Anxiety

Anxiety: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)

Anxiety is the most common psychiatric symptom and can result in significant impairment. A subjective reaction to a real or imagined threat, anxiety is a nonspecific feeling of uneasiness or dread. It may be mild, moderate, or severe. Mild anxiety may cause slight physical or psychological discomfort. Severe anxiety may be incapacitating or even life-threatening.

Everyone experiences anxiety from time to time—it’s a normal response to actual danger, prompting the body (through stimulation of the sympathetic and parasympathetic nervous systems) to purposeful action. It’s also a normal response to physical and emotional stress, which can be produced by virtually any illness. In addition, anxiety can be precipitated or exacerbated by many nonpathologic factors, including lack of sleep, poor diet, and excessive intake of caffeine or other stimulants. However, excessive unwarranted anxiety may indicate an underlying psychological problem.

History and physical examination

If the patient displays acute, severe anxiety, quickly take his vital signs and determine his chief complaint; this will serve as a guide for how to proceed. For example, if the patient’s anxiety occurs with chest pain and shortness of breath, you might suspect myocardial infarction and act accordingly. While examining the patient, try to keep him calm. Suggest relaxation techniques, and talk to him in a reassuring, soothing voice. Uncontrolled anxiety can alter vital signs and exacerbate the causative disorder.

If the patient displays mild or moderate anxiety, ask about its duration. Is the anxiety constant or sporadic? Did he notice any precipitating factors? Find out if the anxiety is exacerbated by stress, lack of sleep, or excessive caffeine intake and alleviated by rest, tranquilizers, or exercise.

Obtain a complete medical history, especially noting drug use. Then perform a physical examination, focusing on any complaints that may trigger or be aggravated by anxiety.

If the patient’s anxiety isn’t accompanied by significant physical signs, suspect a psychological cause. Determine the patient’s level of consciousness (LOC) and observe his behavior. If appropriate, refer the patient for psychiatric evaluation.

Medical causes

Acute respiratory distress syndrome

Acute anxiety occurs along with tachycardia, mental sluggishness and, in severe cases, hypotension. Respiratory signs and symptoms include dyspnea, tachypnea, intercostal and suprasternal retractions, crackles, and rhonchi.

Anaphylactic shock

Acute anxiety is usually the first sign of anaphylactic shock. It’s accompanied by urticaria, angioedema, pruritus, and shortness of breath. Soon, other signs and symptoms develop: light-headedness, hypotension, tachycardia, nasal congestion, sneezing, wheezing, dyspnea, barking cough, abdominal cramps, vomiting, diarrhea, and urinary urgency and incontinence.

Angina pectoris

Acute anxiety may either precede or follow an attack of angina pectoris. An attack produces sharp and crushing substernal or anterior chest pain that may radiate to the back, neck, arms, or jaw. The pain may be relieved by nitroglycerin or rest, which eases anxiety.

Asthma

In allergic asthma attacks, acute anxiety occurs with dyspnea, wheezing, productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, tachycardia, and diaphoresis.

Autonomic hyperreflexia

The earliest signs of autonomic hyperreflexia may be acute anxiety accompanied by a severe headache and dramatic hypertension. Pallor and motor and sensory deficits occur below the level of the lesion; flushing occurs above it.

Cardiogenic shock

Acute anxiety is accompanied by cool, pale, clammy skin; tachycardia; weak, thready pulse; tachypnea; ventricular gallop; crackles; jugular vein distention; decreased urine output; hypotension; narrowing pulse pressure; and peripheral edema.

Chronic obstructive pulmonary disease (COPD)

Acute anxiety, exertional dyspnea, cough, wheezing, crackles, hyperresonant lung fields, tachypnea, and accessory muscle use characterize COPD.

Heart failure

In heart failure, acute anxiety is commonly the first symptom of inadequate oxygenation. Associated findings include restlessness, shortness of breath, tachypnea, decreased LOC, edema, crackles, ventricular gallop, hypotension, diaphoresis, and cyanosis.

Hyperthyroidism

Acute anxiety may be an early sign of hyperthyroidism. Classic signs and symptoms include heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, diaphoresis, an enlarged thyroid, and diarrhea. Exophthalmos also may occur.

Hyperventilation syndrome

Hyperventilation syndrome produces acute anxiety, pallor, circumoral and peripheral paresthesia and, occasionally, carpopedal spasms.

Hypochondriasis

Mild to moderate chronic anxiety occurs in hypochondriasis. The patient focuses more on the belief that he has a specific serious disease rather than on the actual symptoms. Difficulty swallowing, back pain, light-headedness, and upset stomach are common complaints. The patient tends to “physician hop” and isn’t reassured by favorable physical examinations and laboratory test results.

Hypoglycemia

Anxiety resulting from hypoglycemia is usually mild to moderate and associated with hunger, mild headache, palpitations, blurred vision, weakness, and diaphoresis.

Mitral valve prolapse

Panic may occur in patients with this valvular disorder, also known as click-murmur syndrome because its hallmark is a midsystolic click, followed by an apical systolic murmur. Mitral valve prolapse also may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain.

Mood disorder

Anxiety may be the patient’s chief complaint in the depressive or manic form of mood disorder. In the depressive form, chronic anxiety of varying severity occurs along with dysphoria; anger; insomnia or hypersomnia; decreased libido, interest, energy, and concentration; appetite disturbance; multiple somatic complaints; and suicidal thoughts. In the manic form, the patient’s chief complaint may be a reduced need for sleep, hyperactivity, increased energy, rapid or pressured speech and, in severe cases, paranoid ideas and other psychotic symptoms.

Myocardial infarction (MI)

In this life-threatening disorder, acute anxiety commonly occurs with persistent, crushing substernal pain that may radiate to the left arm, jaw, neck, or shoulder blades. MI may be accompanied by shortness of breath, nausea, vomiting, diaphoresis, and cool, pale skin.

Obsessive-compulsive disorder

Chronic anxiety occurs in obsessive-compulsive disorder, which is marked by recurrent, unshakable thoughts or impulses to perform ritualistic acts. The patient recognizes these acts as irrational but is unable to control them. Anxiety builds if he can’t perform these acts and diminishes after he does.

Pheochromocytoma

Acute, severe anxiety accompanies pheochromocytoma’s cardinal sign: persistent or paroxysmal hypertension. Other common findings include tachycardia, diaphoresis, orthostatic hypotension, tachypnea, flushing, severe headache, palpitations, nausea, vomiting, epigastric pain, and paresthesia.

Phobias

In phobias, chronic anxiety accompanies persistent fear of an object, an activity, or a situation that results in a compelling desire to avoid it. The patient recognizes the fear as irrational but can’t suppress it.

Pneumonia

Acute anxiety may occur in pneumonia because of hypoxemia. Other findings include productive cough, pleuritic chest pain, fever, chills, crackles, diminished breath sounds, and hyperresonant lung fields.

Pneumothorax

Acute anxiety occurs in moderate to severe pneumothorax associated with profound respiratory distress. It’s accompanied by sharp pleuritic pain, coughing, shortness of breath, cyanosis, asymmetrical chest expansion, pallor, jugular vein distention, and a weak, rapid pulse.

Postconcussion syndrome

Postconcussion syndrome may produce chronic anxiety or periodic attacks of acute anxiety. The anxiety is usually most pronounced in situations demanding attention, judgment, or comprehension. Associated signs and symptoms include irritability, insomnia, dizziness, and mild headache.

Posttraumatic stress disorder

Posttraumatic stress disorder occurs in patients who have experienced an extremely traumatic event. It produces chronic anxiety of varying severity and is accompanied by intrusive, vivid memories and thoughts of the traumatic event. The patient also relives the event in dreams and nightmares. Insomnia, depression, and feelings of numbness and detachment are common.

Pulmonary edema

In pulmonary edema, acute anxiety occurs with dyspnea, orthopnea, cough with frothy sputum, tachycardia, tachypnea, crackles, ventricular gallop, hypotension, and thready pulse. The patient’s skin may be cool, clammy, and cyanotic.

Pulmonary embolism

Acute anxiety is usually accompanied by dyspnea, tachypnea, chest pain, tachycardia, blood-tinged sputum, and low-grade fever.

Rabies

Anxiety signals the beginning of the acute phase of rabies. This rare disorder is characterized by painful laryngeal spasms associated with difficulty swallowing and, as a result, hydrophobia.

Somatoform disorder

Somatoform disorder, which usually begins in young adulthood, is characterized by anxiety and multiple somatic complaints that can’t be explained physiologically. The symptoms aren’t produced intentionally but are severe enough to significantly impair functioning. Pain disorder, conversion disorder, and hypochondriasis are examples of somatoform disorder.

Other causes

Drugs

Many drugs cause anxiety, especially sympathomimetics and central nervous system stimulants. In addition, many antidepressants may cause paradoxical anxiety.

Special considerations

Supportive care can help relieve anxiety in many cases. Provide a calm, quiet atmosphere and make the patient comfortable. Encourage him to express his feelings and concerns freely. If it helps, take a short walk with him while you’re talking. Anxiety-reducing measures, such as distraction, relaxation techniques, and biofeedback, may also be helpful.

Pediatric pointers

Anxiety in children usually results from painful physical illness or inadequate oxygenation. Its autonomic signs tend to be more common and dramatic than in adults.

Geriatric pointers

Changes in an elderly patient’s routine may provoke anxiety or agitation.

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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