Just Stay Calm! High-Yield Approach to Work-Up Anxiety for the Boards and Wards

Editor’s Note: Don’t get fooled into thinking that psychiatry is distinct from medicine and thus not covered on the ABIM Internal Medicine Board exam. In fact, the ABIM exam blueprint lists Psychiatry as 4% of the exam, the same as Neurology and more than Dermatology. Our special correspondent Psychiatrist Esther Oh, MD breaks down medical illnesses that mimic anxiety.

• Late-onset anxiety (after the age of 35). Most anxiety disorders start early- in childhood, adolescence or early adulthood.
• No personal or family history of anxiety disorder. Anxiety often is a chronic condition and tends to run in families.
• No current life stressors impacting the patient’s life. Anxiety can stem from mild day-to-day problems such as marital conflict or financial hardship to significant events such as a family death or losing one’s job.
• Anxiety associated with a recent headache, cognitive, or neurologic symptoms should be fully worked up.

• Angina
• Pulmonary embolism
• Cardiac arrhythmias
• Chronic obstructive pulmonary disease (COPD)
• Asthma
• Hypoglycemia
• Hyperthyroidism
  • Most common cause is Graves’ disease, an autoimmune disorder affecting the thyroid gland which increases production and release of the thyroid hormone. It can commonly present with anxiety. Other associated symptoms include restlessness, palpitations, heat intolerance, and exophthalmoses.
• Hypoparathyroidism
• Consider in a patient with a history of thyroid surgery who presents with new onset or worsening anxiety.
• Pheochromocytoma
• It is caused by a benign tumor in the adrenal glands which causes an excess production of epinephrine and norepinephrine. Though rare, it’s a serious medical problem that can present with anxiety or panic attacks and severe headaches. Consider in patients between the ages of 30 to 50.
• Cushing syndrome/Cushing’s disease
• Cushing syndrome is caused by the use of corticosteroid medications. Cushing disease is a condition where the pituitary gland produces an excess of ACTH which leads to the increased production of cortisol in the adrenal glands. An increase in cortisol can lead to feelings of anxiety. Consider in patients who present with upper body obesity, moon facies, acne, excess facial and body hair in females, and irregular menses.

• Palpitations:
Palpitations are defined as rapid, irregular heartbeats or fluttering/thumping sensations in the chest. The most common causes of palpitations are heart disease, medications, drugs (including caffeine), or anxiety. Make sure to ask patients about any recent substance use or current medications that may be causing the palpitations.
• Chest pain:
Chest pain is a non-specific symptom that can be caused by just about every major organ system in the body. Before determining the root cause of the chest pain is anxiety, it is crucial to rule out acute medical conditions such as coronary heart disease, pulmonary embolus, aortic dissection, esophagitis, pneumothorax, or myocarditis. Physicians should be more concerned when the chest pain is associated with other symptoms such as dyspnea, weakness, diaphoresis or worse with exertion.
• Shortness of breath:
Shortness of breath can be a common symptom of patients with anxiety especially when they hyperventilate. They will often describe they cannot achieve a full, deep breath or experience a choking sensation that something is in their throat. Shortness of breath is also common in patients with heart disease such as congestive heart failure. Physicians should be more concerned when patients report worsening dyspnea with lying down and notable jugular venous distention, hepatomegaly, peripheral edema and cyanosis on exam.

In addition to medical illnesses, there are a hand-full of medications that can cause anxiety and restlessness such as:

• Bronchodilators: Albuterol and Salmeterol (Advair) are used to treat lung diseases such as asthma and COPD. They belong to the sympathomimetic amine class of drugs which can increase a patient’s heart rate and cause tremor, insomnia, or nervousness- very similar to anxiety.
• Other sympathomimetic agents: They are commonly found in over-the-counter cold and allergy medications. They also include medications such as epinephrine, norepinephrine, Levodopa, and dopamine.
• Theophylline: Theophylline is an oral bronchodilator that belongs to the methylxanthine class which is closely related to caffeine. They can produce agitation, tremor, insomnia, palpitations and also increase the heart rate.
• Xanthene derivatives such as caffeine can produce anxiety especially in excess amounts or withdrawal.
• Steroids: whether inhaled or systemic, it can cause anxiety and/or agitation
• Antidepressants (SSRI’s and MAOI’s) can transiently cause or increase anxiety early in treatment or when dosages are increased.
• Stimulants (Adderall, Concerta, Ritalin) which are used to treat ADHD in children and adults can also lead to anxiety and agitation.

Sometimes medications can lead to a common side effect known as akathisia. Patients describe it as an uncomfortable sensation of inner restlessness, inability to sit still, or requiring constant motion of body parts. They look anxious and unable to settle down. It can be caused by psychotropic medications such as SSRI’s and antipsychotics but also anti-emetic agents such as Reglan and Compazine. Akathisia can be very unpleasant and often resolves with either reducing the dose or discontinuing the offending agent.

Illicit substances can be a common source of anxiety.

• Acute intoxication with stimulants such as cocaine and methamphetamine can lead to paranoia, anxiety and restlessness.
• Acute withdrawal from alcohol or other sedative-hypnotics (opiates and barbiturates) can cause significant anxiety, restlessness, tremors, and discomfort. This is a medical emergency that needs to be acutely treated.

Though anxiety isn’t life-threatening, certain medical conditions that look like anxiety can be. The key to providing quality medical care to our patients is being able to distinguish the difference.