Substance/Medication-Induced Anxiety Disorder

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.

  • The estimated 12-month prevalence is 0.002%, but its prevalence is likely much, much higher.[1]
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):

  1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication
  2. 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.

Note: Tobacco is not listed as a substance that can cause an anxiety disorder in the DSM-5.

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):
  1. Sweating
  2. Trembling or shaking
  3. Unsteady, dizziness, light-headed, or faint
  4. Derealization (feelings of unreality) or depersonalization (being detached from one self)
  5. Excessive/accelerated heart rate, palpitations, or pounding heart
  6. Nausea or abdominal distress
  7. Tingling, numbness, parathesesias
  8. Shortness of breath
  9. Fear of losing control or “going crazy”
  10. Fear of dying
  11. Choking feelings
  12. Chest pain or discomfort
  13. Chills or heat sensations
Note: The symptoms presented in this specifier are for the purpose of identifying a panic attack. However, panic attacks are not a mental disorder. Panic attacks can occur in the context of any anxiety disorder as well as other mental disorders (e.g. - depressive disorders, posttraumatic stress disorder, substance use disorders) and some medical conditions (e.g. - cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is identified, it should be noted as a specifier (e.g. - “social anxiety disorder with panic attacks”). For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier.
Note: Culture-specific symptoms (e.g. - tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.
  • 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)
  • 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.
  • 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.