Research Article |
Corresponding author: Stefka Ivanova ( ivanovastefka_pharm@yahoo.com ) Academic editor: Plamen Peikov
© 2024 Silvia Sarakostova, Diyana Pantileeva, Dancho Dilkov, Niya Semerdzhieva, Mariya Chaneva, Stefka Ivanova, Ventseslava Atanasova, Petar Atanasov, Diana Rangelova.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation:
Sarakostova S, Pantileeva D, Dilkov D, Semerdzhieva N, Chaneva M, Ivanova S, Atanasova V, Atanasov P, Rangelova D (2024) Anxiety in the emergency medical practice – its psychiatric and somatic origin, comorbidities, behavior and treatment. Pharmacia 71: 1-7. https://doi.org/10.3897/pharmacia.71.e124695
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Anxiety conditions and disorders are common in the general population, and patients suffering from them often seek the services of emergency departments. Anxiety is a psychopathological symptom that accompanies not only psychiatric conditions, but a wide range of somatic diseases, and a combination of both. The biochemical and pathophysiological mechanisms of psychosomatic interrelationship and comorbidity are complex and multi-layered. Thus, diagnosing the root cause of anxiety is a clinical challenge. Early, and on time, recognition of an anxiety disorder helps to avoid unnecessary investigations, ensures correct treatment and saves hospital resources. Careful use of medications, psychoeducation and referral to a specialist improves patient outcome with this potentially debilitating disease.
In this article, the authors aim to present in a synthesized form the main epidemiological data on the prevalence of anxiety symptoms and disorders, anatomical localization and biochemical mechanisms and relationships in the pathogenesis of anxiety symptoms, as well as to derive the main guidelines for recognizing and differentiating clinicopathological constellations in somatic conditions in emergency medical practice.
Materials and methods. Existing published studies from an international database, related to the subject of the article, have been thoroughly studied.
Results. Anxiety symptoms, in particular panic attacks and disorders, are widespread in primary care and occupy a significant part of the work process, especially at times of peak loads, natural disasters and situations of mass traumatism.
Conclusions. Timely training and good preparation for recognition and adequate assessment of anxiety conditions in primary and emergency medical care significantly shorten the therapeutic route of patients. They receive competent help on time, and the cost of their treatment is significantly reduced.
Discussion. Modern medical science, including psychiatric, offers advanced drug and non-drug methods for the treatment and prevention of anxiety conditions and disorders.
Anxiety, panic attack, symptoms, stages, pharmacotherapy
In recent years, ‘anxiety’ that does not meet the full criteria for some type of anxiety disorder (e.g. panic disorder) but is characterized by a variety of somatic complaints and resembles a panic attack has become increasingly common in emergency medical care (including psychiatric settings). The diagnostic work-up of such an ‘anxious state’ usually evokes a series of tests conducted on the patient, and various consultations with physicians of different specialties. The latter reinforce the patient’s conviction of the presence of an ‘undetectable physical problem’. The latter is iatrogenic in nature and can become a source of hypochondria and depression for the patient. Although these ‘anxiety states’ cannot be certainly categorized under the diagnosis of ‘anxiety disorder’, their presence requires timely psychiatric intervention and treatment. Anxiety
is an emotional state causing serious discomfort. It is associated with psychophysiological changes and results in an intrapsychic conflict. Anxiety is more intense and ‘exaggerated’, if pathologic and, in such cases, anxiety occurs without an actual threat.
Experimental evidence supports the hypothesis that fear encoding occurs in the amygdala, and the prefrontal cortex exerts controls fear to suppress anxiety. Prolonged stress leads to high levels of glucocorticosteroids, damaging the prefrontal cortex and the control mechanisms of amygdala. The stimulated amygdala becomes overactive: each subsequent signal from the cortex is coded as stronger and more threatening, and as a result the suppression of fear becomes increasingly difficult. Thus, through its central nucleus, the amygdala is involved in triggering panic attacks. If it is also connected to centers in the brainstem that control breathing and heart activity, mechanisms are unlocked for the formation of physical symptoms during a panic attack (Dilkov et al. 2011). A state of distress induces the secretion of norepinephrine, and a state of tension induces the secretion of cortisol, adrenaline and norepinephrine. Cardiovascular centers in the central nervous system (CNS) regulate circulatory response to emotional stress and the impact of psychological processes. Experiencing high- intensity negative emotions is associated with increased blood pressure and heart rate, and increased cardiovascular reactivity to emotional stress could trigger pathologic cardiovascular and brain reactions (
Anxiety disorders are very common in the general population (with an estimated frequency range between 20 and 30%) and a lifetime chance of developing an anxiety disorder of 16.6% (
Table
Organ/system involved | Disorder |
---|---|
Cardiovascular system | congestive heart failure, acute aortic syndrome, acute myocardial infarction, stable and unstable angina pectoris, anemia, hypotension, arterial hypertension, arrhythmias, hypovolemia |
Respiratory system | asthma, acute and chronic bronchiolitis, chronic obstructive pulmonary disease, pneumonia, hyperventilation, sleep apnea |
Metabolic syndrome | hypocalcemia, hypokalemia, porphyria, pellagra, uremia |
Endocrine diseases | hyperadrenocorticism, pituitary dysfunction, hyperthyroidism, hypothyroidism, parathyroid dysfunction, pheochromocytoma, hypoglycemia, polycystic ovary syndrome, premenstrual syndrome |
Neurological diseases | cerebrovascular disease, cerebral neoplasm, encephalitis, migraine, subarachnoid hemorrhage, closed brain injury, multiple sclerosis, Wilson’s disease, vestibular disorders, dementia, delirium, Huntington’s disease, temporal lobe disorders, epilepsy |
Inflammatory diseases | systemic lupus erythematosus, rheumatoid arthritis, temporal arteritis, fibromyalgia, allergic reactions |
Toxicity | caffeine intoxication, amphetamines, heavy metal intoxication, vasopressors and sympathomimetics, organophosphates, alcohol, opiates, phencyclidine, cocaine, ecstasy |
Infectious | septicemia, carcinoid syndrome, infectious mononucleosis, AIDS1, malignancies, subacute bacterial endocarditis, gastrointestinal hemorrhage |
Various | irritable bowel syndrome, dyspepsia, gastro-oesophagic reflux disease, herpes zoster |
This large range of somatic diseases and their acute manifestations are the reason why patients often contact an emergency medical service on suspicion of a medical emergency – e.g. stroke or heart attack, accompanied by tension and anxiety. However, a significant number of patients with panic attacks only without any somatic disorder are admitted as emergency patients in multi-specialty hospitals, e.g. to the neurological clinic with diagnoses ‘vertigo’ or with ‘atypical facial pain’; or to cardiology clinic for ‘acute coronary syndrome’ or suspicion of ‘acute myocardial infarction’, etc. It is important that the doctor in emergency care can distinguish between anxiety and somatic disease. Quite often, the psychiatric morbidity and the somatic morbidity are co-existing.
Many patients suffer anxiety disorder along with other psychiatric illness – such as personality disorders (most commonly borderline personality disorder), various types of addictions, major depression, bipolar affective disorder, schizophrenia, and schizoaffective disorders (
Table
Characteristic features |
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Onset of anxiety symptoms after age 35 |
No past or family history of anxiety disorder |
Lack of childhood history of pathological anxiety, phobia, separation anxiety. There is a number of studies showing that pathologic anxiety in childhood tends to continue later in adulthood ( |
Absence of behavior of avoidance |
Lack of significant life events, the reason for the emergence of anxiety symptoms |
Poor or insufficient response to anxiolytic drug treatment |
When the patient does not meet the conditions described in Table
The patient presenting to the emergency department with a mental problem most often suffers from panic disorder or another anxiety disorder that occurs immediately after experiencing acute stress. Patients who meet the psychiatric criteria of the diagnosis of PD visit emergency departments quite often. Studies show that this frequency is much higher than previously thought (
The panic attack is a brief episode of intense fear or discomfort with four or more of the following symptoms occurring suddenly and peaking within 10 min (
The cases of recurrent and sudden panic attacks, related to continuous fear of having another panic attack with a duration of at least one month and also a significant change in seizure behavior is classified as panic disorder. Six stages have been identified in the development of panic disorder. The stages 1 and 2 are the most common at the time of diagnosis.
Lists the typical and atypical physical complaints seen in a panic attack (
Typical symptoms | Atypical symptoms |
---|---|
tachycardia, palpitations / ‘atypical’ chest pain | chest tightness / pleural chest pain |
Tingling | trembling ‘freezing’, numbness |
Sweating | generalized sweating |
Dyspnea | Stridor |
subjective weakness in the limbs | objective muscle weakness |
apparent lack of coordination redness or chills fever | generalized erythema or rash dry mouth |
feeling of suffocation | mechanical block in swallowing reflex |
dizziness true vertigo | Syncope |
depersonalization and derealization | lack of all-round orientation |
abdominal discomfort | nausea, vomiting |
fear of ‘loss of control’ or other ‘inappropriate’ catastrophic event | strange behavior (not close to fear) |
The stages are as follows: 1. Symptomatic attack, minor; 2. Extended attack; 3. Hypochondria; 4. Limited phobic avoidance/agoraphobia; 5. Extended phobic avoidance/agoraphobia; 6. Secondary depression.
As a rule, the advanced stages of the panic disorder in the respective patient impair seriously his/her daily life and the needed treatment is more difficult and prolonged (Merritt et al. 2000). The diagnosis made in the first two stages is compatible with lower likelihood of deterioration of the disorder (
Table
Stage | Symptom complex |
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I Symptom-limited panic attack | Patients exhibit fewer than the 4 symptoms required for a diagnosis of PD |
II Full-blown panic attack | Patients met the definition of PD in terms of frequency and duration, as well as the presence of 4 or more symptoms |
III Hypochondria | Patients become preoccupied with worries about the presence of bodily disease, regardless of medical evidence to the contrary |
IV Agoraphobia | Panic attacks are tied to certain environmental stimuli – the so-called phobic avoidance behavior |
V Advanced phobic avoidance | Most common fears of driving, visiting shops and crowded places |
VI Secondary depression | It occurs as a result of increasing dysfunction and demoralization |
Patients with PD or anxiety usually present to the emergency department with somatic complaints such as shortness of breath, palpitations, chest pain, etc. Sometimes they are diagnosed with an acute respiratory or cardiac event or other physical illness. Although they have panic attacks, it is extremely important to rule out acute somatic illness. The first steps in the case work-up is to ensure a correct recording of the patient’s history, careful physical examination, an assessment of basic
vital parameters (arterial pressure, pulse rate and characteristics, saturation, respiratory rate) and some laboratory tests – complete blood count, serum electrolytes, levels blood glucose, arterial blood gas analysis, thyroid function tests, and kidney function tests. Electrolyte abnormalities such as low levels of ionized calcium and serum phosphate are seen in patients with hyperventilation. An electrocardiogram should be performed, so as to rule out an acute cardiovascular event. A chest X-ray, ultrasound examination of the lungs, and spirometry are recommended if a respiratory problem is suspected. Toxicological analysis is required in case there is evidence of substance abuse. After excluding possible somatic illness, the patient may be diagnosed with PD or another anxiety disorder. Due to the lack of psychiatrists in the emergency departments, applying DSM-V or ICD-10 diagnostic criteria to such emergency situations can be difficult. This may be the reason for underdiagnosing or misdiagnosing of PD. The use of standardized screening tools can be helpful in such cases.
Table
Screening tools for anxiety/PD | |
---|---|
For anxiety disorder in general | For panic disorder |
Anxiety Disorder Diagnostic Questionnaire ( |
Panic Disorder Self-Report ( |
Generalized Anxiety Disorder 7 ( |
Panic Disorder Severity Scale ( |
Beck Anxiety Inventory ( |
Panic and Agoraphobia Scale ( |
Hamilton Anxiety Rating Scale ( |
NIMH Panic Questionnaire ( |
Panic associated symptoms scale ( |
After careful assessment, the patient may be diagnosed with a somatic illness or an anxiety or panic disorder. The treatment is immediately started by the emergency physician if there is a co-existing somatic illness, and later the patient is referred to a psychiatrist. If a current panic attack or other anxiety disorder is detected – the emergency physician initiates treatment to control the crisis, and then refers the patient to a psychiatrist. It is not uncommon for patients with a primary psychiatric disorder to have underlying somatic illnesses that must be taken into account while making a treatment plan. The treatment of PD/anxiety disorder is pharmacological and includes non-pharmacological methods as well.
The aim of the initial treatment is the control of the symptoms of the panic attack. Benzodiazepines are the drug of choice for this purpose, as they provide rapid results. These are diazepam, clonazepam, lorazepam and alprazolam. Diazepam 10 mg is administered on an emergency basis by muscular or intravenous route: aparenteral preparations of clonazepam (1 mg/1 ml) are already available in Bulgaria. The maximum daily dose of clonazepam in the treatment of anxiety states is 4 mg/day, and after the acute episode, it is taken as tablets or solution by mouth. Clonazepam exerts a weaker sedative effect in contrast to diazepam and is less likely to suppress breathing. Lorazepam is administered in doses of 1–4 mg/day, divided into 2 to 3 daily doses; and its maximum dose is no more than 10 mg/day (
The molecular basis for anxiety disorders is the disturbance in the serotonergic, noradrenergic, GABAergic, and cholecystokininergic neurotransmitter systems (
Table
Medicine | Starting dose | Therapeutic dose |
---|---|---|
Benzodiazepines | ||
Alprazolam | 0.25–0.5 mg, t.i.d | 0.5–2 mg, t.i.d |
Lorazepam | 1–2 mg, b.d. | 1–2 mg, t.i.d |
Clonazepam | 0.25–0.5 mg, b.d. | 0.5–2 mg, b.d. |
Selective Serotonin Reuptake Inhibitors | ||
Paroxetine | 5–10 mg | 20–60 mg b.d. |
Fluoxetine | 20 mg | 20–60 м mg b.d. |
Escitalopram | 5–10 mg | 10–20 mg |
Sertraline | 25–50 mg | 50–200 mg |
Serotonin and Norepinephrine Reuptake Inhibitors | ||
Venlafaxine | 75 mg | 75–150 mg |
Tricyclic antidepressants | ||
Clomipramine | 5–12.5 mg | 50–125 mg |
However, practice shows that the use of these medications is often not sufficient to control the symptoms of anxiety. In such cases, other drug classes – mood stabilizers (valproic acid, carbamazepine, lamotrigine, drugs with gamma-amino butyric acid (GABA), etc.) and antipsychotics (olanzapine, aripiprazole, sulpiride, etc.) should be added (
Anxiety symptoms are prevalent in primary care settings, especially emergency departments. Most of the patients suffering from them have accompanying cardiac, respiratory, gastrointestinal or neurological diseases. Emergency physicians have an important role in diagnosing worrisome psychiatric conditions because they are the first to encounter them. Their early recognition and treatment help reduce psychiatric morbidity and mortality. A holistic approach and clinical assessment, followed by emergency interventions to reduce anxiety and timely referral to a psychiatrist, are paramount for the emergency physician, especially if the patient is at suicidal risk or is severely uncritically aware of the condition, or has an inadequate response to initial interventions. Early referral to a specialist reduces the overall cost of research and treatment.