Substance/Medication-Induced Anxiety Disorder

Substance/Medication-Induced Anxiety Disorder

Substance/Medication-Induced Anxiety Disorder

When the symptoms of anxiety or panic can be attributed to the use of a chemical substance, make the diagnosis of substance/medication-induced anxiety disorder. It can occur during acute intoxication (or heavy use, as with caffeine) or during withdrawal (as with alcohol or sedatives), but the symptoms must be more severe that you’d expect for ordinary intoxication or withdrawal, and they must be serious enough to warrant clinical attention.

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Many substances can produce anxiety symptoms, but those most commonly associated are marijuana, amphetamines, and caffeine. See Table 15.1 in Chapter 15 for a summary of the substances for which intoxication or withdrawal can be expected to create anxiety. If more than one substance is involved, you’d code each separately. Quite frankly, these disorders are probably rare.

Essential Features of Substance/Medication-Induced Anxiety Disorder

The use of some substance appears to have caused the patient to experience anxiety symptoms or panic attacks.

The Fine Print

For tips on identifying substance-related causation, see sidebar.

The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (ordinary substance intoxication or withdrawal, delirium, physical disorders, mood disorders, and other anxiety disorders)

Coding Notes

Specify:

With onset during {intoxication}{withdrawal}. This gets tacked on at the end of your string of words.

With onset after medication use. You can use this in addition to other specifiers.

For specific coding procedures, see Tables 15.2 and 15.3 in Chapter 15.

Bonita Ramirez

Bonita Ramirez, a 19-year-old college freshman, was brought to the emergency room by two friends. Alert, intelligent, and well informed, she cooperated fully in providing the following information.

Bonita’s parents both held graduate degrees and were well established in their professions. They lived in a well-to-do suburb of San Diego. Bonita was their oldest child and only daughter. Strictly reared in the Catholic faith, she hadn’t been allowed to date until a year before. Until sorority rush week, the only alcohol she had tasted had been Communion wine. By her account and that of her companions, she had been happy, healthy, and vivacious when she arrived on campus a fortnight earlier.

Two weeks had made a remarkable difference. Bonita now sat huddled on the examination table, feet drawn up beneath her. With her arms wrapped around her knees, she trembled noticeably. Although it was only September, she wore a sweater and complained of feeling cold. She kept reaching for the emesis basin beside her, as though she might need it again.

Her voice quavered as she said that nothing like this had ever happened to her before. “I had some beer last week. It didn’t bother me at all, except I had a headache the next morning.”

This evening there had been a “big sister, little sister” party at the sorority Bonita had just pledged. She had drunk some beer, and that had prompted her to take a few hits from the marijuana cigarette they were passing around. The beer must have numbed her throat, because she had been able to draw the smoke deep into her lungs and hold it, the way her friends had showed her.

For about 10 minutes Bonita hadn’t noticed anything at all. Then her head began to feel tight, as though her hair was a wig that didn’t fit right. Suddenly, when she tried to inhale, her chest “screamed in pain,” and she became instantly aware that she was about to die. She tried to run, but her rubbery legs refused to support her.

The other girls hadn’t had much experience with drug reactions, but they called one of the men from the fraternity house next door, who came over and tried to talk Bonita down. After an hour, she still felt the panicked certainty that she would die or go mad. That was when they decided to bring her to the emergency room.

At length she said, “They said it would relax me and expand my consciousness. I just want to contract it again.”

Evaluation of Bonita Ramirez

Bonita’s history—she was healthy until the ingestion of a substance that is known to produce anxiety symptoms, especially in a naïve user—is a dead giveaway for the diagnosis (criteria A, B). Other drugs that commonly produce anxiety symptoms include amphetamines, which can also produce panic attack symptoms, and caffeine when used heavily. However, because anxiety symptoms can be encountered at some point during the use of most substances, you can code an anxiety disorder secondary to the use of nearly any of them, provided that the anxiety symptoms are worse than you would expect for ordinary substance withdrawal or intoxication. Because she required emergency evaluation and treatment, we would judge this to be the case for Bonita (E).

Despite the proximity of the development of her symptoms to substance use (C), her clinician would want to be sure that she did not have another medical condition (or treatment with medication for a medical condition) that could also explain her anxiety symptoms.

Although she was severely panicked when she arrived at the emergency room, I would score Bonita’s GAF as a relatively high 80, because her symptoms had caused her no actual disability (plenty of distress) and should be transient; other diagnosticians might disagree. She had not used pot before, so she had no use disorder, and her code comes from the “none” row for cannabis in Table 15.3.