A 60-year-old woman presents to the emergency department for severe anxiety for the past 3 days. She reports that the anxiety is persistent and started suddenly. She reports that she has been experiencing some additional stress at work recently, but primarily she has been having attacks where she feels breathless, perspires, and feels like she is going to die. She reports that she had an especially severe attack two days ago and since then she has been on edge and feeling anxious and out of breath. Vitals signs are significant for heart rate 115 beats/minute and oxygen saturation 91% on room air. On physical examination, the patient is sitting on the exam table leaning forward with a straight back, with her legs hanging off the edge of the table and her arms resting on her thighs. Cardiac examination reveals tachycardia, but the physical examination is otherwise unremarkable.
B) Anxiety disorder due to another medical condition
In this clinical vignette, the patient meets the criteria for panic disorder; however, the patient presents with signs of hypoxia. Oxygen saturation is 91%, and tachycardia. She is in the tripod position which should be the first indication that there might be a respiratory issue. Before diagnosing an anxiety disorder, medical causes of anxiety must be ruled out. Hypoxia can present as anxiety.
Answer choice A: Acute stress disorder, is incorrect. Acute stress disorder is the development of specific fear behaviors that last from 3 days to 1 month after a traumatic event. Such a history is not provided in this vignette.
Answer choice C: Borderline personality disorder, is incorrect. While there is not enough information in the vignette to rule out borderline personality disorder, it is not the primary presenting problem.
Answer choice D: Malingering, is incorrect. Malingering is pretending to have a condition for the purpose of gaining something. This patient has evidence of an underlying physiologic process that makes malingering unlikely. Malingering should be a diagnosis of exclusion.
Answer choice E: Panic disorder, is incorrect. The patient has symptoms consistent with panic disorder; however, the symptoms are a result of an underlying physical condition.
Key Learning Point
In anxiety disorder due to another medical condition, the patient displays evidence of anxiety (e.g., palpitations, sweating, dizziness, shortness of breath) though there is another medical condition present that underlies and leads to the anxiety.
