving quality of life,
(4) reducing disability, and

63. +
Successful treatment of PTSD using CBT will
involve developing an accepting attitude
toward treatment, a capacity to tolerate
distress, outside support, and minimization of
comorbidities.
 Exposure therapy has the strongest evidence of
efficacy in different populations of trauma victims
with PTSD, but a few patients failed to show
sufficient gains with this therapy.

64. + The 1999 consensus statement on PTSD30
recommends starting treatment with an SSRI
three weeks after exposure to a traumatic
event in those patients with no improvement
in their acute stress response.
 An SSRI should be started at a low dose, and the
dose should be gradually titrated upward to the
same or higher level than that used to treat
depression.
 An appropriate trial of initial drug therapy is three
months, but effective pharmacotherapy should be
continued for 12 months or longer, depending on
the severity and duration of illness, as well as the
presence of any comorbid conditions.
 In addition, most patients should be referred for
CBT.

65. +
 No studies support the efficacy of benzodiazepines in
PTSD, but some evidence does suggest that the clinical
condition of patients with PTSD deteriorates when they
are treated with benzodiazepines.
 Even in the setting of sleep disturbance, physicians should
typically avoid benzodiazepines.
 Most recently, atypical antipsychotics have been used off-
label for PTSD. T
 hey show promise both in their effects on mood and
anxiety and in their effects on psychosis.

66. +
Clinical guidelines for primary care
management of PTSD include:
 (1) educating patients regarding the normal stress
response and encouraging them to discuss
experiences with family and friends in the first few
days after exposure to trauma;
 (2) referring the patient to a mental health
professional, especially if there is no clinical
improvement within three weeks;
 (3) ensuring that patients get one or two counseling
sessions to deal with distress and create a sense of
safety with ongoing monitoring within the first two
weeks after the trauma;

67. +
 (4) consider starting a non-benzodiazepine sedative if a
patient has had four consecutive nights of sleep
disturbance;
 (5) consider starting a low-dose SSRI and/or
 (6) continuing effective drug therapy in most patients for 12
months or longer; and
 (7) referring patients who are refractory to initial drug
therapy at three months and those with complicating
comorbid conditions to a psychiatrist. In the ED, the most
important consideration is to ensure that the patient has
close psychiatric follow-up.

68. +
Prevention
 Given that the ED is often the first line of treatment
following traumatic events, the most important role of
the ED is to determine if there are preventive
measures that can be taken to diminish the
progression from acute stress to PTSD.
 Patients should be educated about the normal stress
response and support services should be identified
for follow-up counseling.

69. +
 Normalizing expected acute stress reactions that are
experienced by most people affected by the traumatic event
and which are expected to resolve when the situation has
been stabilized.
 Psychological debriefing used to be considered the
mainstay for community education, as session leaders
would ask participants to describe their thoughts, feelings,
and behavioral reactions during the event.
 Psychoeducation to reassure participants that acute stress
reactions are normal responses to horrific events, and not
necessarily indicative of mental illness.

70. +
Adjustment
Disorders
with
anxiety

71. +
Adjustment Disorder with anxious
mood
 The diagnosis of an adjustment disorder with anxiety
is made if a patient becomes anxious in response to
an identifiable stressor.
 Symptoms must develop within three months and
resolve within six months.
 The distress experienced by these individuals is
meant to be in excess of what would be expected
from the event or result in significant impairment in
social or occupational functioning.

72. +
 Adjustment disorder (AD) is thought to be common, as some
studies suggest prevalence as high as 23% in clinical
populations.
 Comorbidity with other psychiatric diagnoses, such as
personality disorders, anxiety disorders, affective disorders,
and psychoactive substance use disorders, is reported in up to
70% of patients with AD in adult medical settings of general
hospitals.
 Therefore, these comorbidities should be considered when the
diagnosis of AD is considered in patients presenting to the ED.

73. +
Anxiety symptoms related to medical
illnesses or drugs
General Medical
Illness
Conditions
Cardiovascular Angina, arrhythmias, congestive heart failure,
hypertension, hyperventilation, hypovolemia,
myocardial infarction, shock, syncope, valvular
disease
Endocrine Cushing syndrome, hyperkalemia, hyperthermia,
hyperthyroidism, hypothyroidism, hypocalcemia,
hypoglycemia, diabetes mellitus, hyponatremia,
hypoparathyroidism, menopause
Hematologic Acute intermittent porphyria, anemias
Immunologic Anaphylaxis, systemic lupus erythematosus

74. +
General Medical
Illness
Conditions
Infection Acute or chronic infecton
Neoplastic tumor Carcinoid tumor, insulinoma, pheochromocytoma
Neurologic Cerebral syphilis, cerebrovascular insufficiency,
encephalopathies, essential tremor, Huntington’s
chorea, intracranial mass lesions, migraine
headache, multiple sclerosis, postconcussive
syndrome, posterolateral sclerosis, polyneuritis,
seizure disorders (especially temporal lobe
seizures), vertigo, vasculitis, Wilson’s disease
Respiratory Asthma, chronic obstructive pulmonary disease,
pneumonia, pneumothorax, pulmonary edema,
pulmonary embolism

75. +
Medications
Anesthetics/analgesics Ethosuximide
Antidepressants (tricyclics,
SSRIs, bupropion)
Heavy metals and toxins
Antihistamines
Herbal remedies: ginseng root, ma
huang, guarana (found in herbal diet
preparations)
Antihypertensives Hydralazine
Antimicrobials Insulin
Bronchodilators Levodopa
Caffeine preparations Muscle relaxants
Calcium-blocking agents Neuroleptics
Cholinergic-blocking agents Nicotine
Digitalis Non-steroidal anti-inflammatories
Estrogen Procaine

76. +
SSRIs and other antidepressants
 SSRIs can induce anxiety symptoms, particularly
early in the course of treatment (the first few days) or
in combination with other medications.
 Serotonin syndrome or serotonin toxicity is
characterized by neuromuscular excitation (clonus,
hyperreflexia, myoclonus, and rigidity), sympathetic
hyperactivity (hyperthermia, tachycardia,
diaphoresis, tremor, and flushing), and changed
mental status (anxiety, agitation, and confusion).

77. +
 There are several drug combinations that cause
excess serotonin, the most common being
monoamine oxidase inhibitors in combination with
SSRIs.
 Treatment should focus on cessation of one or more
offending agent(s) and supportive care.

78. +
 Discontinuation of certain drugs may also be associated
with anxiety. If alcohol is abruptly stopped, withdrawal
symptoms, including severe anxiety, may appear within
the first day.
 Likewise, benzodiazepines, especially short-acting
formulations, can cause similar withdrawal phenomena.
 Patients dependent on narcotics, whether prescription or
illicit, may also experience anxiety as part of a withdrawal
syndrome.
 When possible, collateral information from family, friends,
and other physicians should be sought, and patients’

79. +
 Other drugs that are often overlooked that can
generate anxiety include over-the-counter
preparations for cold symptoms, weight suppression,
or sleep induction.
 These may include compounds of pseudoephedrine,
phenylephrine, and ephedrine.
 These substances are also found in herbal remedies
under a number of pseudonyms such as ma huang.

80. +
Special considerations: The ACUTE
THERAPEUTIC ENVIRONMENT
 Several hospital-associated factors are associated
with anxiety.
 These include financial burden, intrusive medical
procedures, isolation, loss of autonomy, loss of
privacy, physical discomfort/pain, possibility of death,
and uncertainty regarding cause/prognosis. Often,
the environment of the ED can increase anxiety
instead of alleviating it.

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 Since anxious patients are often over stimulated, a
properly constructed psychiatric emergency service
should offer a quiet environment.
 In addition, given that anxious patients may be
suicidal, it is important to have an environment free
of sharp instruments and other hazards.
 Lastly, anything that might be used for hanging must
be tested for load bearing.

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 The general principles useful in approaching most
psychiatric emergencies are equally applicable to the
handling of an anxious patient.
 Early verbal contact is advised because allowing the
opportunity to put thoughts and emotions into words
invariably helps to reduce initial tension.
 A private and relaxed setting for the interview is important.
 However, this can prove challenging when other
contributing medical conditions have not yet been
excluded.

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 It is important to allow for a delayed final evaluation
because many initially overwhelmed anxious people
may reconstitute within a matter of hours when
allowed to talk, rest, or even sleep.
 The anxious patient’s chief complaint, even if it is
somatic, should be taken seriously.
 A physical examination should be performed
routinely in all cases, especially when there is a
physical complaint.

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 Within the scope of the ED practice, an “organic” etiology for
the anxiety should be ruled out.
 The emergency physician should be careful to avoid a
judgmental or punitive approach, as patients find it most
comforting when they experience the feeling of being
understood.
 While in the ED, every attempt should be made to engage
the family in caring for the patient.
 The emergency medicine physician and the acute care team
need to assess the degree and adequacy of social support
available in the patient’s environment, especially since
sensible disposition may depend on it.

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Suicide
A major priority of any ED is evaluation and
disposition of patients who are at risk for self-
harm.
 Among the anxiety disorders, panic disorder may be
particularly associated with suicidal behavior.
 Uncomplicated panic disorder (i.e., without comorbid
conditions) was also associated with an increased
suicide risk.
 Some authors report a possible additive effect of major
depression and anxiety disorders/agitation, in that
patients with both appear at particularly high risk for
suicide attempts.

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Summary
 Anxiety disorders are among the most common psychiatric
conditions, and the impact of these disorders on patients
is substantial.
 In the acute setting, approach the anxious patient
carefully, as anxiety may be a manifestation of a medical
disorder as well as a possible comorbid or isolated
psychiatric condition.
 A careful history, including a past medical history and a
thorough examination in a safe private setting, is essential.
 An understanding of the psychiatric conditions that can
present with anxiety, along with the judicious use of
pharmacotherapy and counseling, will be critical in