Day # 64: Medical Workup for Anxiety

Welcome back to our current theme of anxiety disorders. Today we will round out some additional clinical pearls to include what medical work-up should be pursued in a patient with new anxiety symptoms.

Today's Content Level: Intermediate; Advanced

INTRODUCTION

•Before making a diagnosis of an anxiety disorder it is very important to first consider medical causes of anxiety.

Anxiety can present with significant physical symptoms along with it's cognitive symptoms. Physical symptoms include:

• General: fatigue, sweating, shivering.

• Cardiac: chest pain, palpitations, tachycardia, hypertension.

• Pulmonary: shortness of breath, hyperventilation.

• Neurologic/MSK: vertigo, lightheadedness, paresthesias, tremors, insomnia, muscle aches or tension.

• Gastrointestinal: abdominal discomfort, anorexia, nausea, vomiting, diarrhea, constipation.

•Anxiety disorders can occur at any age and varies significantly by diagnosis. Overall, the median age of onset is 11 years old and 95% onset by age 51. If anxious symptoms present for the first time far outside of these age ranges, particularly in older patients, a thorough medical workup becomes that much more important.

•Review the vital signs and perform a complete physical exam. If they are normal they don't tell you much but they can be the first clue that something other than purely psychiatric may be going on.

•Clinical interview -> should address all current and significant past general medical illness, medications, substance use, review of systems, and family medical and psychiatric history in order to identify potential medical contributors of the anxious condition.

•Several types of general medical disorders (example: endocrine or neurologic) can cause anxiety disorders. Any additional testing should be guided by abnormal findings in the history and examination.

Known examples of medical causes of anxiety include: 1

• Endocrine/Autoimmune-> Hypercortisolism, hyperthyroidism, pheochromocytoma, hyperparathyroidism, hypoglycemia, systemic lupus erythematosus (SLE), carcinoid syndrome.

• Neurologic-> Temporal lobe epilepsy, stroke or transient ischemic attacks (TIA), multiple sclerosis, traumatic brain injury (TBI), migraine headaches, brain tumors, Huntington disease, porphyria, PANDAS.

• Cardiac-> Angina or infarct, arrhythmia, congestive heart failure (CHF).

• Pulmonary-> Asthma, pulmonary embolism, chronic obstructive pulmonary disease (COPD), pneumonia, pneumothorax.

Known examples of substance use or medication causes of anxiety include:

• Caffeine

• Stimulants: Amphetamines or cocaine

• Phencyclidine (PCP)

• Hallucinogens

• Alcohol (intoxication or withdrawal)

• Tobacco (intoxication or withdrawal)

• Opioid withdrawal, and also marijuana (paradoxically).

• Known medication causes include stimulants, corticosteroids, albuterol, levothyroxine, or decongestants.

•Of note, complicating the diagnosis of anxiety disorders such as GAD and PD is that many conditions in the differential diagnosis are also common comorbidities (they are co-occuring). This includes medical diagnoses as well as other psychiatric disorders include depressive disorders and phobias.

LABS AND IMAGING

•The utility of screening laboratory tests for patients with anxiety has not been consistently demonstrated. Similar to the physical exam comments above it is still often recommended in certain scenarios.

Workup is commonly performed in the following scenarios:

• New onset anxiety in the absence of a new psychosocial stressor.

• No family history of anxiety.

• Onset of anxiety is after age 35.

• There is a lack of avoidance behavior (avoidance almost always seen in psychiatric anxiety)

• Treatment-resistant anxiety (poor effect of anxiolytic medications)

• Patients who have or are at risk for chronic medical conditions.

Commonly performed screening laboratory tests include:

• CBC (complete blood count): screen for underlying anemia and infection which can contribute to anxiety..

• CMP (complete metabolic): rule out electrolyte disturbances (pay attention to calcium and sodium), glucose (hypoglycemia and HHS/DKA can both have significant anxiety), renal failure (creatinine and BUN), and liver function panel (alcohol, fatty liver, hepatitis).

• UA (Urinalysis) and Urine toxicology and Blood Alcohol Level (BAL): screen for alcoholism and drugs of abuse. Also, individuals with anxiety disorders have a disproportionately high rate of comorbid substance use disorders.

• TSH (thyroid stimulating hormone): hyperthyroidism can classically present as anxiety.

• Beta hCG (pregnancy test): affects treatment decisions! This will be discussed in later lessons in detail.

• ACUTE ANXIETY / PANIC -> Symptoms could include palpitations, pounding heart, accelerated heart rate, shortness of breath, sweating, trembling, shortness of breath, chest pain, nausea, chills, paresthesias, etc... Presenting symptoms could be medical (angina, infarction, arrhythmia, pulmonary embolism, etc) or psychiatric (panic attack). Electrocardiogram (EKG) +/- cardiac enzymes (troponin) are commonly obtained in the emergency room in patient's presenting with symptoms of panic. Other considerations if significant concern for pulmonary conditions would be D-Dimer, chest-CT, etc...

Other diagnostic tests that are less commonly indicated, but should still be considered in certain patients. These additional tests should be pursued as guided by the medical history, review of symptoms, and physical examination. Consider the following:

• Serum cortisol: adrenal insufficiency as well as cushing disease has been shown to display a wealth of possible psychiatric presentations including psychosis, depression, anxiety, mania, and cognitive impairment, alongside the known vague physical symptoms.

• Pheochromocytoma: specific testing considerations are debated and will vary based on your institution. Diagnosis is typically made by measurements of urinary and plasma fractionated metanephrines and catecholamines.

• EEG (electroencephalogram): generally not necessary. Used to rule out seizure disorder if there is a history consistent with possible seizure activity.

• Neuropsychiatric testing: you may opt to send the patient for thorough neuropsychiatric testing to gain a more in-depth understanding of the effects on their cognition and personality.

• Brain CT or MRI (computed tomography or magnetic resonance imaging): very rarely indicated. These studies are typically reserved for patients who's presentation and history suggests an increased likelihood of structural brain disease such as those with focal neurologic signs on physical exam or persistent cognitive impairment. It also may be reasonable to obtain in geriatric patients with new onset severe anxiety.

CONCLUSION

Good work today. Next lesson will cover an overview of the treatment options for anxiety disorders.

Resources today include the articles linked in the body of the article, Pocket Psychiatry, First Aid Psychiatry, and UpToDate.

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