Chapter 110   Anxiety Disorders
Eugene E. Kercher and Joshua L. Tobias
Anxiety is essential to the human condition. Confrontation
with anxiety can relieve us from boredom, sharpen our
sensitivity, and create the tension which is necessary to
preserve human existence.
Rollo May
Acute anxiety and apprehension are common in emergency
department (ED) patients. However, many medical entities
mimic anxiety disorders, and up to 42% of patients thought to
have anxiety disorders are later found to have organic disease.
Emergency physicians must thoroughly assess the anxious
patient and identify and appropriately treat any underlying
medical conditions.1
■  PERSPECTIVE
Anxiety is a specific unpleasurable state of tension that fore-
warns the presence of danger. This uneasiness stems from the
anticipation of some imminent danger, the source of which is
unknown or unrecognized. Vigilance is a positive consequence
of anxiety, helping people to recognize threats quickly, which
produces more learning and more intelligence. The capacity
to experience anxiety and the capacity to plan are therefore
related, with anxiety accompanying intellectual activity as its
“shadow.”1
Anxiety facilitates performance up to a point with the well-
described adrenergic responses to stress that contribute to
survival. When responses go beyond this point, further
increases in anxiety may lead to deterioration of performance
and nonadaptive responses may add to the stress of the patient.
The threshold for pain decreases and the person becomes
more aware of bodily discomfort. Respiratory, cardiovascular,
gastrointestinal, genitourinary, and neuromuscular complaints
become prominent.1 Once the normal reaction to a threat is
surpassed and function is impaired, pathologic anxiety (anxiety
disorders) is the result.
The emergency physician should not assume anxiety is
purely functional because physical discomfort and illness often
trigger an anxiety attack. The anxiety state makes significant
metabolic demands that may actually cause a marginally com-
pensated organ system to fail. It is the goal of the emergency
physician to be able to distinguish between the anxiety and
the illness and, if necessary, treat both entities.
■  EPIDEMIOLOGY
Approximately 40 million American over the age of 18 are
affected by anxiety disorders each year. This is nearly 20% of
the adult population of the United States.2 Anxiety disorders
are among the most prevalent psychiatric disorders, and are
the most common psychiatric problem seen by primary care
physicians, with 20% of these patients experiencing a type of
anxiety disorder.3 Most people who use primary care services
have significant mood and anxiety symptoms, such as panic
disorders, generalized anxiety disorders, and depression.
Unfortunately, nearly half of these patients exhibit these
symptoms but never receive appropriate treatment,4 in part,
because the patients would rather present with a physical
complaint to the physician and try to disguise their anxiety,
rather than undergo the perceived stigma that goes with psy-
chiatric complaints.5 Patients with chronic illness and those
who make frequent medical visits have higher rates of anxiety
and depression. The prevalence of anxiety disorders surpasses
that of any other mental health disorder, including substance
abuse. In view of the close relationship between alcohol abuse
and anxiety disorders, those with anxiety disorders often turn
to alcohol and substance abuse as a form of self-medication
and the substance abuser frequently develops underlying
anxiety in relation to the use of alcohol and drugs.6
■  PRINCIPLES OF DISEASE
The precise mechanism for the cause of anxiety has not
been established. Noradrenergic, serotonergic, and other neu-
rotransmitter systems all play a role in the body’s response to
a stressor. The serotonin system and the noradrenergic systems
are common pathways implicated in anxiety. It is believed that
low serotonin system activity and elevated noradrenergic
system activity are involved. Gamma butyric acid (GABA) is
the principal inhibitory neurotransmitter in the central nervous
system. Benzodiazepines’ principal mechanism of action is on
the GABAA receptors. The well-established effectiveness of
benzodiazepines in the treatment of anxiety has led to the
study of the GABA system and its relationship to anxiety.
Newer studies are focusing on the role that corticosteroids may
play in fear and anxiety. Steroids are thought to induce chemi-
cal changes in select neurons that strengthen or weaken certain
neural pathways which affect behavior under stress.7
Other investigators have found anxiety reactions are associ-
ated with aberrant metabolic changes induced by lactate infu-
sion and hypersensitivity of the brainstem to carbon dioxide
receptors. Newer research is focusing on the regulatory centers
found in the cerebral hemispheres. The hippocampus and the
amygdala regulate emotion and memory and are important
areas in relation to an individual’s response to fear.8 Family
studies suggest genetic factors are implicated in anxiety, but
1445
 1446
the precise nature of the inherited vulnerability is unknown.
Psychological and environmental factors, as outlined in psy-
chodynamic, behavioral, and cognitive theories, also play a
PART III  ■  Medicine and Surgery / Section Eight • Psychiatric and Behavioral Disorders
causative role in the generation of anxiety in biologically pre-
disposed individuals.8
■  CLINICAL FEATURES
Many patients entering the unfamiliar environment of the ED
are going to experience anxiety and stress, and for some this
can be a significant clinical issue. The ED patient encounters
a world of both internal and external dangers: assaults on
bodily integrity in the form of uncomfortable procedures and
forced intimacy with strangers; the atmosphere of illness, pain,
and death; and separation from loved ones and familiar sur-
roundings. The patient typically experiences uncertainty
about his or her illness, the implications that the illness may
have on personal relationships and employment, and the finan-
cial burden that may accompany the illness.
The anxious patient can be a diagnostic challenge. The
presence of anxiety may represent the patient’s reaction to
medical illness or the medical setting or a manifestation of the
physical disorder itself, or the anxiety may be an expression of
an underlying psychiatric disorder. The distinction between
anxiety as a symptom and anxiety as a syndrome may be dif-
ficult to make in the ED. There is an overlap between normal
situational anxiety and fear, anxiety-like symptoms resulting
from a variety of organic disease states and their treatments,
and the characteristic presentation of anxiety itself.
The physical symptoms of autonomic arousal (e.g., tachy-
pnea, tachycardia, diaphoresis, light-headedness) may be the
only manifestation of anxiety (Box 110-1). Patients may only
complain of overall poor health or vague subjective findings
when they visit the physician. Classic panic disorder symp-
toms of chest pain, shortness of breath, and the sense of
impending doom will often lead the patient to the ED, espe-
cially if it is the primary episode.7 Anxiety associated with
organic etiologies is more likely to present with physical
BOX 110-1 Somatic Symptoms of Anxiety
Respiratory
Hyperventilation
Sense of dyspnea
Cardiovascular
Palpitations
Chest discomfort
Awareness of missed beats
Gastrointestinal
Dry mouth
Difficulty in swallowing
Epigastric discomfort
Excessive flatulence
Frequent or loose stools
Genitourinary
Frequent or urgent micturition
Failure of erection
Amenorrhea
Menstrual discomfort
Neuromuscular
Tremor
Aching muscles
Prickling sensations
Headache
Dizziness, tinnitus
symptoms and less likely to be associated with avoidance
behavior.9
■  DIFFERENTIAL CONSIDERATIONS
Medical Illness Presenting as Anxiety
Patients with anxiety disorders may present with apparent
physical disease, and many physical diseases may be strongly
associated with symptoms of anxiety. Differentiating between
these two scenarios is a daunting task for the emergency physi-
cian. Several factors help distinguish an organic anxiety syn-
drome from a primary anxiety disorder10 (Box 110-2). With
anxiety, the somatic symptoms can be so prominent that they
occupy most of the patient’s attention, making it difficult to
differentiate between a primary anxiety disorder or reactive
anxiety to a situation or disease. Anxiety disorder classifica-
tions, in the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV), include anxiety caused by a general medical condi-
tion11 (Box 110-3).
Anxious patients are frequently convinced that their problem
is purely physical. The emergency physician must realize that
the patient with anxiety is not in control of the symptoms and
frequently cannot immediately identify the correct precipi-
tant. Even though the patient may be uncomfortable, uncoop-
erative, impatient, and unreasonable, triage medical personnel
must recognize that the patient believes an illness truly exists
and is not being consciously manipulative. Because anxiety
may be the most obvious symptom of an underlying disease
or condition, the patient should be evaluated for exacerbation
of known preexisting disease as well as for onset of new illness.
The emergency physician must keep in mind that anxiety is
associated with increased medical risk in the acute exacerba-
tion of chronic illness.12
The classic scenarios of pulmonary embolism and hyperthy-
roidism causing anxiety are well documented. Cardiac disease
studies indicate poorer outcomes in post-myocardial infarction
patients with anxiety than those without documented anxiety.
Patients with respiratory diseases, such as asthma or chronic
obstructive pulmonary disease, often develop anxiety with
their long-standing illnesses. In addition, many of the medica-
tions used to treat the above illnesses may induce anxiety.5
The most common organic cause of anxiety is alcohol and drug
use, from either intoxication or, more typically, withdrawal
states.
Cardiac Diseases
Various psychiatric conditions may present to the ED with
complaints of chest pain. Approximately 25% of patients with
chest pain that present to the ED have panic disorder. Their
panic disorder often goes undiagnosed, resulting in multiple
visits and expensive cardiac workups with each visit.13 Some
of the symptoms of myocardial infarction and angina pectoris may
BOX 110-2 Predictors of Organic Anxiety Syndrome
1. Onset of anxiety symptoms after age 35 years
2. Lack of personal or family history of an anxiety disorder
3. Lack of childhood history of significant anxiety, phobias,
or separation anxiety
4. Lack of avoidance behavior
5. Absence of significant life events generating or
exacerbating the anxiety symptoms
6. Poor response to antipanic agents

BOX 110-3 Definitions of Anxiety Disorders
Panic attack is a discrete period in which there is a sudden
onset of intense apprehension, fearfulness, or terror,
often associated with feelings of impending doom.
Agoraphobia is an anxiety about, or avoidance of, places or
situations from which escape might be difficult.
Panic disorder with agoraphobia is characterized by both
recurrent, unexpected panic attacks and agoraphobia.
Agoraphobia without a history of panic disorder is
characterized by the presence of agoraphobia and
panic-like symptoms without a history of unexpected
panic attacks.
Specific phobia is characterized by clinically significant
anxiety provoked by exposure to a specific feared object
or situation, often leading to avoidance behavior.
Social phobia is characterized by clinically significant
anxiety provoked by exposure to certain types of social
or performance situations, often leading to avoidance
behavior. Blushing is the cardinal characteristic
symptom.
Obsessive-compulsive disorder is characterized by
obsessions that cause marked anxiety or distress and by
compulsions that serve to neutralize anxiety.
Post-traumatic stress disorder is characterized by
experiencing of an extremely traumatic event,
accompanied by symptoms of increased arousal and by
avoidance of stimuli associated with trauma.
Acute stress disorder is characterized by symptoms similar
to those of post-traumatic stress disorder that occur
immediately in the aftermath of an extremely traumatic
event.
Generalized anxiety disorder is characterized by at least
6 months of persistent and excessive anxiety and worry.
Anxiety disorder caused by a general medical condition is
characterized by prominent symptoms of anxiety that
are judged to be a direct physiologic consequence of a
general medical condition.
Substance-induced anxiety disorder is characterized by
prominent symptoms of anxiety that are judged to be a
direct physiologic consequence of a drug of abuse or
medication or toxin exposure.
Anxiety disorder not otherwise specified is included for
coding (1) disorders with prominent anxiety or phobic
avoidance that do not meet criteria for specific anxiety
disorders and (2) anxiety symptoms with inadequate or
contradictory information.
From American Psychiatric Association: Diagnostic and Statistical Manual
of Mental Disorders, 4th ed, Text Revision. Washington, DC, American
Psychiatric Association, 2000.
include crushing chest pain, shortness of breath, nausea, pal-
pitations, heavy perspiration, and a feeling of impending
death. These are also the primary symptoms of acute anxiety,
but the pain is usually described as atypical, and patients are
generally female and younger.14 Because of the morbidity and
mortality of cardiovascular disease, a patient warrants a full
cardiac evaluation when the differentiation between myocar-
dial infarction and acute anxiety is unclear.
Cardiac dysrhythmias can cause palpitations, discomfort, diz-
ziness, respiratory distress, and fainting. An anxious patient
with a panic disorder will frequently have similar symptoms.
Fortunately, most dysrhythmias can be documented and char-
acterized by an electrocardiogram. Mitral valve prolapse syn-
drome can be associated with palpitations and panic attacks
indistinguishable from a panic disorder. Benzodiazepines can
1447
be used to provide symptomatic relief to patients who experi-
ence chest pain. Studies have shown that benzodiazepines
reduce anxiety, pain, and cardiovascular activation. It is hypoth-
Chapter 110 / Anxiety Disorders
esized that secondary to the reduction in circulating catechol-
amines, benzodiazepines may cause coronary vasodilatation,
prevent dysrhythmias, and block platelet aggregation.15
Endocrine Diseases
The DSM-IV defines the most common endocrinologic
conditions associated with anxiety states as hypoparathyroid-
ism, hyper- and hypothyroidism, hypoglycemia, pheochromo-
cytoma, and hyperadrenocorticism.11 Anxiety is the predominant
symptom in 20% of patients with hypoparathyroidism. Other
symptoms include paresthesias, muscle cramps, muscle spasm,
and tetany. Most cases are idiopathic or the result of surgical
removal of the parathyroid glands during thyroidectomy, and
studies indicate a higher incidence of anxiety in the surgically
removed subset of patients.16 The diagnosis of hypoparathy-
roidism is suggested by a low serum calcium level, a high
phosphate level, and confirmed by a parathyroid hormone
assay.
Approximately 14% of diabetic patients suffer from anxiety
disorders, and elevated anxiety symptoms are seen in up to
40% of diabetics. There is evidence that diabetics who are
treated with antianxiety medication not only experience a
reduction in anxiety but also a decrease in glycosylated hemo-
globin levels and high-density lipoprotein.17 Many patients
with anxiety, somatoform, or characterologic disorders are
convinced that they have reactive hypoglycemia. A normal
fingerstick blood glucose analysis done during an attack can
exclude this diagnosis.
Pheochromocytomas are rare tumors that produce elevated
levels of catecholamine in the body. Common symptoms
include paroxysmal hypertension, headache, anxiety, sweat-
ing, flushing, abdominal and back pain, and vomiting and diar-
rhea. Pheochromocytoma attacks can present just like panic
attacks and can be precipitated by emotional stress. While the
sweating associated with pheochromocytoma attacks involves
the whole body, the sweating in panic attacks is more likely
to be confined to the hands, feet, and forehead. Elevated
urinary catecholamine or plasma metanephrine can confirm a
pheochromocytoma.18
Hyperthyroidism is one of the most frequently encountered
endocrine diseases associated with anxiety. As with panic dis-
orders, hyperthyroidism is associated with acute episodic anxiety.
Thyrotoxicosis causes anxiety, palpitations, perspiration, hot
skin, rapid pulse, active reflexes, diarrhea, weight loss, heat
intolerance, proptosis, and lid lag.19 Psychiatric presentations
are often the first sign of hypothyroidism, occurring as the initial
symptom in approximately 2 to 12% of reported cases along
with organic mental deficits. Anxiety and progressive mental
slowing associated with diminished recent memory and speech
deficits with diminished learning ability are the characteristic
initial progression of symptoms. The development of severe
anxiety disorders in hypothyroid states are more related to the
rapidity of change of thyroid hormone levels than the absolute
levels encountered. In general, checking the serum thyroid-
stimulating hormone and free thyroxine levels will suffice in
the ED to make the diagnosis of thyroid emergencies.20
Respiratory Diseases
Most conditions causing airway compromise or impairing gas
exchange would never be mistaken for a psychiatric disorder.
However, certain conditions that cause hypoxemia or hyper-
carbia may present with significant anxiety, and up to a third
 1448
of the patients with chronic obstructive pulmonary disease
meet the criteria for anxiety disorder.21
Asthma is characterized by episodic attacks of dyspnea and
PART III  ■  Medicine and Surgery / Section Eight • Psychiatric and Behavioral Disorders
often anxiety. Anxiety can also precipitate and prolong asthma
attacks. Patients who have severe asthma are twice as likely to
have an anxiety disorder and almost five times as likely to have
a phobia compared with nonasthmatics. Severe asthmatics are
almost five times as likely to have a panic disorder and about
four times as likely to have a panic attack. Acute dyspnea sec-
ondary to asthma is easily differentiated from pure panic in
that there is good air movement with normal lung sounds in a
patient experiencing a panic attack, but studies consistently
show that anxiety disorders increase asthma morbidity and
mortality.22
Shortness of breath is a common complaint in the ED.
When accompanied by anxiety, panic attacks or anxiety disor-
ders may be high on the differential diagnosis. The clinician
must always fully evaluate these patients, as these are often
the complaints of a patient presenting with a pulmonary embo-
lism. Acute shortness of breath in any patient should never be
dismissed lightly, especially since pulmonary embolus can
present with only shortness of breath as the major symptom.
These patients can be distinguished by close attention to
history and examination, assessing risk factors for thromboem-
bolic disease and use of basic investigations (e.g., pulse oxim-
etry, electrocardiogram, chest radiography, arterial blood gas
analysis, and D-dimer) and further tests as indicated.23
Neurologic Disorders
Many neurologic conditions are associated with anxiety symp-
toms.24-26 Temporal lobe seizures, complex partial seizures,
tumors, arteriovenous malformation and ischemia or infarction
all have been reported to present with panic attacks. Anxiety
often accompanies a transient ischemic attack and may be the
major symptom on presentation if the transient ischemic attack
has resolved by the time the patient reaches the ED. In
Huntington’s disease, anxiety has been reported as the most
common prodromal symptom. Anxiety occurs in up to 40% of
patients with Parkinson’s disease and up to 37% of patients
with multiple sclerosis. Similarly, anxiety symptoms have
been noted to be common in moderate Alzheimer’s disease. The
coexistence of anxiety disorders plays an important role in the
prognosis and impairment of patients who have had cerebral
vascular accidents with neurologic sequelae. Anxiety and depres-
sion are associated with left-hemispheric strokes and anxiety
alone with right-hemispheric strokes. And finally, anxiety dis-
orders have also been reported in the aftermath of traumatic
brain injury.27
Drug Intoxication and Withdrawal States
Amphetamines, cocaine, and sympathomimetic drugs are abused for
their stimulant and mind-altering properties. Amphetamine
use has exploded over the past decade, and cocaine use is still
the drug of choice in many large cities. Patients often present
to the ED agitated, anxious, or aggressive when these drugs
are taken in large doses and with prolonged use. Caffeine is a
common stimulant, and energy drinks and gourmet coffee
represent a constantly growing market in the United States.
These drinks are packed with caffeine and the herbal equiva-
lent guarana as well as ginkgo biloba. Studies indicate that 240
to 300 mg of caffeine per day should be the upper limit of
healthy consumption. Many of these energy drinks contain
that amount in a single serving.25 Lower doses of caffeine can
be pleasantly stimulating, but higher doses cause hyperalert-
ness, hypervigilance, motor tension, tremors, gastrointestinal
distress, and anxiety. The acute symptoms of caffeine intoxi-
cation and generalized anxiety disorder are almost identical.
Stimulants such as Ephedra and ephedrine-based compounds were
found in many dietary supplements and listed by the herbal
name of Ma Huang. Despite the Food and Drug Administra-
tion ban on Ephedra-containing compounds in 2004, access
still exists over the Internet.
Many illicit drug users who use marijuana believe that the
drug reduces their anxiety. But some experience a deperson-
alization that provokes severe anxiety, fearfulness, and
agoraphobic symptoms. Lysergic acid diethylamide (LSD),
phencyclidine (PCP), and ecstasy are hallucinogens that can
produce anxiety and paranoia from chronic use or “bad trips.”
Flashbacks affect some users of LSD, where the person may
experience the symptoms of anxiety and paranoia weeks or
months after use.26
Sedative-hypnotic drugs (e.g., benzodiazepines, barbitur­
ates, meprobamate, methaqualone, chloral hydrate, and par­
aldehyde) are taken to relieve anxiety or sleeplessness, but
their discontinuation can cause sedative withdrawal and rebound
anxiety. The severity of the withdrawal syndrome depends
on the drug, dosage, duration of use, and speed of elimination.
In general, the intermediate-acting sedative-hypnotics
(4–6 hours) cause the worst withdrawal symptoms. These
symptoms include hyperalertness, motor tension, muscle
aches, agitation, anxiety, insomnia, hyperactive reflexes, pos-
tural hypotension, tremulousness, nausea, vomiting, convul-
sions, delirium, and even death.
Benzodiazepine withdrawal is rarely fatal but can be very
unpleasant. In anxious patients, severe rebound anxiety can
occur after a few weeks’ use of recommended therapeutic
doses. Lorazepam and alprazolam are short-acting agents and
their abrupt discontinuation frequently causes panic attacks
within 1 to 2 days. With longer-acting agents, withdrawal
symptoms typically peak in about one week. Normal people
may experience this rebound as stimulating. Although antide-
pressants are rarely abused, their abrupt withdrawal can also
cause an abstinence syndrome of insomnia, vivid nightmares,
and extreme anxiety.27
Alcohol withdrawal, in alcohol-dependent individuals or
heavy binge drinkers, can appear 6 to 12 hours after the last
drink or significant reduction in consumption of alcohol.
Patients often have detectable alcohol still in their systems at
this time. Anxiety is one of the first and most prominent symp-
toms and is seen within 24 to 48 hours of the withdrawal
state.28
Anxiety in Primary Psychiatric Disorders
Even in patients with known mental illness, a panic disorder
is a diagnosis of exclusion because several mental illnesses
cause panic attacks as a secondary manifestation. The pres-
ence of panic often influences the treatment and outcome of
the primary mental illness. Panic attacks can occur as part of
a bipolar (manic-depressive) disorder, in either the manic or the
depressed phase. In manic and hypomanic disorders the
patient’s predominant affect is usually cheerful and euphoric
but may also be dysphoric with irritability and extreme anxiety
of panic proportions.29
Early in the course of schizophrenia, a patient will often
experience panic attacks. Fearfulness, tension, agitation, immo-
bility, disorganized thinking, dilated pupils, extreme insecu-
rity, suspiciousness, and delusions of reference and persecution
may characterize schizophrenic panic attacks. The hallucina-
tions often have derogatory accusative content. Social anxiety
is a highly prevalent and disabling condition with schizophrenia
that is unrelated to clinical psychotic symptoms.30

Patients with somatoform disorders report a variety of somatic
symptoms, including panic attacks, and 68% report a history
of anxiety. Patients claim to have most of the physical symp-
toms they are asked about, even when evidence excluding
illness is presented to the patient. Fear and anxiety initiate,
facilitate, and maintain many of the symptoms encountered in
the somatoform patient. Patients with “pure” anxiety disor-
ders tend to be hypochondriacal, while those with somatiza-
tion are more likely to improve transiently on active medication
or placebo but rarely respond so well that they stop seeking
unnecessary medical attention. Patients with panic disorders,
however, seek at least as much psychiatric attention as those
with somatoform disorders.31
Approximately 50% of patients with a primary panic disor-
der develop major depression and many others are bothered by
some degree of depression in mood. Twenty percent of
patients with depression have panic attacks, and the remainder
have considerable anxiety. Depression with panic attacks
responds less well to treatment. Agitated depression with
anxiety and psychosis, sometimes called “involutional melan-
cholia,” responds well to electroconvulsive therapy. Depres-
sion with anxiety and hostility responds well to antidepressants
but benzodiazepines can exacerbate symptoms.32
Post-traumatic stress disorder is an anxiety disorder character-
ized by the reexperiencing of an extremely traumatic event.
The symptoms are closely related to and worsened by remind-
ers of the trauma. The “flashbacks,” in which patients reex-
perience the original trauma, can have the same symptoms as
panic attacks. These patients often avoid crowds or social
situations.33
A panic disorder is one of the easier psychiatric diseases to
feign because most of the symptoms can be duplicated by
intentional hyperventilation. Functional hyperventilation can
be distinguished from organic hyperventilation by its irregular-
ity and interruptions by sighs. When in doubt, formal psychi-
atric evaluation is indicated, particularly before prescribing a
potentially dangerous or addictive drug therapy.
A phobia is an irrational fear that results in avoidance and is
considered normal in children. The objects of fear tend to be
things that seem dangerous to a child (e.g., spiders, snakes,
bats, cats, enclosed places, the dark, open spaces). Phobia
becomes a disorder when it interferes with day-to-day function
in an individual’s life. A social phobia is characterized by clini-
cally significant anxiety provoked by exposure to a specific
feared object or situation, often leading to avoidance behavior.
Social phobias prevent a patient from doing such activities as
public speaking, performing, visiting, using public showers or
restrooms, or eating in public places. Agoraphobia is a fear of
being alone in public places. Nearly 75% of agoraphobic
patients have panic attacks.34 Those with panic attacks are
more likely to seek treatment, whereas those with uncompli-
cated agoraphobia tend to stay at home. Agoraphobia without
panic attacks may not differ fundamentally from other simple
phobias. Most panic disorder patients have multiple phobias,
including agoraphobia. The latter is believed to result from
the panic patient’s increasing attempts to avoid places or situ-
ations in which the panic attacks would be particularly incon-
venient or difficult to control. Agoraphobic patients particularly
avoid places from which escape would be difficult (e.g., bridges,
crowded theaters). When they do attend theaters, they favor
seats on the aisle and near the door. Panic attacks in agorapho-
bic patients are more likely to include fear of losing control,
whereas those not associated with agoraphobia are more likely
to include dyspnea and dizziness.35
An obsessive-compulsive disorder (OCD) is characterized by
recurrent, obtrusive, unwanted thoughts (obsessions), such as
fears of contamination, and compulsive behaviors or rituals
1449
(compulsions), such as handwashing or checking. OCD is clas-
sified as an anxiety disorder because (1) anxiety or tension is
often associated with obsessions and resistance to compul-
Chapter 110 / Anxiety Disorders
sions, (2) anxiety or tension is often immediately relieved by
yielding to compulsions, and (3) OCD often occurs in associa-
tion with other anxiety disorders. In summary, the obsessions
and intrusive thoughts increase anxiety and the compulsions
and repetitive behaviors decrease anxiety but with significant
disruption of one’s life.9
■  MANAGEMENT
Initial Evaluation
The patient should first be placed in a quiet area for evalua-
tion. Some patients calm down when removed from the ED
environment. If the emergency physician encounters difficulty
in calming the patient, supportive family members may help.
Often a known and trusted face helps anxious patients make
order out of their inner turmoil. Prior discussion and clarifica-
tion with the family are essential to elicit their support.1
Once the patient is calmed, a more formal evaluation can
begin. The emergency physician should ask open-ended
questions and observe the patient’s responses carefully. Ques-
tions regarding drug or alcohol use should be delayed until
rapport has been established. Reassurance should not be pre-
mature, because this important interventional technique is
more effective when it is delayed until after the patient’s
specific concerns are clarified.1
The extent of the medical workup for significant anxiety
will vary depending on the age and health status of the patient,
the nature of the anxiety, and the range and severity of associ-
ated symptoms. The emergency physician should consider the
anxiogenic effects of medications, including beta-adrenergic
agonists, theophylline, corticosteroids, thyroid hormones, and
sympathomimetics. Potential contributory medical illness
(e.g., thyroid dysfunction, hypoglycemic episodes in diabetes,
hyperparathyroidism, dysrhythmias, chronic obstructive pul-
monary disease, seizure disorders), substance use (e.g., caf-
feine, amphetamines, cocaine) and withdrawal states (e.g.,
alcohol, sedative-hypnotics) must also be considered.
If a somatic concern is the major component of the acute
anxiety attack, a physical examination with particular attention
to the area of complaint is important, even when there is over-
whelming evidence of a functional etiology to the patient’s
complaints. Anxiety attacks are stressful experiences in them-
selves and can cause deterioration in marginally compensated
organ systems. Careful evaluation reassures the patient and
avoids the problem of a premature “medical clearance.”
Abnormal vital signs should immediately alert the emergency
physician to an organic cause of the anxiety symptoms.9
Because of the physical nature of the symptoms, patients
with anxiety and panic attacks often seek treatment in the ED
rather than in a psychiatric setting. A calm manner and willing-
ness to listen usually relieves some of the patient’s initial
anxiety. An anxiety or panic reaction may be precipitated by
the loss of a significant relationship, a job, a living situation, or
self-esteem, as well as by physical illness or injury. Once the
patient describes a trigger event, the emergency physician
should restate it, as if experiencing a similar situation. This
gives the patient authoritative approval for expressing embar-
rassing feelings. A patient who has frequent anxiety reactions
is usually suggestible and will respond to reassurance. Con-
versely, an anxious or unsympathetic physician will only com-
pound the problem.1
Even an apparently calm patient may communicate anxiety
through worried looks, nervousness, pressured speech, or
 1450
covert assaults on the physician’s competence. In turn, the
physician may empathetically respond to the patient’s hidden
anxiety by also becoming anxious. This is a strong clue that
PART III  ■  Medicine and Surgery / Section Eight • Psychiatric and Behavioral Disorders
the patient’s anxiety is real and significant. Without this self-
awareness, physicians may focus on a patient’s physical symp-
toms rather than on the irrational anxiety. The pressure to see
patients quickly and to move them out of the ED expeditiously
may result in limited interactions with patients, the misdiagno-
sis of anxiety disorders, and excessive and unnecessary medical
workups. A careful medical evaluation is important, but exces-
sive focus on unlikely illness suggests to the patient a reason to
worry, avoids recognition of crucial psychological factors, and
may increase anxiety and the severity of symptoms.
After organic illness, medications, and obvious psychiatric
causes of the acute anxiety state have been ruled out, the phy-
sician should determine whether the anxiety is endogenous or
exogenous. If the anxiety arises spontaneously without an
identifiable stress, is unpredictable, and is accompanied by
agoraphobia, an endogenous component is likely to be present.
Such patients should be referred to a psychiatrist for evaluation
and treatment. If the anxiety appears to be related to an iden-
tifiable external event or circumstance, the anxiety is exoge-
nous and patients should be encouraged to discuss their feelings
with a mental health worker. Talking about fears allows anxious
patients some sense of mastery and control over events. These
patients often require ongoing advice, support, and assistance
in mobilizing necessary resources from family members,
friends, and social agencies to achieve realistic expectations.
Anxiety is common in elders, with prevalence rates conser-
vatively estimated at 10%, with higher rates in patients with
chronic illness. Anxiety disorders may be the most common
psychiatric ailments experienced by older adults, but that age
group is the least studied of all patients.36 Older patients with
anxiety often have somatic complaints. These patients require
a careful investigation for underlying medical illness, other
psychiatric conditions, and the use of over-the-counter and
prescription drugs.
Pharmacologic Treatment
Before medication is prescribed, education of the patient
about their illness is a key component in the treatment of
anxiety disorders. Patients are often worried and confused
about their illness. Reassurance that they are not alone, educa-
tion about what to expect and that therapy is available, and
involvement of family are all critical pieces in the treatment
of anxiety. Use of intravenous medication is rare but may be
necessary when an anxiety state renders a patient so helpless
and out of control that there is a significant threat of safety to
self or others. Intravenous medication is also appropriate for
the anxious patient experiencing a significant medical illness
or undergoing a medical procedure. Lorazepam in small incre-
ments every 20 minutes can be helpful in alleviating the
anxiety associated with substance withdrawal states. Mid-
azolam is frequently used to reduce anxiety and increase
amnesia for ED procedures.
Selective serotonin-reuptake inhibitors (SSRIs) have
become the first-line treatment for most anxiety disorders
because of their broad spectrum of efficacy and good tolerance
by most patients. SSRIs have a lower potential for dependence
and are safer than the previous classes of antidepressants and
anxiolytics. This class of drugs includes fluoxetine, sertraline,
fluvoxamine, paroxetine, citalopram, venlafaxine, and sertra-
line. Improvement is usually seen in 3 to 4 weeks, and the
medication may have to be adjusted if no improvements in
anxiety are seen. It is important to start the patient on low
doses of SSRIs as an initial increase in anxiety may be seen.
In the past few years, emergency physicians and the public
have become increasingly concerned about the growing use
of benzodiazepines in the United States. Over 1 million
Americans are physically dependent on tranquilizers. When
tranquilizers are given in place of understanding, support, and
intrapersonal therapies, patients are taught to rely on the
external support of a pill rather than on inner resources.8
Benzodiazepines can be prescribed for motivated patients
with acute exogenous anxiety for time-limited stress. Patients
who are cooperative, employed, educated, married, and aware
that their symptoms have a psychological basis are more likely
to respond. Benzodiazepines are an attractive alternative to
SSRIs when an immediate reduction of symptoms is desired
because of the delayed response with SSRIs or a short-term
treatment is needed. Benzodiazepines can be given in one or
two daily doses to make use of their short half-lives; alterna-
tively, a bedtime dose may minimize daytime sedation and
still manifest a daytime anxiolytic effect. Benzodiazepines
should not be prescribed for more than a week. Patients who
do not improve within a week are unlikely to benefit from the
drug. Patients with a history of alcoholism or drug abuse, who
are excessively and emotionally dependent, or who become
anxious in response to normal stress are at greater risk of drug
dependency and are not good candidates for this treatment
from an emergency physician. Dependence and abstinence
syndromes have been reported to occur with low doses of
tranquilizing drugs, especially if they are taken for more than
8 months. Short-acting benzodiazepines (e.g., lorazepam,
oxazepam) should be prescribed at low dosages for patients
with liver disease, organic brain syndrome, and those taking
medications that either depress central nervous system func-
tion or inhibit benzodiazepine metabolism and clearance.
Withdrawal rebound symptoms are more common with dis-
continuation of benzodiazepines than with other antianxiety
treatments. Short-acting benzodiazepines produce a more
severe abstinence syndrome when they are stopped abruptly,
and thus many physicians prefer the longer-acting benzodiaz-
epines.7 For some patients, switching from a short-acting agent
(e.g., alprazolam) to a long-acting agent (e.g., clonazepam) can
be helpful before initiating a taper.
Buspirone is a nonbenzodiazepine tranquilizer used in the
treatment of generalized anxiety disorder. Buspirone does not
appear to cause dependency, is less sedating than benzodiaz-
epines, and tolerance does not occur at therapeutic doses. It is
the therapeutic lag in efficacy of 2 to 3 weeks that has limited
the use of buspirone. It has had variable and sometimes
disappointing results in clinical practice, particularly when
used in patients with prior exposure to benzodiazepines.36
Monoamine oxidase inhibitors (MAOIs) demonstrate high
effectiveness in the treatment of social phobia, panic, general-
ized anxiety disorders, OCD, and comorbid conditions (e.g.,
atypical depression). MAOIs (phenelzine and tranylcypro-
mine) may be difficult to tolerate and require discipline and
strict dietary restrictions and thus are rarely appropriate in the
emergency setting.
Tricyclic antidepressants (TCAs) are effective for panic disor-
ders and generalized anxiety disorders but are ineffective for
social phobias and, with the exception of clomipramine, are
largely ineffective for OCD as well. TCAs have been used
effectively for depressive and anxiety symptoms associated
with post-traumatic stress disorder. TCAs include imipramine,
nortriptyline, desipramine, amitriptyline, and doxepin. The
TCAs have been supplanted by the SSRIs as first-line
interventions for the treatment of anxiety and depressive
disorders.37
Patients with endogenous anxiety (panic attacks with or
without agoraphobia) should be referred to a psychiatrist to

Table 110-1 Pharmacotherapy for Anxiety Disorders
SSRIs TCAs
Panic disorder + +
GAD + +
Social phobia + −
Specific phobia − −
PTSD + +/−
OCD + −*
*Clomipramine is effective.
†
Used adjunctively with serotonergic antidepressant.
BDZs, benzodiazepines; CBT, cognitive-behavioral therapy; GAD, generalized anxiety disorder; MAOIs, monoamine oxidase inhibitors; OCD, obsessive-compulsive
disorder; PTSD, post-traumatic stress disorder; SSRIs, selective serotonin-reuptake inhibitors; TCAs, tricyclic antidepressants.
establish a good therapeutic relationship before using
anxiolytic medication. Benzodiazepines, tricyclics, SSRIs, and
MAOIs are safe and effective in endogenously anxious patients
who are under psychiatric care (Table 110-1). Recurrence rates
of panic attacks are high when drug therapy is discontinued.8
Nonpharmacologic Therapy
Psychotherapies may be helpful for individuals whose psycho-
logical makeup, coping style, interpersonal dynamics, and situ-
ational stressors contribute to their pathologic anxiety. The use
of supportive, insight-oriented family is helpful when these
factors appear prominently in the patient’s presentation.8
Cognitive-behavioral therapy is predicated on the theory that
the distress and impairment associated with anxiety and panic
are mediated by maladaptive cognitive responses that promote
anxiety and avoidance. The core components of cognitive-
behavioral therapy for panic disorder include correction
of cognitive misperceptions and overreactions to anxiety
symptoms, breathing retraining, muscle relaxation, as well as
exposure and desensitization to phobic situations. Cognitive-
behavioral therapy is very effective, but requires commitment
from the patient.8,9
Meditation (e.g., Zen, yoga, transcendental) has been pro-
posed by many authorities, but little clinical data support its
efficacy in anxiety disorders. Biofeedback appears promising for
the treatment of generalized anxiety disorder. Hypnotic sugges-
tion may be effective because anxious patients tend to be
cognitively scattered, unable to focus their attention, and
highly suggestible. A hypnotic state can often be induced by
certain stimuli.38
These nonpharmacologic techniques take anxious patients
out of the future, about which they are frightened, and place
them into the present. These techniques should be reinforced
by the development of a physically and psychologically healthy
lifestyle. A significant social support system not only protects
against vulnerability to illness but also is highly anxiolytic.
Regular exercise (e.g., dancing, swimming, bicycling, walking,
jogging) also promotes tranquility. Encouraging activity that
focuses on hand-eye-ear coordination (e.g., painting, playing
keyboard, needlework) helps anxious patients regain and
maintain control by bringing them into the present.1
■  DISPOSITION
Many patients with anxiety-related symptoms can be effec-
tively treated in the ED. The emergency physician can proceed
with the following general measures:
1451
Chapter 110 / Anxiety Disorders
MAOIs BDZs BUSPIRONE CBT
+ + − +
+ + + +
+ + − +
− +/− − +
+ +/− − +
+ +/−† +/−† +
1. Rule out organic illnesses as cause of anxiety.
2. Evaluate for substance abuse and medications associated
with anxiety.
3. Determine whether anxiety is endogenous or exogenous.
4. Clarify what is currently frightening the patient.
5. Evaluate the patient’s capacity for self-awareness.
6. Assess techniques that have worked in the past.
7. Support coping skills.
8. Give the patient as much control over the care plan as
feasible.
9. Select patients to start on a short course of benzodiaze-
pines and educate patients about treatment.
10. Apply adjunctive techniques as appropriate for the
patient’s personality and the physician’s preference (e.g.,
hypnotic suggestion, breathing exercises).
Patients with a panic disorder associated with suicidal or
homicidal ideation or with severe depression require urgent
psychiatric attention and admission to the hospital. Other
patients with suspected endogenous or severe exogenous
anxiety disorders should be referred for psychiatric evaluation.
The Anxiety Disorders Association of America can be con-
tacted (240-485-1001) for a national registry of clinicians and
treatment programs specializing in anxiety disorders or can be
found online at www.adaa.org.
KEY CONCEPTS
■ Anxiety may accompany the onset of serious disease,
may have significant metabolic demands, and may
cause a marginally compensated organ system to fail.
■ As many as 42% of patients thought to have anxiety
disorders are later found to have organic disease.
■ Anxiety caused by physical illness is usually suggested
by the patient’s physical findings but may require
adjunctive testing.
■ Anxiety affects at least 10% of elderly patients.
■ Intravenous medication may be necessary for patients
who are a significant threat to themselves or others
and for anxious patients with significant medical
illness.
■ Limited benzodiazepine therapy may be helpful for
select patients with exogenous anxiety.
The references for this chapter can be found online by accessing the
accompanying Expert Consult website.