Anxiety Disorders

Must know

• Symptom Differentiation (Figure 9-1)Anxiety symptoms manifest in two domains: psychological (apprehension, fear, obsession) and physiological (muscle tension, tachycardia, tachypnea, chest tightness, stomach discomfort, restlessness).

  • Anxiety symptoms manifest in two domains: psychological (apprehension, fear, obsession) and physiological (muscle tension, tachycardia, tachypnea, chest tightness, stomach discomfort, restlessness).
  • Normal anxiety is defined as a proportional response to a real external threat that does not impair daily function.
  • Anxiety disorders (pathological anxiety) are defined by excessive responses or threat-free onset combined with significant functional impairment.
  • Medical conditions that mimic anxiety symptoms span cardiovascular (myocardial infarction), respiratory (COPD, pulmonary embolism), and metabolic (hypoglycemia, pheochromocytoma) systems.
  • Pharmacological triggers of anxiety include stimulants, sympathomimetics, theophylline, diphenhydramine (paradoxical excitation in older adults), levodopa, and antipsychotic-induced akathisia.
  • Generalized anxiety disorder requires excessive worry on most days for at least 6 months plus 3 of 6 physical/cognitive symptoms in adults (1 in children), whereas panic attack surges peak within 10 minutes.
• Which of the following symptoms is not consistent with a panic attack?A. Sensation of shortness of breath

  • A. Sensation of shortness of breath
  • C. Fear of dying
• The Diagnostic Pivot LogicNormal anxiety is a reasonable, adaptive response to a real external threat, whereas anxiety disorder requires an excessive response or no external threat plus demonstrable functional impairment.

  • Normal anxiety is a reasonable, adaptive response to a real external threat, whereas anxiety disorder requires an excessive response or no external threat plus demonstrable functional impairment.
  • Gate 1 (Medical Rule-Out): Always rule out physiological mimics first, including hyperthyroidism, pheochromocytoma, COPD, pulmonary embolism, myocardial infarction, and hypoglycemia.
  • Gate 2 (Substance Rule-Out): Evaluate for symptoms starting within 1 month of substance use, intoxication, or withdrawal. Key culprits include theophylline, diphenhydramine, levodopa, stimulants, and withdrawal from alcohol or benzodiazepines.
  • Gate 3 (Stressor Timeline): Symptoms emerging within 3 months of an identified stressor that resolve within 6 months after termination represent adjustment disorder.
  • Gate 4 (Trauma Pivot): Symptoms developing after severe trauma lasting 3 days to 1 month are acute stress disorder (ASD); symptoms persisting greater than 1 month become post-traumatic stress disorder (PTSD).
  • Gate 5 (Primary Chronic Disorders): Generalized anxiety disorder (GAD) requires excessive worry on most days for 6 months or more with 3 or more WATCHERS symptoms (1 symptom in children). Panic disorder requires recurrent, unexpected attacks peaking within 10 minutes, followed by 1 month of anticipatory worry or behavioral change.
• Step 1: Normal vs. Pathological AnxietyIs there an actual external threat?

  • Is there an actual external threat?
  • Is the autonomic and emotional response proportional to the threat?
  • Is there significant impairment in social, occupational, or personal functioning?
• Step 2: The 5-Gate Diagnostic FilterNever diagnose a primary psychiatric anxiety disorder without running the patient through the systematic 5-gate filter. Missing an underlying medical crisis or drug toxicity can be fatal.

  • Never diagnose a primary psychiatric anxiety disorder without running the patient through the systematic 5-gate filter. Missing an underlying medical crisis or drug toxicity can be fatal.
  • 1. Gate 1: Rule Out Medical Conditions
  • Assess for medical mimics before considering primary psychiatric illness.
  • Endocrine and metabolic triggers: hyperthyroidism, pheochromocytoma, and hypoglycemia (which triggers sympathoadrenal epinephrine release).
  • Cardiopulmonary triggers: myocardial infarction, COPD, and pulmonary embolism.
  • 2. Gate 2: Rule Out Substance and Medication Triggers

  Safety. Never diagnose a primary psychiatric anxiety disorder without running the patient through the systematic 5-gate filter. Missing an underlying medical crisis or drug toxicity can be fatal.

• Compare and DistinguishNormal Anxiety vs. Anxiety Disorder

  • Normal Anxiety vs. Anxiety Disorder
  • Think: Normal anxiety is adaptive and proportional; anxiety disorder is excessive and disabling.
  • Priority: Differentiate real external threat from pathologically generated hyperarousal.
  • Boards are testing: Functional impairment as the defining threshold for psychiatric diagnosis.
  • Acute Stress Disorder vs. Post-Traumatic Stress Disorder
  • Think: The 1-month calendar cutoff determines the diagnostic label.

  Board trap. Test writers love presenting an older adult with acute anxiety who was recently started on diphenhydramine or theophylline, or a patient with new-onset panic who is actually experiencing hypoglycemia or hyperthyroidism. Selecting a primary anxiety disorder or prescribing an SSRI before completing Gate 1 and Gate 2 medical and medication rule-outs is a classic distractor trap.

• C) MethotrexateWhy It Is Correct: Methotrexate is an immunosuppressive disease-modifying antirheumatic agent that does not cause central nervous system stimulation or autonomic hyperarousal, making it least likely to induce anxiety symptoms.

  • Why It Is Correct: Methotrexate is an immunosuppressive disease-modifying antirheumatic agent that does not cause central nervous system stimulation or autonomic hyperarousal, making it least likely to induce anxiety symptoms.
  • Why the Other Choices Are Wrong:
  • A: Theophylline is a xanthine bronchodilator with central stimulant properties that commonly causes tachycardia, tremors, and severe anxiety.
  • B: Diphenhydramine has significant anticholinergic effects that frequently trigger paradoxical central nervous system excitation, restlessness, and anxiety in older adults.
  • D: Levodopa increases central dopamine levels, which routinely causes agitation, anxiety, and neuro-psychiatric side effects.
• C) HyperglycemiaWhy It Is Correct: Hyperglycemia does not acutely stimulate the sympathoadrenal system to produce acute panic or autonomic anxiety symptoms, whereas hypoglycemia triggers an immediate catecholamine surge.

  • Why It Is Correct: Hyperglycemia does not acutely stimulate the sympathoadrenal system to produce acute panic or autonomic anxiety symptoms, whereas hypoglycemia triggers an immediate catecholamine surge.
  • Why the Other Choices Are Wrong:
  • A: Chronic obstructive pulmonary disease causes acute hypoxia and hypercapnia, which directly trigger respiratory panic and intense autonomic anxiety.
  • B: Myocardial infarction induces severe autonomic hyperarousal and acute apprehension, often described as a feeling of impending doom.
  • D: Hypoglycemia triggers a massive epinephrine release, causing acute tachycardia, diaphoresis, tremors, and severe anxiety.
• D) I am terrified that another attack will happen so I avoid leaving my apartment aloneWhy It Is Correct: Panic disorder requires recurrent, unexpected panic attacks that occur spontaneously out of the blue. Attacks that occur predictably after a specific emotional argument are situational responses rather than unexpected panic.

  • Why It Is Correct: Panic disorder requires recurrent, unexpected panic attacks that occur spontaneously out of the blue. Attacks that occur predictably after a specific emotional argument are situational responses rather than unexpected panic.
  • Why the Other Choices Are Wrong:
  • B: Depersonalization and derealization are characteristic psychological symptoms during a panic attack.
  • C: Abrupt onset peaking within 10 minutes out of the blue is the cardinal feature of unexpected panic attacks.
  • D: Persistent anticipatory worry and behavioral avoidance lasting 1 month or more are core criteria for panic disorder.
• D) The diagnosis cannot be made until symptoms have persisted for at least 6 monthsWhy It Is Correct: Symptoms occurring between 3 days and 1 month following exposure to a severe traumatic event meet the specific time frame for acute stress disorder.

  • Why It Is Correct: Symptoms occurring between 3 days and 1 month following exposure to a severe traumatic event meet the specific time frame for acute stress disorder.
  • Why the Other Choices Are Wrong:
  • A: The diagnosis of post-traumatic stress disorder requires symptoms to persist for greater than 1 month, regardless of trauma severity or type.
  • C: Adjustment disorder is used for non-trauma stressors or trauma reactions that do not meet full symptom criteria for ASD or PTSD.
  • D: PTSD can be diagnosed as soon as symptom duration exceeds 1 month; waiting 6 months is unnecessary.
• Diagnostic Branching Hierarchy (Figure 9-2)Gate 1 Medical Rule-Out: Before diagnosing a primary psychiatric disorder, rule out medical conditions such as hyperthyroidism, pheochromocytoma, COPD, pulmonary embolism, myocardial infarction, and hypoglycemia.

  • Gate 1 Medical Rule-Out: Before diagnosing a primary psychiatric disorder, rule out medical conditions such as hyperthyroidism, pheochromocytoma, COPD, pulmonary embolism, myocardial infarction, and hypoglycemia.
  • Gate 2 Substance Rule-Out: Substance-induced anxiety disorder is diagnosed when symptoms occur within 1 month of substance ingestion, intoxication, or withdrawal. Key offending agents include sympathomimetics, stimulants, theophylline, levodopa, diphenhydramine, and withdrawal from alcohol or benzodiazepines.
  • Gate 3 Adjustment Disorder: Adjustment disorder with anxious mood requires symptom onset within 3 months of an identifiable stressor and resolution within 6 months after the stressor or its consequences end.
  • Gate 4 Trauma Timeline: Trauma-related symptoms lasting 3 days to 1 month after exposure represent acute stress disorder. Symptoms persisting for greater than 1 month represent post-traumatic stress disorder (PTSD).
  • Gate 4 GAD Criteria: Generalized anxiety disorder (GAD) requires excessive, uncontrollable worry on most days for at least 6 months, accompanied by at least 3 of the WATCHERS physical/cognitive symptoms (only 1 symptom required in children).
  • Gate 4 Panic Disorder Criteria: Panic disorder requires recurrent, unexpected panic attacks peaking within 10 minutes, followed by at least 1 month of persistent concern about additional attacks or significant maladaptive behavior change.
• Step 1: Primary Medical Assessment (Gate 1)What it is: Evaluating whether physical illness or altered lab parameters directly cause the anxiety presentation.

  • What it is: Evaluating whether physical illness or altered lab parameters directly cause the anxiety presentation.
  • Check TSH for hyperthyroidism, EKG and cardiac enzymes for myocardial infarction, blood glucose for hypoglycemia, and urinary catecholamines for pheochromocytoma.
  • Never assume acute anxiety or panic in an older adult or new-onset case is primary psychiatric without obtaining vital signs, physical exam, and basic lab work.
  • Mistaking physical symptoms of hypoxia or respiratory distress from COPD or pulmonary embolism for a primary panic attack.

  Board trap. Mistaking physical symptoms of hypoxia or respiratory distress from COPD or pulmonary embolism for a primary panic attack.

  Safety. Never assume acute anxiety or panic in an older adult or new-onset case is primary psychiatric without obtaining vital signs, physical exam, and basic lab work.

• Step 2: Substance and Medication Assessment (Gate 2)What it is: Identifying anxiety caused by exogenous substances, prescriptions, or withdrawal.

  • What it is: Identifying anxiety caused by exogenous substances, prescriptions, or withdrawal.
  • Timelines: Symptoms occur within 1 month of substance use, intoxication, or discontinuation.
  • Common offending drugs: theophylline, bronchodilators, levodopa, diphenhydramine, OTC decongestants, caffeine, amphetamines, and abrupt withdrawal from benzodiazepines or alcohol.
  • Abrupt discontinuation of alprazolam or lorazepam can precipitate severe withdrawal seizures, delirium, and autonomic crisis.
  • Attributing new-onset agitation in a Parkinson patient to worsening anxiety instead of levodopa toxicity or akathisia from antipsychotics.

  Board trap. Attributing new-onset agitation in a Parkinson patient to worsening anxiety instead of levodopa toxicity or akathisia from antipsychotics.

  Safety. Abrupt discontinuation of alprazolam or lorazepam can precipitate severe withdrawal seizures, delirium, and autonomic crisis.

• Step 3: Stressor and Adjustment Assessment (Gate 3)What it is: Evaluating emotional or behavioral reactions to identifiable psychosocial stressors.

  • What it is: Evaluating emotional or behavioral reactions to identifiable psychosocial stressors.
  • Timelines: Onset occurs within 3 months of the stressor. Symptoms must resolve within 6 months once the stressor or its consequences end.
  • Distress is out of proportion to the stressor severity and causes functional impairment, but does not meet full criteria for another primary disorder.
• Step 4: Primary Anxiety and Related Disorders Screening (Gate 4: The Big Five)SSRIs (sertraline, paroxetine) or SNRIs plus trauma-focused psychotherapy. Prazosin (3 to 15 mg) at bedtime targets trauma nightmares. Avoid benzodiazepines in PTSD.

  • Trauma spectrum:
  • Acute stress disorder: Symptoms emerge within 3 days to 1 month following exposure to actual or threatened death, serious injury, or sexual violence.
  • Post-traumatic stress disorder: Symptoms persist for greater than 1 month post-trauma, spanning intrusion, avoidance, negative mood/cognitions, and hyperarousal.
  • SSRIs (sertraline, paroxetine) or SNRIs plus trauma-focused psychotherapy. Prazosin (3 to 15 mg) at bedtime targets trauma nightmares. Avoid benzodiazepines in PTSD.
  • Social and phobic spectrum:
  • Social anxiety disorder: Marked fear of scrutiny or embarrassment in social or performance situations lasting at least 6 months.

  Board trap. A panic attack is a specifier, not a standalone DSM-5-TR diagnosis.

• Step 5: Unspecified Classification (Gate 5)What it is: Used when anxiety symptoms cause significant functional impairment but fail to meet full diagnostic thresholds for any specific primary disorder.

  • What it is: Used when anxiety symptoms cause significant functional impairment but fail to meet full diagnostic thresholds for any specific primary disorder.