Clinical Practice Guidelines for Assessment and Management of Anxiety and Panic Disorders in Emergency Setting

INTRODUCTION

Anxiety disorders, primarily characterized by pathological anxiety, are very common in the general population with estimates ranging from 20 to 30 percent, and the lifetime prevalence rate is calculated at 16.6 percent.[1] It is to be noted that pathological anxiety is experienced as more intense and exaggerated which arises without any real threat.

The word anxiety was taken from the Latin root “anxieta” meaning disturbance in the mind about an uncertain event, and the Greek root “anxo” meaning to squeeze, strangle, or press tight.[2]

Anxiety is an unpleasant emotional state that is associated with psychophysiological changes as a result of an intrapsychic conflict. Anxiety disorder is a disorder in which the most prominent disturbance is anxiety or in which patients experience anxiety when they refuse to give in to their symptoms.[3]

Panic is an acute, intense attack of anxiety associated with disorganization in personality. It is characterized by overwhelming anxiety and feelings of impending doom. A panic attack is an acute intense anxiety episode, which occurs in panic disorder (PD), major depression, schizophrenia, and somatization disorder. PD is characterized by acute intense anxiety attacks in the presence or absence of agoraphobia.[3]

The onset of panic symptoms is often spontaneous and rapid. Many patients seek help in an emergency department (ED) because of these characteristics, combined with its overwhelming intensity.[4]

Anxiety-related complaints are commonly associated with alcohol and substance abuse, which further complicates the emergency physician’s assessment.[5]

PDs and exacerbations of previous acute stress symptoms are common patient presentations in the ED for primary anxiety disorders. Individuals with anxiety disorders may feel debilitated during an anxiety attack and feel embarrassed after the episode. To support the patient both during and after the anxiety episode, it is essential for ED clinicians to be aware of anxiety and PDs.[6] Table 1 outlines clinical predictors of anxiety caused by an underlying medical disorder.

Table 1.

Predictors of anxiety caused by an underlying medical issue[7]

Onset of anxiety symptoms after age of 35 years

Lack of personal or family history of an anxiety disorder

Lack of childhood history of significant anxiety, phobias, or separation anxiety

Lack of avoidance behavior

Absence of significant life events generating or exacerbating the anxiety symptoms

Poor response to antianxiety agents

CLINICAL PRESENTATION

In ED, anxiety presentations may be classified into four groups[5]:

1. Primary psychiatric illness, such as generalized anxiety disorder

2. Response to a stress or stressful event, such as acute stress disorder

3. Medical conditions or substance abuse that mimic the symptoms of anxiety, such as hyperthyroidism

4. Anxiety disorder comorbid with another physical or mental illness

Six stages of development have been identified for PD, with stage 1 or stage 2 being the most common for patients. These stages are (1) limited symptom attack, (2) full panic attack, (3) hypochondriasis, (4) limited phobic avoidance, (5) extensive phobic avoidance, and (6) secondary depression. Stage progression is associated with increasing degrees of disability and corresponding treatment implications.[8] It is believed that the disorder is less likely to worsen if the diagnosis is made in stage 1 or 2 and treated.[9] Table 2 outlines various stages of PD.

Table 2.

Stages of panic disorder[10]

Stage	Name of the stage	Symptomatology
Stages
I	Limited symptom attack	Patients display fewer than the four symptoms necessary for diagnosis of panic disorder.
II	Panic attack	Patients meet the definition of panic disorders with the appropriate frequency, duration, and four or more of the symptoms.
III	Hypochondrias	Patient becomes preoccupied with concerns about medical illness, despite medical assurances. The panic attacks may become associated with environmental stimuli. This is known as phobic avoidance behavior. Driving and going to stores or shopping malls are the most frequent fears.
IV	Agoraphobia
V	Extensive phobic avoidance
VI	Secondary depression	It is believed to result from progressive disability and demoralization.

The main distinguishing feature of PD is the combination of physical and cognitive symptoms. The onset is rapid, reaching its peak within 10 min and the attack around 1 h. The typical patient experiences 2–4 attacks per week, commonly accompanied by anticipatory anxiety.[11]

Panic attack

A brief period of intense fear or discomfort in which ≥4 of the following signs or symptoms occur abruptly and peak within 10 min[12]:

• Palpitations, pounding heart, or accelerated heart rate

• Sweating

• Trembling or shaking

• Sensation of shortness of breath or smothering

• Feeling of choking

• Chest pain or discomfort

• Nausea or abdominal distress

• Feeling dizzy, unsteady, light-headed, or faint

• Derealization (feelings of unreality) or depersonalization (being detached from oneself)

• Fear of losing control or going crazy

• Fear of dying

• Parasthesis (numbness or tingling sensations)

• Chills or hot flushes.

Table 3 outlines the typical and atypical symptoms of panic attacks.

Table 3.

Typical and atypical symptoms of panic attacks[4]

Typical symptoms	Atypical symptoms
Tachycardia, palpitations “Atypical” chest pain	Vice-like/crushing chest pain Pleuritic chest pain
Trembling, shaking	Shaking rigor
Sweating	Diaphoresis (generalized, drenching)
Dyspnea	Stridor
Subjective weakness in arms and legs	Objective muscular weakness Overt lack of coordination
Flushes or chills	Fever, generalized erythema, or rash
Dry mouth Choking sensation	Mechanical inability to swallow
Dizziness, lightheaded feeling	True vertigo, syncope
Depersonalization, derealization	Disorientation to person, time, or place
Nausea, abdominal distress	Vomiting (projectile, bilious, or recurrent)
Fear of losing control or other “irrelevant” catastrophe	Bizarre behavior (unrelated to fear of the attack)

PD: Recurrent, sudden panic attacks that are followed by a minimum of 1 month of persistent concern about having another panic attack, worry about the potential implications or consequences of the attacks, or a significant change in behavior related to the attacks.[11]

Table 4 outlines the medical conditions that may cause anxiety.

Table 4.

Medical conditions that may cause anxiety[13]

System	Conditions
Cardiovascular diseases	Congestive heart failure, acute chest pain, acute myocardial infarction, angina, anemia, hypotension, hypertension, arrhythmias, hypovolemia
Respiratory	Asthma, acute and chronic bronchitis, COPD, pneumonia, hyperventilation, sleep apnea
Metabolic syndrome	Hypocalcemia, hypokalemia, porphyria, pellagra, uremia
Endocrine disorders	Hyperadrenocorticism, pituitary dysfunction, hyperthyroidism, hypothyroidism, parathyroid dysfunction, pheochromocytoma, hypoglycemia, virilization disorders in females, premenstrual syndrome
Neurologic disorders	Cerebrovascular disease, cerebral neoplasm, encephalitis, migraines, subarachnoid hemorrhage, closed head injuries, multiple sclerosis, Wilson disease, vestibular dysfunctions, dementia, delirium, Huntington’s disease, temporal lobe diseases, seizure disorders, psychomotor epilepsy
Inflammatory disorders	Systemic lupus erythematosus, rheumatoid arthritis, temporal arteritis, fibromyalgia, allergic reactions
Toxicity	Caffeine intoxication, amphetamines, heavy metals, vasopressors and sympathomimetic agents, organophosphates, alcohol, opiates, phencyclidines, cocaine, ecstasy
Infectious and other diseases	Septicemia, carcinoid syndrome, infectious mononucleosis, AIDS, systemic malignancies, subacute bacterial endocarditis, gastrointestinal hemorrhage
Miscellaneous	Irritable bowel syndrome, dyspepsia, GERD, shingles (herpes zoster)

AIDS, acquired immunodeficiency syndrome; COPD, chronic obstructive pulmonary disease; GERD, gastroesophageal reflux disease; HIV, human immunodeficiency virus

Management of the PD

Assessment

Patients with PD or anxiety usually present to the ED with somatic symptoms of breathlessness, palpitations, chest pain, etc. It is not uncommon for them to be diagnosed as having an acute respiratory or cardiac event or any other physical illness. Even though the patient is having a panic attack, it is highly essential to rule out all acute physical emergencies. A proper history taking along with a careful physical examination of the vital parameters and certain basic investigations help the emergency physician to rule out a physical illness.

These include the measurement of vital data like blood pressure, oxygen saturation, pulse rate and characteristics, and respiratory rate. Hematological investigations like complete blood counts, serum electrolytes, blood glucose levels, arterial blood gas analysis, thyroid function tests, and renal function tests are to be done. Electrolyte abnormalities like reduced ionized calcium and serum phosphate levels are usually seen in patients with hyperventilation. An electrocardiogram to rule out any acute cardiac abnormalities can be done.

Point of care ultrasonography of the lungs, bedside X-ray of the chest, and peak flowmetry to rule out any respiratory abnormalities are advisable. A toxicological screening to rule out any drug abuse is also helpful in an emergency setting. After ruling out the possible physical causes, the patient could be diagnosed with a PD or an anxiety disorder.

Application of DSM-V or ICD-10 guidelines in an emergency setting could be difficult due to the unavailability of a psychiatrist in the ED. This could lead to underdiagnosing or misdiagnosing the PD. Hence, using certain screening tools that can be applied by an emergency physician or any general physician could be useful in diagnosing a patient with panic or anxiety disorders.

Screening tools

Following are some of the available screening tools that can be used by physicians or primary care doctors in an emergency setting [Table 5]:

Table 5.

Screening tools for anxiety/panic disorder

Anxiety Disorder	Panic Disorder
Anxiety Disorder Diagnostic Questionnaire[14]	Panic Disorder Self-Report[18]
Generalized Anxiety Disorder 7[15]	Panic Disorder Severity Scale[19]
Beck Anxiety Inventory[16]	Panic and Agoraphobia Scale[20]
Hamilton Anxiety Rating Scale[17]	NIMH Panic Questionnaire[21]
	Panic associated symptoms scale[22]

Treatment in an emergency setting

After careful history taking and a careful assessment, patients can be diagnosed with a physical illness or with anxiety or PD. If the patient is found to have a physical illness, he or she can be treated by the emergency physician immediately and later referred to the concerned specialist physician. If the patient is found to have a psychogenic panic attack or an anxiety disorder, he can be treated by the emergency physician to subvert the crisis situation and then referred to a psychiatrist. However, it is not uncommon for patients diagnosed with primary mental illness to have an underlying medical condition, and should be taken into consideration while treating the patient. Patients can be treated using both pharmacological and non-pharmacological measures.

Pharmacotherapy

The most important step in the management is to abort the panic attack. A benzodiazepine with rapid onset of action is the choice of pharmacotherapy. Alprazolam, lorazepam, and clonazepam are used to treat anxiety/panic symptoms. Alprazolam is usually started at a low dose of 0.25 mg, three times a day, but doses of 4 mg/day or more may be required.[23] The initial starting dose of lorazepam is 2 mg to 3 mg, can repeat the dose 2 to 3 times per day; the maximum dosage is 10 mg per day.[24] It can also be administered via intravenous (IV) or intramuscular (IM) injection (2 mg/mL solution, and 4 mg/mL solution). The onset of its action is 1 to 3 min if administered IV and 15 to 30 min if administered IM. Clonazepam is given orally at a starting dose of 0.25 mg and can be used with a maximum dose of 4 mg/day. Abrupt cessation of the benzodiazepines might lead to withdrawal and hence careful tapering of the medication must be done. Caution must be taken with the use of long-term benzodiazepines because of the dependence potential.

In the long-term treatment of anxiety/PD, selective serotonin reuptake inhibitors (SSRIs) are the first-line medications. Examples of SSRIs approved by the FDA to treat the PD include escitalopram, paroxetine, sertraline, and fluoxetine. Even though all of them are equally effective, because of their sedating property, paroxetine is more commonly used.[25] These medications must be titrated slowly and take several weeks to be effective. Common side effects of SSRIs include nausea, diarrhea, constipation, headache, tremors, agitation, dizziness, sweating, and sexual dysfunction. Tricyclic antidepressants include imipramine, clomipramine, etc. Serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine are also used in the treatment of PD. A brief course of alprazolam can be prescribed in conjunction with an SSRI for short-term management of PD and should be slowly titrated when the therapeutic actions of the SSRI become apparent (2–4 weeks). Medications and their dosages used in PD are summarized in Table 6.

Table 6.

Medications used in anxiety/panic disorder

Drug	Initial dose	Maintenance dose
Benzodiazepines
Alprazolam	0.25-0.5 mg tid	0.5-2 mg tid
Lorazepam	1-2 mg bid	1-2 mg tid
Clonazepam	0.25-0.5 mg bid	0.5-2 mg bid
SSRI
Paroxetine	5-10 mg	20-60 mg
Fluoxetine	20 mg	20-60 mg
Escitalopram	10 mg	10-20 mg
Sertraline	12.5-25 mg	50-200 mg
TCA
Clomipramine	5-12.5 mg	50-125 mg
Imipramine	10-25 mg	150-500 mg
Desipramine	10-25 mg	150-200 mg
SNRI
Venlafaxine	6.25-25 mg	50-150 mg

Non-pharmacological therapy

Most panic attacks spontaneously resolve within half an hour, and patients can sometimes present with the attacks subsiding or with feelings of anticipatory anxiety. Therefore, during such an attack, the treating physician should reassure the patient and explain the brief nature of the illness. Psychoeducation of the patient and the caregivers regarding the course and prognosis of the illness helps in alleviating the anxiety. For further information on psychoeducation in the management of anxiety, refer to Clinical Practice Guidelines for Psychoeducation in Psychiatric Disorders General Principles of Psychoeducation.[26] In the long term, psychotherapies such as cognitive behavioral therapy,[27] interpersonal therapy, and mindfulness therapy can be used to treat PD, but also take effect after several weeks. Therefore, healthcare providers in the ED should properly refer and educate on general lifestyle recommendations to reduce and identify any anxiety-related symptoms, such as eliminating stimulants, obtaining adequate sleep, and exercising daily. In addition, relaxation techniques[17] can easily be administered in ED settings and have the potential to reduce anxiety. Deep breathing exercises,[28] which involve consciously slowing respirations and focusing on taking regular slow deep breaths have been shown to reduce anxiety or panic symptoms. Another strategy may include guided imagery,[29] where the emergency physician encourages the patient to imagine a serene location free of stress. Both of these methods may have a profound effect on the anxiety of patients who present with a panic attack or known PD.

Role of emergency physicians

PD is a very common presentation in the primary care setting, especially in an ED. Most of the patients have cardiac, gastrointestinal, ear, nose, and throat (ENT), or neurological comorbidities. As the first point of contact with the patients, emergency physicians have an important role in the management of PDs. A holistic history and clinical assessment are of paramount importance. Early recognition and management help to reduce both morbidity and mortality. The emergency physician should be able to abate the panic attack and put in a referral to a psychiatrist especially if the patient has suicidality or any self-neglect or inadequate response to the primary intervention. Early referral decreases overall cost in the assessment and management of PDs.[30] The management of patients presenting to the emergency department has been summarized in Figure 1.

Figure 1.

Algorithm depicting the management of patients presenting to the emergency department with anxiety/panic symptoms

SUMMARY

Anxiety/PD is common in the general population and often presents to the ED. The emergency physician must be able to identify the underlying cause for the presentation, which could be either a primary mental illness or an underlying medical condition presenting with the symptoms of anxiety/PD to initiate proper treatment. Basic investigations help in the assessment of the symptoms. If the cause is an underlying medical illness, referral to the concerned specialist would be helpful and if symptoms are purely due to a primary mental illness, the patient can be screened for an anxiety or PD. Early and timely recognition of primary anxiety disorder helps in avoiding unnecessary investigations and can be treated with both pharmacological and non-pharmacological options. The main aim is to calm down the patient and abort the panic attack. Benzodiazepines and SSRIs remain the mainstay of treatment. Reassurance and psychoeducation of the patient as well as his caregivers help a long way in the management of the symptoms. Judicious use of medication, patient education, and referral to a physician whenever necessary improve the outcome of patients with this otherwise potentially disabling disorder.

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Conflicts of interest

There are no conflicts of interest.