Evaluating and treating anxiety in patients who present with psychiatric symptoms and undiagnosed medical illness can be particularly challenging.
"There is a long list of illnesses that can cause anxiety," said Dr. Larry S. Goldman, director of adult psychiatry at the University of Chicago. Most psychiatrists are familiar with the usual suspects: pulmonary disease, heart disease, and hyperthyroidism. But uncommon conditions are likely to be overlooked unless a more aggressive evaluation is done.
A tip-off that generalized anxiety or panic may have medical origins is the departure from expected patterns, Dr. Goldman said. When the onset is later than normal; a distinct life event or other precipitating factor is lacking or small, compared with the symptom picture; or the patient has neither a family history of anxiety nor the expected personality type, "it [is] more likely that a physiological process is involved."
Among the conditions that might present as a result of a thorough work-up are more obscure endocrine disorders such as hyperparathyroidism or pheochromocytoma, an epinephrine-secreting tumor.
Temporal lobe seizures can present with waves of anxiety and depersonalization. Suspect that possibility in a patient with a history of head trauma or seizures early in life that have resolved, Dr. Goldman said.
On the other hand, the stress of any serious medical condition can evoke sub-stantial anxiety. "Being frightened is an essential part of the illness experience," said Dr. Thomas N. Wise, professor and vice chair of psychiatry at Georgetown University, Washington. Uncertainty, the prospect of painful procedures, and the traumas of hospitalization are all contributors.
Psychiatric and medical conditions are not mutually exclusive. Symptoms may represent the unmasking or exacerbation of a preexisting anxiety disorder under the stress of illness, said Dr. Eduardo Colon, director of psychiatric consultation and vice chief of psychiatry at Hennepin County Medical Center, Minneapolis. In any case, underlying medical conditions must be addressed.
Lung disease is a case in point. Patients with chronic obstructive lung disease or asthma frequently present with anxiety, which may be a direct, physiologic result of breathing difficulties. In addition, drugs such as steroids, theophylline, and [alpha]-adrenergic bronchodilators that are used to treat lung disorders can cause anxiety.
But there also is "a high incidence of anxiety disorders in people with respiratory problems," Dr. Colon said. Some patients have perceived air hunger even though tests indicate they are receiving enough oxygen. Controlled studies are limited, but the use of selective serotonin reuptake inhibitors (SSRIs) after pulmonary status has been optimized appears to decrease the perception of dyspnea, along with accompanying anxiety, he said.
If benzodiazepines are given, care must be taken not to suppress respiratory drive, particularly in patients who retain carbon dioxide. Buspirone may be an attractive option (for generalized anxiety, not panic) because it does not decrease, and may enhance, respiratory drive, Dr. …