- Last edited on February 3, 2022
Substance/Medication-Induced Anxiety Disorder
Primer
Substance/medication-induced anxiety disorder is diagnosed after an individual uses a substance (e.g., a drug of abuse, a medication, or a toxin exposure) that leads to prominent symptoms of panic or anxiety.
Epidemiology
- The estimated 12-month prevalence is 0.002%, but its prevalence is likely much, much higher.[1]
DSM-5 Diagnostic Criteria
Criterion A
Panic attacks or anxiety is predominant in the clinical picture.
Criterion B
There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):
- The symptoms in
Criterion A
developed during or soon after substance intoxication or withdrawal or after exposure to a medication - The involved substance/medication is capable of producing the symptoms in
Criterion A
Criterion C
The disturbance is not better explained by an anxiety disorder that is not substance/medication-induced. Such evidence of an independent anxiety disorder could include the following:
- The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g. - about
1
month) after the cessation of acute withdrawal or severe intoxication: or there is other evidence suggesting the existence of an independent non-substance/medication-induced anxiety disorder (e.g. - a history of recurrent non-substance/medication-related episodes).
Criterion D
The disturbance does not occur exclusively during the course of a delirium.
Criterion E
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specifiers
Specifiers
Specify the substance:
- Other (or unknown) substance
Onset Specifier
Specify if: (see Table 1 in the DSM-5 chapter “Substance-Related and Addictive Disorders” for diagnoses associated with substance class):
- With onset during intoxication: This specifier should be used if criteria are met for intoxication with the substance/medication and symptoms developed during the intoxication period.
- With onset during discontinuation/withdrawal: This specifier should be used if criteria are met for discontinuation/withdrawal from the substance/medication and symptoms developed during, or shortly after, discontinuation of the substance/medication.
- With onset after medication use: Symptoms may appear either at initiation of medication or after a modification or change in use.
Panic Attack Specifier
Specify if:
- Recurrent unexpected panic attacks. An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time at least
4
of the following symptoms occur (Note: The abrupt surge can occur from a calm state or an anxious state):
- Sweating
- Trembling or shaking
- Unsteady, dizziness, light-headed, or faint
- Derealization (feelings of unreality) or depersonalization (being detached from one self)
- Excessive/accelerated heart rate, palpitations, or pounding heart
- Nausea or abdominal distress
- Tingling, numbness, parathesesias
- Shortness of breath
- Fear of losing control or “going crazy”
- Fear of dying
- Choking feelings
- Chest pain or discomfort
- Chills or heat sensations
Substances/Medications
- Panic or anxiety can occur in association with intoxication with the following substances:
- Alcohol, caffeine, cannabis, phencyclidine, other hallucinogens, inhalants, and stimulants.
- Panic or anxiety can occur in association with withdrawal from the following classes of substances:
- Alcohol, opioids, sedatives, hypnotics, anxiolytics, stimulants (including cocaine)
- Medications that can cause anxiety symptoms include:
- Anesthetics, analgesics, sympathomimetics, bronchodilators (e.g. - theophylline), anticholinergics, insulin, thyroid replacement, oral contraceptives, antihistamines, antiparkinsonian medications, corticosteroids, antihypertensives, cardiovascular medications, anticonvulsants, lithium, antipsychotics, and antidepressants.
- Heavy metals and toxins can also cause panic or anxiety symptoms, including:
- Oganophosphate insecticide, nerve gases, carbon monoxide, carbon dioxide, and volatile substances (e.g. - gasoline, paint)
Differential Diagnosis
- Substance intoxication and substance withdrawal
- Anxiety symptoms are common in substance intoxication and substance withdrawal. For example, panic or anxiety symptoms are characteristic of alcohol withdrawal.
- Anxiety disorder (i.e. - not induced by a substance/medication)
- Substance/medication-induced anxiety disorder is different from a primary anxiety disorder based on the onset, course, and other factors with respect to substances/medications.
- For drugs of abuse, there must be evidence from the history, physical examination, or laboratory findings for use, intoxication, or withdrawal.
- A primary anxiety disorder diagnosis is warranted if the panic or anxiety symptoms persist for a substantial period of time (about 1 month or longer) after the end of the substance intoxication or acute withdrawal or there is a history of an anxiety disorder.
- Anxiety disorder due to another medical condition
- Features atypical of a primary anxiety disorder, such as unsual age at onset (e.g. - onset of panic disorder after age 45 years) or symptoms (e.g. - atypical panic attack symptoms such as true vertigo, loss of balance, loss of consciousness, loss of bladder control, headaches, slurred speech) may suggest a medical etiology.
-
- If panic or anxiety symptoms occur exclusively during the course of delirium, they are a feature of the delirium.
- Anxiety disorder due to another medical condition
- If the panic or anxiety symptoms are attributed to the physiological consequences of another medical condition (i.e. - rather than to the medication taken for the medical condition), anxiety disorder due to another medical condition should be diagnosed. The history often provides the basis for such a judgment. At times, a change in the treatment for the other medical condition (e.g. - medication substitution or discontinuation) may be needed to determine whether the medication is the causative agent.
Investigations
- Depending on the initial presenting symptoms (e.g. - dizziness, tachycardia), potential investigations can include: CBC, fasting glucose, fasting lipid profiles, electrolytes, liver enzymes, serum bilirubin, serum creatinine, urinalysis, urine toxicology for substance use, thyroid stimulating hormone (TSH).[2]
- Urine toxicology should also be done if warranted.[3]
- An ECG and beta-HCG should be ordered if relevant.