Diagnosis of Agoraphobia
Agoraphobia Diagnosis: Book Excerpts
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ANXIETY:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the anxiety intermittent or constant? Intermittent anxiety suggests the possibility of psychomotor epilepsy, a pheochromocytoma, or insulinoma. It is also possible that the patient is suffering from an intermittent cardiac arrhythmia such as paroxysmal supraventricular tachycardia or atrial fibrillation.
- What is the patient's age? The young or middle-aged patient is more likely to be suffering from a psychiatric disorder, whereas the older patient may be suffering from cerebral arteriosclerosis or some other type of dementia.
- If there is tachycardia, is it sustained during sleep? Tachycardia that is sustained during sleep would suggest hyperthyroidism, caffeine effects, or other drug effects.
- Is there associated weight loss? Sustained tachycardia with weight loss makes hyperthyroidism a very likely possibility.
DIAGNOSTIC WORKUP
Patients with intermittent anxiety with long periods of calmness in between should have a wake-and-sleep EEG and possibly a CT scan to rule out a cerebral tumor. A 24-hr urine collection for catecholamines should be done also to rule out a pheochromocytoma. Twenty-four-hr Holter monitoring may be necessary to rule out a paroxysmal cardiac arrhythmia. In difficult cases, a 24-hr EEG or an EEG with nasopharyngeal electrodes inserted may be necessary.
Patients with constant anxiety should have a thyroid profile, a drug screen, and an EKG. If these are not revealing, perhaps 24-hr Holter monitoring may be of some value. With a negative workup, a referral to a psychiatrist is in order. It may be even wiser to consult a psychiatrist before undertaking an expensive workup.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Anxiety:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Generalized anxiety disorder
–Excessive worry associated with at least three symptoms, including restlessness or edgy feeling, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
–The most common anxiety disorder in primary care
- Panic disorder
–Recurrent, unpredictable panic attacks with intense apprehension, fear or terror, and somatic symptoms (e.g., tachycardia)
–May present with or without agoraphobia
-
Depression: Anxiety often presents in a mixed state with depression
-
Medications (e.g., bronchodilators, steroids, antidepressants, antihypertensives)
-
Substance use, including drugs (e.g., alcohol, caffeine, cocaine, cannabis)
-
Obsessive-compulsive disorder
–Obsessions are persistent ideas, images, or impulses that generate anxiety
–Compulsions are intentional repetitive behaviors or mental acts aimed at reducing the distress of obsessions
- Anxiety disorder due to a general medical condition
–Cardiovascular etiologies include MI, angina, arrhythmias, CAD, CHF, MVP
–Respiratory etiologies include asthma, COPD, and pulmonary embolism
–Endocrine etiologies include hyper- or hypothyroidism, hypoglycemia, and Cushing's syndrome
–Neurological etiologies include Parkinson's disease and epilepsy
–Cancer
-
Pheochromocytoma: Adrenal tumor that usually presents with hypertension and increased heart rate and sometimes with fright reaction of sweating, headache, and pale facial appearance
-
Parkinson's disease: Presents with tremor at rest, usually in one hand (as opposed to the more generalized essential tremor in anxiety)
-
Post-traumatic or acute stress disorder
-
Social anxiety disorder
-
Specific phobia
-
Bipolar disorder (especially manic stage)
Workup and Diagnosis
- Detailed history of onset, duration, and type of anxiety symptoms as well as specific events, stressors, or medical illnesses that produce anxiety
–Complete drug and medication history, including caffeine, alcohol, over-the-counter preparations, herbals, illicit drugs, and prescription drugs
–Physical exam should be directed toward ruling out organic medical diseases that may present with anxiety, including cardiovascular, pulmonary, endocrine, and neurologic disorders
–A complete psychiatric examination is indicated for all patients (e.g., appearance, sleep evaluation, mini-mental status exam, affect)
-
DSM-IV criteria are used to determine the specific psychiatric disorders
-
No diagnostic tests are indicated except those that may determine underlying medical disorders (e.g., thyroid function tests, ECG, urine catecholamines)
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
DEPRESSION, ANXIETY, AND OTHER ABNORMAL PSYCHIC STATES:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The association of other symptoms and signs is all important. A triiodothyronine (T3) level, total thyroxine (T4) level, and free thyroxine index (FT4), a urine for porphobilinogen, serum electrolytes, toxicology screen, lead level, 24-hour urine, 17-ketosteroid level, and 17-hydroxycorticosteroid level should be done on anyone suspected of having endogenous depression. (Possibly all depressed patients should get this screen.) Skull x-ray film, EEG, CT scan and even a spinal tap [to rule out multiple sclerosis (MS) and lues] may be worthwhile when other neurologic signs are present.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Anxiety:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient displays acute, severe anxiety, quickly take his vital signs and determine his chief complaint; this will serve as a guide for how to proceed. For example, if the patient’s anxiety occurs with chest pain and shortness of breath, you might suspect myocardial infarction and act accordingly. While examining the patient, try to keep him calm. Suggest relaxation techniques, and talk to him in a reassuring, soothing voice. Uncontrolled anxiety can alter vital signs and exacerbate the causative disorder.
If the patient displays mild or moderate anxiety, ask about its duration. Is the anxiety constant or sporadic? Did he notice precipitating factors? Find out if the anxiety is exacerbated by stress, lack of sleep, or caffeine intake and alleviated by rest, tranquilizers, or exercise.
Obtain a complete medical history, especially noting drug use. Then perform a physical examination, focusing on any complaints that may trigger or be aggravated by anxiety.
If the patient’s anxiety isn’t accompanied by significant physical signs, suspect a psychological basis. Determine the patient’s level of consciousness (LOC) and observe his behavior. If appropriate, refer the patient for psychiatric evaluation.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Generalized anxiety disorder:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
For characteristic findings in patients with this condition, see Diagnosing generalized anxiety disorder.
Laboratory tests must exclude organic causes of the patient’s signs and symptoms, such as hyperthyroidism, pheochromocytoma, coronary artery disease, supraventricular tachycardia, and Ménière’s disease. For example, an electrocardiogram can rule out myocardial ischemia in a patient who complains of chest pain. Blood tests, including complete blood count, white blood cell count and differential, and serum lactate and calcium levels, can rule out hypocalcemia.
Because anxiety is the central feature of other mental disorders, psychiatric evaluation must rule out phobias, obsessive-compulsive disorder, depression, and acute schizophrenia.
Behaviors commonly associated with a diagnosis of anxiety may have cultural origins or acceptance. For example, Hispanics may experience “susto,” or a state of anxiety, insomnia, anorexia, and social withdrawal, following a frightening stimulus. Koreans may experience “Hwa-byung” — a state of anxiety and irritability, with various physiologic symptoms, such as headache and palpitations. African-Americans may experience “blockout,” involving collapse, dizziness, and reduced physical movement in time of stress.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Anxiety:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient displays acute, severe anxiety, quickly take his vital signs and determine his chief complaint; this will serve as a guide for how to proceed. For example, if the patient’s anxiety occurs with chest pain and shortness of breath, you might suspect myocardial infarction and act accordingly. While examining the patient, try to keep him calm. Suggest relaxation techniques, and talk to him in a reassuring, soothing voice. Uncontrolled anxiety can alter vital signs and exacerbate the causative disorder.
If the patient displays mild or moderate anxiety, ask about its duration. Is the anxiety constant or sporadic? Did he notice any precipitating factors? Find out if the anxiety is exacerbated by stress, lack of sleep, or excessive caffeine intake and alleviated by rest, tranquilizers, or exercise.
Obtain a complete medical history, especially noting drug use. Then perform a physical examination, focusing on any complaints that may trigger or be aggravated by anxiety.
If the patient’s anxiety isn’t accompanied by significant physical signs, suspect a psychological cause. Determine the patient’s level of consciousness (LOC) and observe his behavior. If appropriate, refer the patient for psychiatric evaluation.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Anxiety:
History.
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
The most common physical symptoms associated with anxiety disorders include palpitations, shortness of breath, dizziness, sweating, and abdominal and chest pain. Common psychological symptoms can include shakiness, nervousness, fear of dying or going crazy, derealization, or depersonalization. Some patients attribute their anxiety to their physical symptoms (“Of course, I was anxious. I thought I was having a heart attack”).
The assessment of anxiety disorders should include the nature, frequency, and duration of symptoms, precipitants, and impact of symptoms. A careful review of all medications (esp. stimulants, sympathomimetics, xanthines) and use of legal (e.g., caffeine) and illegal (e.g., cocaine) substances is essential. Comorbid medical and psychiatric illnesses should be assessed. The following symptoms should be specifically solicited: discrete episodes of severe anxiety (panic), intense fear of social settings, specific fears or phobias, obsessions or compulsions, and nightmares or flashbacks.
Physical examination.
The extent of the physical examination or medical workup depends on the age of the patient, severity of symptoms, and presence or suggestion of comorbid medical illnesses (3). Although many patients with chronic medical illnesses may suffer from anxiety, relatively few medical illnesses
directly cause anxiety. These include hyperthyroidism, hyperparathyroidism, tachyarrhythmias, and hypoxia from any cause (esp. chronic obstructive pulmonary disease).
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Anxiety:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Situational/characterologic
❑ Post-traumatic stress disorder
❑ Drugs/withdrawal
❑ Generalized anxiety disorder
❑ Panic disorder
❑ Phobia
❑ Agitated depression
❑ Hypoglycemia
❑ Hyperthyroidism
Diagnostic Approach
Anxiety ranges from a vague sense of uneasiness to one of imminent danger and dread. Thoughts race and concentration is difficult. There is a heightened self-awareness and startle response. Restlessness, bitten fingernails, tremor, tic, and excessive sweating are often noticeable. Sympathetic nervous system activation may cause palpitations, flushing, sweating, or diarrhea. Hyperventilation may occur, with lightheadedness, and circumoral numbness.
Heightened perception and negative interpretation of normal bodily sensations is a common stimulus to visit the physician. Anxiety is frequently somatized to symptoms of chest pain, palpitations, or shortness of breath. Anxiety-related air swallowing (aerophagia) produces belching.
Repression is a defense mechanism, leading to dissociation from awareness and conversion to hysterical symptoms such as paralysis, anesthesia, aphonia, or amnesia. Blocking of one side of a conflict (a common defense mechanism) distorts the perception of reality, causing decision-making to become difficult.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Anxiety disorder, generalized:
Diagnosis
(Handbook of Diseases)
For characteristic findings in patients with this condition, see Diagnosing generalized anxiety disorder.
In addition, laboratory tests must exclude organic causes of the patient’s signs and symptoms, such as hyperthyroidism, pheochromocytoma, coronary artery disease, supraventricular tachycardia, and Ménière’s disease. For example, an electrocardiogram can rule out myocardial ischemia in a patient who complains of chest pain. Blood tests — including a complete blood count, white blood cell count and differential, and serum lactate and calcium levels — can rule out hypocalcemia.
Because anxiety is the central feature of other mental disorders, psychiatric evaluation must rule out phobias, obsessive-compulsive disorders, depression, and acute schizophrenia.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Anxiety:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient displays acute, severe anxiety, quickly take his vital signs and determine his chief complaint; this will serve as a guide for how to proceed. For example, if the patient’s anxiety occurs with chest pain and shortness of breath, you might suspect myocardial infarction and act accordingly. While examining the patient, try to keep him calm. Suggest relaxation techniques, and talk to him in a reassuring, soothing voice. Uncontrolled anxiety can alter vital signs and exacerbate the causative disorder.
If the patient displays mild or moderate anxiety, ask about its duration. Is the anxiety constant or sporadic? Did he notice any precipitating factors? Find out if the anxiety is exacerbated by stress, lack of sleep, or excessive caffeine intake and alleviated by rest, tranquilizers, or exercise. Obtain a complete medical history, especially noting drug use.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Anxiety:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient displays acute, severe anxiety, quickly take his vital signs and determine his chief complaint; this will serve as a guide for how to proceed. For example, if the patient's anxiety occurs with chest pain and shortness of breath, you might suspect myocardial infarction and act accordingly. While examining the patient, try to keep him calm. Suggest relaxation techniques, and talk to him in a reassuring, soothing voice. Uncontrolled anxiety can alter vital signs and exacerbate the causative disorder.
If the patient displays mild or moderate anxiety, ask about its duration. Is the anxiety constant or sporadic? Did he notice precipitating factors? Find out if the anxiety is exacerbated by stress, lack of sleep, or caffeine intake or alleviated by rest, tranquilizers, or exercise.
Obtain a complete medical history, especially noting drug use including over-the-counter drugs and herbal supplements. Then perform a physical examination, focusing on any complaints that may trigger or be aggravated by anxiety.
If the patient's anxiety isn't accompanied by significant physical signs, suspect a psychological basis. Determine the patient's level of consciousness (LOC) and observe his behavior. If appropriate, refer the patient for psychiatric evaluation.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
DEPRESSION, ANXIETY, AND OTHER ABNORMAL PSYCHIC STATES:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The association of other symptoms and signs is all important. A
triiodothyronine (T3) level, total thyroxine (T4) level, and free
thyroxine index (FT4), a urine for porphobilinogen, serum electrolytes,
toxicology screen, lead level, 24-hour urine, 17-ketosteroid level, and
17-hydroxycorticosteroid level should be done on anyone suspected of having
endogenous depression. (Possibly all depressed patients should get this
screen.) Skull x-ray film, EEG, CT scan, and even a spinal tap (to rule out
multiple sclerosis [MS] and lues) may be worthwhile when other neurologic
signs are present.
case presentation #14
A 62-year-old white woman is brought to your office because the family
has noticed that she is depressed. The patient has insomnia, frequent
nightmares, and weight loss over the past 6 months despite the fact that she
has a good appetite.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Infection in Unusual Spaces:
Diagnosis
(Pediatric Infectious Disease)
Several tests have been used in an attempt to document the progression of
cellulitis to necrotizing fasciitis. The presence of leukocytosis and acidosis
has been used to identify patients with progressive disease. The appearance of
gas on plain radiograph is an inconsistent finding and is seen in less than 20%
of cases. Magnetic resonance imaging (MRI) has been reported to detect
extension of the inflammatory process into the subcutaneous tissue. High signal
intensity of the fascia in the T2-weighted images strongly suggests the
diagnosis.
The gold standard of diagnosis for necrotizing fasciitis is surgical biopsy;
biopsies reveal acute inflammation of the dermis and fascia with accompanying
thrombosis of blood vessels.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Infectious Disease, 2004
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