Anxiety Disorder Due to Another Medical Condition

Anxiety Disorder Due to Another Medical Condition

Anxiety Disorder Due to Another Medical Condition

Many medical disorders can produce anxiety symptoms, which will usually resemble those of panic disorder or generalized anxiety disorder. Occasionally, they may take the form of obsessions or compulsions. Most anxiety symptoms won’t be caused by a medical disorder, but it is supremely important to identify those that are. The symptoms of an untreated medical disorder can evolve from anxiety to permanent disability (consider the dangers of a growing brain tumor).

ORDER COMPREHENSIVE SOLUTION PAPERS ON Anxiety Disorder Due to Another Medical Condition

Essential Features of Anxiety Disorder Due to Another Medical Condition

A physical medical condition appears to have caused panic attacks or marked anxiety.

The Fine Print

For pointers on deciding when a physical condition may have caused a disorder, see sidebar.

The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use disorders, delirium, mood disorders, other anxiety disorders, adjustment disorder)

Coding Notes

In recording the diagnosis, use the name of the responsible medical condition, and list first the medical condition, with its code number.

Millicent Worthy

“I wonder if we could just leave the door open.” Millicent Worthy got up from the chair and opened the examining room door. She had fidgeted throughout the first part of the interview. Part of that time, she had hardly seemed to be paying attention at all. “I feel better not being so closed in.” Once she finally settled down, she told this story.

Millicent was 24 and divorced. She had never touched drugs or alcohol. In fact, until about 4 months ago, she’d been well all her life. She had visited a mental health clinic only once before, when she was 12: Her parents were having marital problems, and the entire family had gone for family counseling.

She had first felt nervous while tending the checkout counter at the video rental outlet where she worked. She felt cramped, hemmed in, as if she needed to walk around. One afternoon, when she was the only employee in the store and she had to stay behind the counter, her heart began to pound and she perspired and became short of breath. She thought she was about to die.

Over the next several weeks, Millicent gradually became aware of other symptoms. Her hand had begun to shake; she noticed it one day at the end of her shift when she was adding up the receipts from her cash register. Her appetite was voracious, yet in the past 6 weeks her weight had dropped nearly 10 pounds. She still loved watching movies, but lately she felt so tired at night that she could barely keep awake in front of the TV. Her mood had been somewhat irritable.

“As I thought about it, I realized that all this started about the time my boyfriend and I decided to get married. We’ve been living together for a year, and I really love him. But I’d been burned before, in my first marriage. I thought that might be what was bothering me, so I gave back his ring and moved out. If anything, I feel worse now than before.”

Several times during the interview Millicent shifted restlessly in her chair. Her speech was rapid, though she could be interrupted. Her eyes seemed to protrude slightly, and although she had lost weight, a fullness in her neck suggested a goiter. She admitted that she was having trouble tolerating heat. “There’s no air conditioner in our store. Last summer it was no problem—we kept the door open. But now it’s terrible! And if I wore any less clothing to work, they’d have to give me a desk in the adult video section.”

Millicent’s thyroid function studies proved to be markedly abnormal. Within 2 months an endocrinologist had brought her hyperactive thyroid under control, and her anxiety symptoms had disappeared completely. Six months later, she and her fiancé were married.

Evaluation of Millicent Worthy

Millicent had at least one panic attack (criterion A); her distress was palpable (E). The only remaining requirements would involve ruling out other causes of her problem.

If she had had repeated panic attacks and if the symptoms of her goiter had been overlooked, she could have been misdiagnosed as having panic disorder. Her restlessness could have been misinterpreted as generalized anxiety disorder; her feelings of being closed in sound like a specific phobia. (Even Millicent interpreted her own symptoms as psychological, C.) Such scenarios reinforce the wisdom of placing physical conditions at the top of the list of differential diagnoses.

Irritability, restless hyperactivity, and weight loss also suggest a manic episode, but these are usually accompanied by a subjective feeling of high energy, not fatigue. Millicent’s rapid speech could be interrupted; in bipolar mania, often it cannot. Her lack of previous depressions or manias would also militate against any mood disorders. Her history rules out a substance/medication-induced anxiety disorder. And her attention span and orientation were good, so that we can disregard delirium (D). Finally, we know that the physiological effects of hyperthyroidism can cause anxiety symptoms of the sort Millicent experienced (B).

The broken engagement was noted not because it seemed a cause of her anxiety symptoms, but because her relationship with her fiancé was a problem that should be addressed as part of the overall treatment plan. I’d put her GAF score at an almost-healthy, but still-needs-to-be-addressed 85.