7 Medical Illnesses That May Present as Anxiety

May 18, 2017

Yu Dong, MD, PhD, Fatima Noorani, MD, Rushi Vyas, MD, Chandrika Balgobin, DO, Vanessa Torres-Llenza, MD, Catherine Crone, MD

Beyond psychosocial implications of anxiety disorders, an array of physiological effects may ensue.

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Patients with anxiety disorders, such as generalized anxiety disorder (GAD), panic disorder, and phobias, as well as PTSD, report a higher rate of certain medical illnesses than are observed in the general population. Anxiety disorders are associated with an increased incidence of any number of medical illnesses, including those presented in this partial list.

Anxiety disorders are associated with an increased incidence of cardiovascular disease, frequent panic attacks, and worse cardiac outcomes. PTSD is linked to increased risk of cardiovascular disease, increased rates of re-hospitalization, and decreased adherence to treatment regimens. Cardiac illnesses such as angina, arrhythmias, cardiac tamponade, congestive heart failure (left sided), myocardial infarction, or valvular disease may present as anxiety.

Neuroendocrine systems can be affected by anxiety by creating excessive sympathetic activation and disruption of the hypothalamic-pituitary-adrenal axis-predisposing patients to increased health risks. Some medical disorders that may present as anxiety include Cushing disease, diabetes mellitus, parathyroid disease (hyperparathyroidism, pseudo-hyperparathyroidism), pancreatic tumors, pheochromocytoma, pituitary disease, and thyroid disease (hyperthyroidism, hypothyroidism, thyroiditis).

Patients with primary anxiety disorders are more likely to suffer from GI, respiratory, cardiac, and neurological disorders, even after adjusting for confounding factors such as sex, depression, and substance use disorders. Among patients with panic disorder, GAD, and PTSD, rates of irritable bowel syndrome are much higher than in those with no psychiatric diagnoses. GI issues might include gastroesophageal reflux disease, irritable bowel syndrome, peptic ulcer disease, and others.

Anxiety can create an alteration in inflammatory response. Polyarteritis nodosa, rheumatoid arthritis, systemic lupus erythematous, temporal arteritis, and other inflammatory conditions may present as anxiety.

Metabolic issues might include hyperkalemia, hyperthermia, hypoglycemia, hyponatremia, hypoxia, porphyria, or substance ingestion/overdose. Biologically, acute anxiety may be the first sign of exacerbation of an underlying illness, an undiagnosed medical condition, or substance intoxication or withdrawal. To aid in diagnosis, the patient examination includes a detailed history; focused physical examination; complete review of medications; collateral information; and diagnostic testing, such as toxicology screens.

Primary anxiety disorders, particularly panic disorder, can be comorbid with seizure disorder. Social anxiety disorder and panic attacks are often seen in patients with Parkinson disease [see reference 8 here]. Other illnesses, such as akathisia, cerebral trauma and/or post-concussive syndrome, cerebrovascular disease, cerebral syphilis, encephalopathy, Huntington disease, mass lesions, migraines, multiple sclerosis, seizure disorders, subarachnoid hemorrhage, vertigo, and others may present as anxiety.

Anxiety can be camouflaged as somatic symptoms to mimic a medical illness, especially in the primary care setting. Some of the somatic expressions of anxiety include tachycardia, palpitations, sweating, flushing, dry mouth, dizziness, tremor, muscle tension, headaches, and fatigue. These symptoms could present as a “false alarm” because of an underlying anxiety disorder or a somatoform disorder. Respiratory conditions that may present as anxiety might include asthma, chronic obstructive pulmonary disease, pneumothorax, pulmonary edema, pulmonary embolism, sleep apnea, obstructive/non-obstructive, and others.

Treatment modalities should be discussed with the patient to ensure autonomy, minimize the subjective feeling of losing control, increase adherence, and ultimately strengthen the therapeutic alliance. Collaboration with other treatment teams is essential in reducing health care utilization. For more information, see the Psychiatric Times article, Managing Anxiety in the Medically Ill, on which this slideshow is based. To view a PDF, of this slideshow, click here.