+

ANXIETY DISORDERSMaria Ysabella Bondoc, MD

+Anxiety Disorders

One of the most common psychiatric conditions 36% of psychiatric diagnoses only a minority requires emergency psychiatric

consultationPatients 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.

+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.

+EMERGENCY ASSESSMENT

Medical Stability and Safety must be ensured BEFORE PSYCHIATRIC EVALUATION proceeds.

+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

+Signs that suggest a primary medical or substance-related conditionpinpoint or dilated pupils, nystagmus, stereotypic movements, facial asymmetry, muscle weakness, or clouded consciousness

+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.

+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

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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.

+

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 UseShould be asked in ALL patientsamount, frequency, and pattern of use

Family History of Anxiety

+Mental Status Examination and Physical Examination in Patients with Primary Anxiety DisorderMental Status

ExaminationPhysical Examination

Fairly unremarkableSomewhat rapid speech, anxious and restlessMay also be depressed and tearfulDistractible but INTACT cognition

Typically unremarkableIsolated sinus tachycardia (120 bpm) with slightly elevated BP

**if >140bpm and a lower than expected BP, increased respiratory rate, for further medical workup

+PRIMARY ANXIETY DISORDERS

+ Click icon to add picture

Click icon to add picturePANIC

DISORDER

+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)

+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.

+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.

+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.

+Clinical PresentationPresentationCatastrophic 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

+Patients with Panic Disorder often present with a PRIMARY SOMATIC COMPLAINTCHEST PAIN

25% meet criteria for panic disorderHalf 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.

+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 investigated.

+Epidemiology

Common in the general populationTwice as common in Females than in MalesGreatest 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.

+Comorbidity

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

+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

+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 age5. a high level of self-reported anxiety.

+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 painpulmonary embolus, pneumothorax,

pericarditis, pneumonia, perforated viscous, and dissection

+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 EnzymesUrine AnalysisSerum and urine toxicology To screen for presence of illicit

or other substancesMonitoring of the electrocardiogram and the cardiac statusCSF fluid analysis CNS infection, if necessary

+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.

+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.

+Treatment: Pharmacotherapy and Psychological TherapyPsychological 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)

+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

+PANIC DISORDER Treatment: Pharmacotherapy and Psychological TherapyPharmacotherapy• 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.

+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.

+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

+ Click icon to add picture

Click icon to add pictureGeneraliz

ed Anxiety Disorder

+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.

+Clinical Presentation

Chronic, fluctuating coursePatients often present with unpleasant

overarousal and/or somatic symptoms likemuscle aching, fatigue, tension headaches, rapid heart rate, diaphoresis, gastrointestinal distress, or frequent urination.

+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.

+Comorbidity

Extremely high rates of comorbidity in persons with GAD Depressive disorders are the most

common comorbid diagnoses.

+Differential Diagnoses

Anxiety due to GMC or substance useThe 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.

+Workup

same with Panic Disorder work-up

+TreatmentMedication

Benzodiazepines Treats arousal and somatic anxiety

Dependence potentialDiscontinuation 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

+ Click icon to add picture

Click icon to add pictureObsessive Compulsi

ve Disorder

+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

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Lowest rate of treatment in ED settingsBecause 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.

+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.

+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).

+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.

+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.

+Workup

Complete mental status disturbance of mood and affect,

hallucinations or delusions, orientation, memory, and insight/judgment.

Evaluate for tic disordersFindings on neurologic and cognitive

examinations should otherwise be normal.

+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.

+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.

+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.

+ Click icon to add picture

Click icon to add picture

Acute Stress Disorder and Posttraumati

c Stress Disorder

+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.

+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.

+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.

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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.

+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.

+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.

+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.

+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.

+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 (5) reducing comorbidity.

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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.

+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.

+

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.

+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;

+

(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.

+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.

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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.

+ Click icon to add picture

Click icon to add pictureAdjustme

nt Disorders

with anxiety

+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.

+

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.

+Anxiety symptoms related to medical illnesses or drugsGeneral 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

+

General Medical Illness

Conditions

Infection Acute or chronic infectonNeoplastic 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

+MedicationsAnesthetics/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

+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).

+

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.

+

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’ medication bottles, if available, should be examined closely.

+

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.

+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.

+

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.

+

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.

+

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.

+

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.

+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.

+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 creating the most appropriate treatment plan.