What is the best approach to manage a patient with a history of recurrent episodes of anxiety and sensory hypersensitivity, who had a similar episode 5 years ago that resolved on its own?

Management of Recurrent Episodes of Anxiety and Sensory Hypersensitivity

For patients with recurrent episodes of anxiety and sensory hypersensitivity that previously resolved spontaneously, a watchful waiting approach with supportive care is recommended as first-line management, while preparing for intervention if symptoms worsen or persist.

Assessment and Classification

When evaluating a patient with recurrent anxiety and sensory hypersensitivity:

1. Rule out anaphylaxis or severe allergic reaction:

   • Assess for cutaneous manifestations (urticaria, angioedema, flushing)
   • Check for respiratory symptoms (upper or lower airway obstruction)
   • Evaluate for gastrointestinal symptoms (nausea, vomiting, diarrhea)
   • Look for cardiovascular symptoms (syncope, hypotension) 1

2. Determine severity of current episode:

   • Mild: Primarily anxiety symptoms with sensory hypersensitivity
   • Moderate: Symptoms affecting daily functioning
   • Severe: Significant distress or functional impairment

Management Algorithm

Initial Management (First 1-2 Weeks)

1. Watchful waiting with supportive care:

   • Based on patient's history of spontaneous resolution within weeks to months 1
   • Monitor symptoms without immediate pharmacological intervention
   • Educate patient on symptom recognition and management techniques

2. Non-pharmacological interventions:

   • Stress reduction techniques (deep breathing, meditation)
   • Environmental modifications to reduce sensory triggers
   • Regular sleep schedule and physical activity

3. Patient education:

   • Reassurance about the typically self-limiting nature of episodes
   • Explanation of the relationship between anxiety and sensory hypersensitivity 2
   • Discussion of warning signs that would necessitate escalation of care

If Symptoms Persist (After 2-4 Weeks)

1. Consider short-term pharmacological management:

   • H1 antihistamines may help with sensory hypersensitivity symptoms 1
   • Short-term anxiolytics may be considered for severe anxiety symptoms

2. Specialist referral:

   • Consider referral to allergist-immunologist to rule out underlying conditions 1
   • Mental health evaluation may be appropriate if anxiety symptoms predominate

For Persistent or Severe Symptoms (Beyond 4-6 Weeks)

1. Pharmacological options:

   • Consider a short course of systemic corticosteroids if symptoms are significantly affecting quality of life 1
   • SSRI medications may be appropriate for persistent anxiety with sensory symptoms 3

2. Comprehensive evaluation:

   • Evaluate for potential triggers or underlying conditions
   • Consider the possibility of central sensitization contributing to symptoms 4

Special Considerations

• Monitoring for biphasic reactions: While primarily applicable to anaphylaxis, the concept of symptom recurrence should be considered, especially if previous episodes have shown a pattern of waxing and waning 5

• Risk factors for prolonged episodes:

  • History of multiple previous episodes 6
  • Comorbid chronic stress 7
  • Extreme defensive high anxious personality type 4

• Warning signs requiring immediate attention:

  • Development of respiratory symptoms
  • Cardiovascular changes (significant changes in blood pressure or heart rate)
  • Rapid progression of symptoms 1

Follow-up

• Schedule follow-up within 2-4 weeks to assess symptom progression
• Document episode characteristics to establish patterns for future management
• Consider preventive strategies if episodes become more frequent or severe

Conclusion

Given the patient's history of spontaneous resolution of similar episodes within weeks to months, a watchful waiting approach with supportive care is most appropriate initially. This approach minimizes unnecessary medication exposure while maintaining readiness to escalate treatment if symptoms persist or worsen.