What are the medical causes of severe anxiety?

From the Guidelines

Severe anxiety can be caused by several medical conditions beyond primary anxiety disorders, including hyperthyroidism, heart conditions, respiratory conditions, neurological issues, endocrine disorders, and substance use, as noted in the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders 1. When evaluating severe anxiety, it is essential to consider these medical causes through appropriate testing, including blood work, imaging, and specialist consultation, before attributing symptoms solely to a psychiatric condition. Some of the medical conditions associated with anxiety include:

• Hyperthyroidism
• Heart conditions like arrhythmias or mitral valve prolapse
• Respiratory conditions such as asthma or COPD
• Neurological issues including seizure disorders, vestibular dysfunction, or early dementia
• Endocrine disorders like pheochromocytoma (adrenal tumor), Cushing's syndrome, or hypoglycemia
• Substance use, including caffeine, alcohol withdrawal, and recreational drugs
• Vitamin deficiencies, particularly B12 or folate The most recent guideline on management of anxiety and depression in adult survivors of cancer also recommends screening for anxiety and assessing for generalized anxiety disorder (GAD) using the GAD-7 scale 1. It is crucial to determine the associated home, relationship, social, or occupational impairments and the duration of anxiety-related symptoms. Referral to a psychiatrist, psychologist, or equivalently trained professional may be necessary for patients with moderate to severe or severe symptomatology. Medical and substance-induced causes of anxiety should be diagnosed and treated, and assessments should be a shared responsibility of the clinical team. The assessment should identify signs and symptoms of anxiety, severity of symptoms, possible stressors, risk factors, and times of vulnerability, and explore underlying problems/causes. A patient considered to have severe symptoms of anxiety should have confirmation of an anxiety disorder diagnosis before any treatment options are initiated. Overall, a comprehensive evaluation and appropriate testing are necessary to determine the underlying cause of severe anxiety and develop an effective treatment plan.

From the FDA Drug Label

Panic disorder (DSM-IV) is characterized by recurrent unexpected panic attacks, i.e., a discrete period of intense fear or discomfort in which four (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes: (1) palpitations, pounding heart, or accelerated heart rate; (2) sweating; (3) trembling or shaking; (4) sensations of shortness of breath or smothering; (5) feeling of choking; (6) chest pain or discomfort; (7) nausea or abdominal distress; (8) feeling dizzy, unsteady, lightheaded, or faint; (9) derealization (feelings of unreality) or depersonalization (being detached from oneself); (10) fear of losing control; (11) fear of dying; (12) paresthesias (numbness or tingling sensations); (13) chills or hot flushes

The medical causes of severe anxiety include panic disorder, which is characterized by recurrent unexpected panic attacks. These attacks are discrete periods of intense fear or discomfort that reach a peak within 10 minutes and are accompanied by symptoms such as palpitations, sweating, trembling, and sensations of shortness of breath or smothering 2.

• Panic disorder is a condition that is defined in the DSM-IV and is characterized by recurrent unexpected panic attacks.
• Severe anxiety can be a symptom of panic disorder, as well as other conditions such as posttraumatic stress disorder (PTSD) and premenstrual dysphoric disorder (PMDD).
• The symptoms of panic disorder include intense fear or discomfort, palpitations, sweating, trembling, and sensations of shortness of breath or smothering.

From the Research

Medical Causes of Severe Anxiety

• Anxiety disorders are the most common group of mental disorders, and they can be influenced by genetic factors, environmental factors, and their epigenetic relations 3
• Severe anxiety can be a symptom of various medical conditions, including endocrine disorders such as pheochromocytoma and hyperthyroidism 4, 5
• Pheochromocytoma is a rare neuroendocrine tumor that secretes high levels of catecholamines, which can cause serious metabolic and cardiovascular effects, including hypertension, tachycardia, and anxiety 5
• Catecholamines can also influence the extracellular matrix, leading to collagen deposition and subsequent fibrosis in the arterial wall and myocardium, which can contribute to cardiovascular complications 5
• Other medical conditions that can cause severe anxiety include cardiomyopathy, myocardial infarction, arrhythmias, and heart failure, which can be caused by pheochromocytoma or other conditions 6, 7
• Tachyarrhythmias, such as sinus tachycardia, atrial fibrillation, and ventricular tachycardia, can be caused by catecholamine excess in pheochromocytoma patients, and require special considerations for treatment and complication avoidance 7