3-5
Thought content—not delusional, may have hopelessness and dread that gives rise to suicidal ideation.
Obsessions (recurring irresistible thoughts or feelings that cannot be eliminated by logical effort) may be
present.
Thought processes—usually logical, linear and goal directed; may perseverate (go over and over) on one
idea or theme
Mood—generally miserable, worried, or sad
Affect—often anxious, but if describing panic attacks, may appear normal.
Cognition—intact, though present anxiety may slow cognition or responsiveness
Insight—variable; may be poor to good
Assessment:
Differential Diagnosis - Always maintain a high index of suspicion for a physical or CNS injury!
Occult injuryà a hypotensive or hypoxic service member will appear anxious! DO NOT MISS THESE!
Substance Withdrawal - patients in early alcohol withdrawal look anxious. (see Mental Health chapter)
Hyperthyroidism - see Endocrine Chapter.
Combat or Operational Stress Reaction - see Mental Health chapter
Battle Fatigue - see Mental Health: Operational Stress
Mental Disorders associated with anxiety are:
Panic Disorder - discrete recurring episodes of sudden onset panic attacks
Phobias - specific fears, triggered by environmental stimuli, that are unreasonable under the circumstances
Generalized Anxiety Disorder - a pervasive, nearly constant and impairing sense of free-floating anxiety
Acute Stress Disorder - circumscribed period lasting 2+ days of anxious symptoms and unpleasant,
intrusive recollections of a recent unusual or traumatic event; occurring within 4 weeks of the event and
resolving within 4 weeks of onset.
Post Traumatic Stress Disorder - chronic symptoms of anxiety with recurring, unpleasant, intrusive recol
lections of a past unusual or traumatic event, beginning anywhere from immediately following the event
to years later.
Plan:
Primary Treatment - Basic
Symptomatic relief through rest, reassurance.
Benzodiazepines (lorazepam mg po q 6-8 hours or diazepam 2-5 mg po q 8-12 hours as needed)
Relaxation exercise:
- Slow deep breathing—use a paper bag or simply work with patient to take slow deep breaths.
- Progressive muscle relaxation—focus on separate muscle groups (such as the balls of the feet) contract
them then relax slowly on the count of 5, move on to next muscle group - Visualization—encourage patient to visualize a relaxing setting like sitting on a beach or shing by a
cool stream.
Primary Treatment - Advanced
When available, consider initiation of denitive treatment with a Selective Serotonin Reuptake Inhibitor (SSRI),
starting with a low dose (1/2 therapeutic dose). (See Symptom: Depression)
Patient Education
General: Reassure patient that this condition is not life threatening, and he is not going crazy.
Activity: Normal. Try to keep on duty.
Diet: Avoid caffeine or other stimulants.
Prevention and Hygiene: Sleep, relaxation, stress management
Follow-up Actions
Return evaluation: Frequent, scheduled follow-ups as opposed to “come in as needed”, support and assist
patients with management of their anxiety.
Evacuation/Consultation Criteria: Most anxiety disorders do not need to be evacuated. Consult when there
is evidence of mild impairment in function that has not been responsive to rest and reassurance.