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Fear—a universal response to a perceived threat-prepares one to run away or do battle. At times, this response is maladaptive. Anxiety occurs when mental and physical manifestations of fear develop but serve no purpose, leaving the patient in a state of tension and dread. Because physical symptoms typically accompany anxiety, it is among the most common psychiatric conditions you will see in the emergency setting. This chapter reviews organic anxiety syndrome, panic disorder, generalized anxiety, and anxiety disorders with special symptoms, such as phobias, obsessions, compulsions, and posttraumatic stress disorder.
Anxiety is a mental and physical condition, with major symptoms resulting from stimulation of the autonomic nervous system. The clinician must rule out organic anxiety syndrome before any other anxiety disorder can be diagnosed. In the emergency setting, the differential diagnosis is a routine procedure, although the extent of the examination varies with the clinician's index of suspicion.
Suspect organic anxiety syndrome if the patient has prominent. recurrent panic attacks or generalized anxiety; if the patient's history, physical examination, or laboratory tests indicate a specific organic cause; or if anxiety does not occur exclusively during the course of delirium (DSM-III-R, 1987). Organic anxiety syndrome is also likely if the patient is older than age 40 and has no previous psychiatric history, has few psychosocial stressors, abuses alcohol or drugs, or has symptoms that began in response to an illness or medical treatment.
In addition to asking questions about psychosocial stressors and the current illness, focus on the patient's medical history (especially for endocrine disease). Determine if the patient is taking prescribed medication (bronchodilators, stimulants, decongestants. psychotropics, or steroids) or over-the-counter drugs (cold capsules, appetite suppressants, or nasal sprays). Also inquire about the patients caffeine intake and use of illegal drugs, especially amphetamines. cocaine, and cannabis.
A patient with organic anxiety syndrome experiences a sense of dread that is not connected to a life event. Some patients begin to avoid situations in which their anxiety could be discovered.
Key findings include mild hypertension and tachycardia, sweating. restlessness, muscle tension, and tremor.
Measure any prescription drug blood levels, and obtain blood and urine screens for drugs of abuse, especially cocaine and other stimulants.
The clinician's first task when evaluating an anxious patient is to rule out medical causes of the anxiety (see Medical disorders associated with anxiety). Organic anxiety syndrome can also be traced to the patient's use of prescribed medication, including antidepressants, antipsychotics, benzodiazepines, lithium carbonate (Eska-lith), aminophylline (Phyllocontin), theophylline (Slo-Phyllin), steroids, sympathomimetics, antiarrhythmics, digoxin (Lanoxin). beta-blockers, reserpine (Serpasil), anabolic steroids, anticholinergics, stimulants, appetite suppressants, isoniazid (Laniazid). nasal decongestants, and salicylates. In some cases, the patient's anxiety's may arise from abuse of certain substances, including cannabis (especially high-potency forms), cocaine (especially freebased forms or "crack"), amphetamines, volatile solvents, hallucinogens (especially phencyclidine), sympathomimetic agents, over-the-counter cold remedies, and alcohol.
| Medical Disorders Associated with Anxiety | |
| Gastrointestinal system | |
| · | Colitis |
| · | Crohn's disease |
| · | Irritable bowel syndrome |
| · | Peptic ulcer disease |
| Cardiovascular system | |
| · | Cardiac arrhythmias |
| · | Cardiomyopathies |
| · | Congestive heart failure |
| · | Coronary insufficiency |
| · | Mitral valve prolapse |
| · | Postmyocardial infarction |
| Respiratory system | |
| · | Asthma |
| · | Chronic obstructive pulmonary disease |
| · | Hyperventilation syndrome |
| · | Pneumothorax |
| · | Pulmonary edema |
| · | Pulmonary embolism |
| Neurologic system | |
| · | Acquired immunodeficiency syndrome |
| · | Dementia and delirium |
| · | Epilepsy |
| · | Essential tremor |
| · | Huntington's disease |
| · | Multiple sclerosis |
| · | Parkinson's disease |
| · | Vestibular dysfunction |
| · | Wilson's disease |
| Endocrine system | |
| · | Adrenal insufficiency |
| · | Carcinoid syndrome |
| · | Cushing's syndrome |
| · | Hyperparathyroidism |
| · | Hyperthyroidism |
| · | Hypoglycemia |
| · | Hypothyroidism |
| · | Hypokalemia |
Discuss with the patient the nature of his symptoms, and reassure him that they will subside once the underlying medical cause is treated. A psychodynamic or cognitive-behavioral approach is not a component of the interpersonal intervention for a patient with organic anxiety syndrome.
The clinician should consider pharmacologic intervention for a patient in need of immediate relief from anxiety symptoms or insomnia. However, be cautious when prescribing benzodiazepines for known or suspected drug or alcohol abusers. Substance abusers may enter the emergency department (ED) with complaints of anxiety but have a concealed history of benzodiazepine abuse.
If the suspected or known cause of organic anxiety syndrome can be controlled by the patient (for example, by reducing or eliminating caffeine intake), direct educational efforts accordingly. For instance, provide dietary advice or instruct the patient to consult with his primary care physician. Direct compulsive drug users to self-help groups or rehabilitation programs. In addition, because many patients with organic anxiety believe they have a mental disorder, help them to develop a more realistic view of their illness. Tell them that a chemical imbalance has fooled the brain into sensing danger and that this feeling will pass once the imbalance has reversed.
Because a medical illness may be causing the patient's anxiety, refer the patient to a primary care physician for further evaluation and treatment rather than to a nonmedical therapist. If the anxiety is caused by drug abuse, firmly recommend that the patient enter a drug detoxification or rehabilitation program.
Panic disorder is a psychiatric illness that can create a subjective sense of emergency for the patient, whose chief complaint may be a "panic attack" or a "heart attack" or feelings of "losing control" or "going crazy." Because serious medical conditions arc associated with anxiety and panic disorder, any new patient should receive a thorough physical examination to rule out organic anxiety syndrome (Raj and Sheehan, 1988).
Menial status findings include depersonalization and a fear of dying or of going crazy. Many patients with panic disorder report an overwhelming need to feel safe and try to avoid places or situations they deem unsafe.
Physical findings include mildly elevated pulse rate and blood pressure; dilated pupils; rapid, shallow breathing; sweating; shortness of breath; chest discomfort; light-headedness; urinary urgency: nausea; diarrhea; and hot flashes or chills. In addition, the patient's history reveals no major psychosocial stressors and no known organic basis for the disorder.
Although most signs and symptoms of panic disorder arc physical, medical tests tend to be negative. As a result, an unknowing clinician may dismiss the patient's complaints. Be alert for patients whose chief complaint is a cardiac, gastrointestinal, or neurologic problem, with anxiety as a secondary problem. The clinician can easily misdiagnose the condition, especially if the patient abuses alcohol to escape the anxiety and the clinician fails to recognize the abuse as self-medication (Weiss, 1988).
After ruling out myocardial infarction, pulmonary embolism, and other life-threatening conditions, the clinician then orders a drug screen. Organic anxiety syndrome is sometimes caused by druginduced anxiety and panic states. Treatment for such conditions is obviously different from that for panic disorder alone. Laboratory evaluation should also include blood levels of prescription and nonprescription drugs. For asthmatic patients, serum levels ofmethylxanthines and sympathomimetic bronchodilators should be measured.
The physical symptoms of panic disorder overlap with several common medical conditions-organic anxiety syndrome, atypical angina or arrhythmia, pulmonary embolism, hypoglycemia, and complex partial epilepsy (Raj and Sheehan, 1988). No standard protocol is followed when evaluating patients with acute anxiety: the clinician is guided by experience and intuition.
The clinician must rule out several other psychiatric conditions when making the differential diagnosis for panic disorder. These conditions include generalized anxiety disorder, adjustment disorder with acute anxiety, post-traumatic stress disorder, major depressive disorder with agitation, somatoform disorders, psychotic disorders, confusional state (typically with dementia), and factitious disorder or compensation neurosis (see DSM-III-R for more detailed information on these disorders).
Because the clinician does not usually encounter the patient during a panic attack, medication is not the first consideration. And because the panic attack lasts minutes, whereas medications may take a half hour to work, the clinician should not prescribe medication to "catch up" with panic attacks.
Because of the bewildering array of symptoms in panic disorder, the patient needs support in starting treatment. Reassure the patient that he is not "going crazy." Allow him opportunities to express fear and confusion. The patient must understand that panic disorder is a real illness that responds to treatment. Although the patient should be encouraged to enter therapy, help him to realize that much effort will be needed for a successful outcome.
For a patient who has just had a panic attack and remains fearful and autonomically overaroused, consider prescribing an antianxiety medication. Benzodiazepines are the drugs of choice for such patients. Diazepam (Valium), the best orally absorbed and most rapidly acting benzodiazepine, should be given in oral doses of 5 to 10 mg. Do not administer diazepam IX, which is a slower route: oral diazepam is effective within 30 minutes.
Although some clinicians routinely prescribe alprazolam (Xanax) as needed for patients with panic disorder, both patient-administered and as-needed doses of alprazolam should be discouraged. The antipanic use of alprazolam requires regular dosing to produce sustained blood levels and must be closely supervised. Alprazolam is usually started at 0.5 mg three times daily. A lasting antipanic effect may require larger doses, prescribed during outpatient treatment.
Before discharging the patient, teach him about the illness and its treatment. Explain that although panic disorder is a mental illness, the patient is not "going crazy." Discuss progression of physical and mental symptoms to help the patient understand his behavior (for example, "Given your illness, your behavior is perfectly natural. Now you can do something about it."). The patient should realize that panic disorder does not resolve spontaneously and that he needs treatment, including psychiatric care. Reassure him that medical and psychological treatments can be highly successsful.
In some cases, the patient may suffer from shortness of breath. Because of the resulting hyperventilation, typical symptoms accompanying respiratory alkalosis-air hunger, light-headedness, par-esthesias, carpal spasm, or even loss of consciousness—may occur. Education is the most important emergency intervention for hyperventilation. Try to bring its symptoms within the patient's control by having him hyperventilate for a minute or two to replicate the symptoms and then coaching him to slow down the breathing pace or to rebreathe using a bag (the rebreathing maneuver reverses the symptoms of alkalosis). Patients are greatly relieved to learn that symptoms are not part of a life-threatening disorder. Teach the patient to control breathing by mentally counting to 12 before exhaling or by carrying a paper or plastic bag for rebreathing.
The patient with panic disorder must understand that ongoing professional care is necessary. Successful therapy entails blocking the attacks, reducing anticipatory anxiety and irrational fears, and dealing with secondary problems (such as interpersonal or occupational difficulties or substance abuse). Therapy may take several months, and the patient must be discouraged from expecting a quick solution. Refer the patient to a psychiatrist skilled in treating panic disorder.
Generalized anxiety disorder (formerly called free-floating anxiety:. is characterized by excessive worry and physical symptoms without a perceived stimulus. The illness is usually not a psychiatric emergency, and most patients seek treatment from primary care physicians. A psychiatric emergency can arise, however, if the patient waits until anxiety is unbearable before seeking treatment. Even moderate anxiety can be debilitating and lead to secondary psychosocial, occupational, and medical problems. The varied symptoms of generalized anxiety can occur in any combination. To be diagnosed with generalized anxiety disorder, a patient must have symptoms for 6 months or more.
Mental status findings include poor concentration, irritability, and edginess.
Physical findings include trembling, twitching, or shakiness; muscle tension, aches, or soreness; restlessness; fatigue; shortness of breath; palpitations or tachycardia; sweating or cold, clammy hands: dry mouth; dizziness or light-headedness; nausea, diarrhea, or other GI distress; hot flashes or chills; frequent urination; difficulty swallowing; exaggerated startle response; and difficulty falling asleep or staying asleep.
A drug screen can be helpful in diagnosis and in ruling out benzodiazepine abuse. Otherwise, unless the clinician suspects an underlying medical illness, diagnostic tests are usually left to the patient's primary care physician.
Rule out organic anxiety syndrome (for instance, from cocaine use). Also remember that patients with panic disorder can develop generalized symptoms during their illness.
The patient with generalized anxiety disorder develops a set of maladaptive thoughts that correspond to anxious feelings. These thoughts, in turn, perpetuate the anxiety, color the patient's view of the world, and create self-fulfilling failures. For example, the patient may think, "I have no control" or "The world is a dangerous place" or "Everything scares me." To help the patient surmount these problems, the clinician should begin cognitive intervention. McMullin (1986) offers this series of questions to ask the patient in crisis, called brief cognitive restructuring:
Benzodiazepines are standard drug therapy for anxiety in psychiatric emergency patients. All benzodiazepines are effective sedatives; selection of a particular drug depends on its anticipated onset and duration of action. For instance, diazepam is the most rapidly acting oral agent; lorazepam (Ativan) is most rapidly absorbed intramuscularly and is not associated with paradoxical disinhibition; oxazepam (Serax) produces little euphoria and is rarely abused; and clorazepate (Tranxene) has a very long-acting active metabolite and can be given only once or twice daily. Three of the benzodiazepines-oxazepam, lorazepam, and temazepam (Restoril)-do not require extensive metabolism by liver enzymes, which makes them safer for use in patients with liver disease.
Because parenteral administration of antianxiety drugs is not recommended, prescribe an oral agent. Most patients become calm within 30 to 60 minutes of receiving the medication. Many patients experience a transitory euphoria after taking a benzodiazepine. especially diazepam. Such euphoria can lead to a psychological dependence that interferes with the patient's stopping the drug later in therapy.
Although benzodiazepines are safe and effective, warn the patient about possible adverse effects, including daytime drowsiness, psychomotor impairment (ataxia), cognitive impairment (mental dullness), paradoxical disinhibition, and euphoria leading to abuse.
In addition, the patient may become tolerant to or dependent on the medication, and discontinuing the drug may cause withdrawal symptoms. The clinician must also be aware of possible drug interactions. The combination of a benzodiazepine and ethanol can cause potentiation and disinhibition; a benzodiazepine combined with any depressant drug can cause oversedation, a serious concern because it can lead to falls or automobile accidents.
If the patient with generalized anxiety abuses alcohol or drugs. benzodiazepines may be more of a liability than an asset because of cross-addiction. For such patients, the clinician should prescribe a suitable alternative medication, such as buspirone (BuSpar).
With the exception of buspirone and possibly antihistamines. other psychotropic agents (such as antipsychotics and antidepressants) are not recommended for treatment of generalized anxiety. especially in psychiatric emergency patients. Older agents, such as barbiturates and meprobamate (Equanil), have been replaced by benzodiazepines and should not be prescribed for new patients. Buspirone, a relatively new compound from the chemical class of azapirones, can be used to treat generalized anxiety. This agent is not a benzodiazepine, a sedative, or a controlled substance. Its lack of an immediately perceived effect makes buspirone questionable as an emergency drug. The ideal candidate for buspirone therapy is the patient with long-standing anxiety who does not require asneeded medication and who is willing to delay symptom relief for the week or more required for the drug to take effect. In this way, the patient can avoid the drug's side effects. The dosage of buspirone is 5 mg three times daily for the first week and 10 mg three times daily for the second through fourth weeks. After that, the dosage is increased gradually to 60 mg daily, if needed. Encourage the patient to follow up with outpatient medication supervision, psychotherapy, and other appropriate life-style changes. Buspirone is not the treatment of choice for the patient who needs medication for insomnia or immediate relief from anxiety. Short-term management of insomnia and anxiety can be accomplished with a benzodiazepine or a sedating antihistamine, such as diphenhydramine (Benadryl). Avoid prescribing controlled substances for known or suspected alcohol or drug abusers.
The purpose of the emergency visit is not only to relieve anxiety but also to educate and direct the patient toward definitive treatment so that crisis intervention is no longer necessary. Inform the patient that medication, if used, will not be effective on an as-needed basis and that regular dosing with a benzodiazepine or buspirone is required for an anxiety-blocking effect. Encourage the patient to avoid alcohol, caffeine, stimulants, appetite suppressants, tobacco products, and all illicit drugs because these substances can exacerbate anxiety. Because anxiety is accompanied by negative thoughts and other problems in living, suggest psychotherapy, even if the patient is taking medication,
Before discharging the patient, reassure him that generalized anxiety disorder is not life-threatening, and refer him to a psychiatrist for follow-up care. Various treatment options include drug therapy with buspirone or a benzodiazepine, psychotherapy, cognitive therapy, and behavior therapy. The clinician need not determine the appropriate therapy at the time of the emergency visit. If the discharge plan includes a prescription for a benzodiazepine, never give the patient more than a 3-day supply. Advise the patient that successful treatment requires an ongoing commitment and regular psychiatric visits - not simply waiting until anxiety is severe enough to make an emergency visit.
Other symptoms that reflect anxiety include phobias (irrational fear and avoidance), obsessions (intrusive, anxiety-producing thoughts), compulsions (repetitive, unwanted behaviors) and post-traumatic stress disorder (PTSD—intrusive reminiscences).
Transient or persistent irrational fear and avoidance is common in adults and normal in children to a degree (Marks, 1987). People with phobias can live comfortably, as long as they avoid the feared object. Phobias are classified as simple, social, and agoraphobia (DSM-III-R, 1987). Simple phobias include fear of animals (snakes, dogs, insects), blood or injury, dental work, eating (fear of gagging). flying in airplanes, heights, thunderstorms, and enclosed space? Common social phobias include looking foolish, ridiculous, or ignorant; eating and drinking in public; speaking to persons in authority; blushing, sweating, fainting, or vomiting in front of other people; writing (fear of the hand shaking); and being criticized. Agoraphobia is the avoidance pattern associated with panic disorder: that is, avoiding places that the patient associates with a panic attack
Obsessions and compulsions — unwanted and intrusive thoughts and behaviors-are distressing to the patient and may warrant a visit to the ED. Obsessive thoughts may relate to contaminating others or being contaminated, harming others (for instance, killing an infant), swearing, or being sexually promiscuous. Patients who suffer from compulsions may feel abnormally compelled to clean themselves or objects, repeat words or numbers, check things (especially locks), hoard trash or useless articles, or maintain orderliness by arranging objects. Intensity of symptoms can be so severe that the clinician may suspect a psychosis. Subjectively, the patient feels on the verge of "going crazy" from lack of control over thoughts and deeds. Objectively, the patient may be markedly incapacitated by obsessive thoughts or compulsive acts.
PTSD can develop in victims of traumatic situations-an automobile accident (with or without physical injury), assault and battery, rape, combat, internment in a prisoner-of-war or concentration camp, or severe or protracted illness. Post-traumatic stress symptoms are commonly florid, severe, and disabling. The patient may or may not show immediate distress but will describe an inability to "feel" things (psychic numbing), vivid nightmares, fear of going to sleep, and a startle response to noise. The patient may also experience flashbacks of the traumatic event (which can be dramatic enough to suggest a departure from reality) and may try to avoid reminders of the trauma. During the course of PTSD, which can last for years, the patient may be so disturbed (or family members so disturbed by the patient's behavior) that psychiatric emergency care is needed.
A phobic patient clearly states his fear; for instance, "You're going to think I'm crazy, but I'm afraid of...." An agoraphobic patient describes symptoms of panic disorder. An obsessive-compulsive patient describes intrusive, unpleasant ideas and irresistible behaviors designed to make the thoughts go away. A patient with PTSD clearly relates symptoms to the original traumatic event.
A patient with compulsive hand washing may show evidence of skin injury. A patient with compulsive hair pulling (trichotillomania) may have spotty baldness.
Order appropriate studies if you suspect organic anxiety syndrome.
The primary differential diagnoses are psychosis and organic menial disorders. A patient with schizophrenia may display social avoidance and excessive tearfulness similar to phobic behavior. A psychotic patient may behave idiosyncratically, with auditory hallucinations and strange, ritualistic behavior reminiscent of obsessive-compulsive symptoms. Repetitive and seemingly compulsive behavior is also a characteristic of the chronic amphetamine abuser. Other differential diagnoses include those for phobias (avoidant personality, schizoid or schizotypal personality, schizophrenia, transitorv childhood symptoms, normal fear, chronic drug or alcohol abuse, body dysmorphic disorder, and anorexia nervosa), PTSD (dream anxiety and, with accident victims, malingering), and obsessive compulsive behavior (transitory childhood symptoms, compulsive personality, amphetamine abuse, and culturally sanctioned ritual)
To calm the patient, the clinician can use a brief psychotherapy format. Take the patient's complaint seriously, but remind him that his symptoms will not lead to "insanity." Have the patient or a family member carefully recount the history of the problem. This history provides information for a psychosocial formulation, aids in making the differential diagnosis, and allows the patient to express anxious feelings, especially the fear of losing control (Walker, 1983). Anxiety in a phobic patient may or may not be precipitated by an obvious psychosocial stressor. Although phobias may have uncertain causes, reassure the patient that his symptoms can readily respond to behavior therapy.
An obsessive-compulsive patient is difficult to manage, either in an emergency or outpatient setting. Research in obsessive-compulsive disorder suggests that it is a biologically based illness resistant to standard interpersonal intervention. Nevertheless, tell the patient that behavior therapy and pharmacotherapy are promising treatments.
A patient with PTSD can benefit greatly from the opportunity to talk about his experiences, although an open discussion of feelings is not necessarily as healing as time itself. Many PTSD patients feel responsible for their trauma, although few contribute to the problem. Interpreting PTSD as a defense against rage must be done with caution and probably should be left to a psychotherapist, to whom the patient should be referred.
Use medications sparingly, for several reasons: a definitive treatment is beyond the scope of the emergency setting, the patient should not leave with the impression that drug therapy is a complete treatment, antianxiety medications can block the patient's ability to express feelings, and abuse of and dependence on antianxiety medications can complicate therapy.
The clinician should avoid administering medication to phobic patients, except for those with agoraphobia secondary to panic disorder. A patient with social phobia may request help for a fear of public speaking or flying. For such patients, but not necessarily for those with phobic anxiety in general, a 10- to 20-mg dose of propranolol (Inderal) 1 hour before the feared event will reduce anxiety symptoms. Beta blockers have little long-term usefulness in treating phobia (Gorman, 1989).
A patient with sleep complaints associated with PTSD may require a sedative, such as flurazepam (Dalmane) 15 to 30 mg at bedtime, for no more than 3 days. The definitive drug therapy of PTSD is not established and should not be attempted. Suspect drug abuse in any patient claiming PTSD symptoms who asks for a specific controlled drug (such as diazepam), and alert the patients scribing physician. Some PTSD patients enter the ED after taking antipsychotic or antidepressant medication. Before continuing such treatments, attempt to contact the prescribing physician for verification.
The most promising drugs for obsessive-compulsive disorder are antidepressants that block serotonin re-uptake, such as clomipramine (Anafranil) and fluoxetine (Prozac). However, these drug? take several weeks to exert their effect on compulsive behavior and should be used only under the supervision of a psychiatrist involved in the patient's ongoing care, thus ruling out their use in the emergency setting. For an acutely anxious obsessional patient, consider a benzodiazepine, such as lorazepam 1 to 2 mg up to 4 times daily. Some patients respond better to antipsychotic medication, which the clinician should continue cautiously.
Patient teaching entails discussing the therapeutic options available outside the emergency setting, including pharmacotherapy, psychotherapy, and behavior therapy. Additionally, reassure the patient that anxiety does not lead to insanity and that unrealistic fears can be treated without an invasive intervention. Emphasize that phobias, obsessions, and compulsions need not dominate the patient's conscious life, and caution the patient to abstain from alcohol and illegal drugs, which can exacerbate anxiety symptoms.
Hospitalize a patient who exhibits suicidal ideation or behavior. abuses alcohol or drugs, displays evidence of an underlying psychotic illness, or participates in a medication trial with an experimental agent. Refer all other patients for outpatient treatment. Patients with simple and social phobias respond best to behavior therapy. Refer PTSD patients who are combat veterans to programs run by the Veterans Administration or related groups. Refer rape victims to an appropriate support group, such as Women Against Rape (see Chapter 12). Patients with obsessive-compulsive disorder can benefit from behavior therapy or a program that combines behavioral and pharmacologic approaches. For all patients, stress the need for expert intervention and their active participation in treatment.
Because organic anxiety can mimic common nervousness, a clinician can easily overlook the cause of a patient's complaint. Misdiagnosis or premature discharge can lead to increased morbidity and mortality. To avoid this situation, conduct a thorough examination of all patients.
Never prescribe a benzodiazepine or other controlled drug without determining that the patient needs the drug and will not misuse or abuse it. Document the reason for the prescription in the medical record. Be especially careful not to prematurely discharge a patient given a benzodiazepine because a disinhibition reaction could occur after the patient leaves. All patients who receive benzodiazepines should be observed for at least 2 hours after treatment and should not drive a vehicle for at least 24 hours because of possible psychomotor impairment.
Legal problems can result from errors of commission (prescribing an antidepressant for a suicidal patient, an amipsychotic for a patient with panic disorder, or a benzodiazepine for a drug or alcohol abuser) or omission (failing to detect a serious physical illness, suicidal ideation, or drug withdrawal or toxicity).
The diagnosis of PTSD has been widely used (and probably overused) in the civil courts by plaintiffs' attorneys when attempting to demonstrate psychic injuries after an accident. Sometimes the attorney suggests that the client be examined by a psychiatrist to build a case for PTSD. The clinician may see mild symptoms but not at the level of PTSD. When a patient exaggerates or fabricates post-traumatic symptoms to help the legal case, the clinician must recognize that the patient is malingering, key indicators for which are listed here:
If you suspect malingering, consider charting "atypical anxiety" or "impression deferred" rather than allow yourself to be intimidated into a premature diagnosis.