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Acute procedure anxiety in adults: Course, screening, assessment, and differential diagnosis Author Yujuan Choy, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2013. | This topic last updated: Set 30, 2013. INTRODUCTION Acute procedure anxiety is an excessive fear of medical, dental, or surgical procedures that results in acute distress or interference with completing necessary procedures. Patients may experience anxiety in anticipation of and/or during many types of procedures, including for screening (eg, mammography), diagnosis (eg, amniocentesis or endoscopy), and treatment (eg, angioplasty or open heart surgery). Specific phobias are a subset of the varied manifestations of acute procedure anxiety, diagnosed under DSM-5 criteria only when the patients fears are specific to the procedure and its immediate effects (eg, fear of suffocation during an MRI) rather than fears not specific to the procedure itself (eg, a fear of the underlying illness that might be diagnosed). Specific phobias related to clinical procedures include blood-injection-injury phobia, dental phobia, and MRI claustrophobia. This topic addresses the course, screening, assessment, and differential diagnosis of acute procedure anxiety in adults, related to common medical and surgical procedures. The topic includes specific phobias with anxiety related to clinical care. Specific phobias unrelated to clinical care are discussed separately. The epidemiology, clinical manifestations, and treatment of acute procedure anxiety are also discussed separately. (See "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis" and "Psychotherapy for specific phobia in adults" and "Pharmacotherapy for specific phobia in adults" and "Acute procedure anxiety in adults: Epidemiology and clinical presentation" and "Treatment of acute procedure anxiety in adults".) COURSE In most cases of acute procedure anxiety, the anxiety tends to peak prior to the procedure and decrease immediately after the procedure. This pattern has been observed in short, prospective studies of sigmoidoscopy screening for colorectal cancer [1], colposcopy [2], neurosurgery/brain biopsy [3], percutaneous coronary intervention (PTCA) [4], and cardiac surgery [5,6]. However, a study of PTCA that followed patients for a longer period of time after PCTA found anxiety level to be equally high six to eight months post-procedure [7]. The course of specific phobia is discussed separately. (See "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis", section on 'Course'.) SCREENING Given the prevalence of acute procedure anxiety in response to certain procedures (eg, dentistry, prenatal testing, MRI examinations, colposcopy, breast and prostate biopsy, cardiac surgery, and neurosurgery), it can be useful to routinely screen these patients during the pre-procedural workup. The role of screening for other procedures is less clearly established. Among the instruments available for screening patients for acute procedure anxiety, we find the following to provide the best balance of psychometric properties and burden. Dental anxiety The Dental Anxiety ScaleRevised (DAS-R), a brief, four-item patient self-administered questionnaire, is suggested for screening and measuring the severity of dental anxiety. The Dental Anxiety Scale has been shown to be a valid and highly reliability measure for dental anxiety [8]. A score of 13 or above constitutes a positive screen. A score of 15 or higher indicates a highly anxious patient. MRI claustrophobia The Claustrophobia Questionnaire, a 26-item patient self-administered questionnaire, measures fear of restriction and fear of suffocation in certain situations [9]. It is used in research, but is long for use in clinical practice. A six-question version, known as the Claustrophobia Miniscreen, is suggested for screening Section Editor Murray B Stein, MD, MPH Deputy Editor Richard Hermann, MD

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patients for MRI claustrophobia. A study of 80 adult MRI patients suggested that the six items can discriminate between patients who will and will not panic during an MRI scan [10]. A score of nine or above on the Miniscreen was highly predictive of panic during the scan. Further psychometric evaluation of the Miniscreen has not been conducted. IDENTIFICATION The presence of acute procedure anxiety can be identified by the following features: Excessive fear or anxiety about a procedure triggered by the thought of needing to undergo the procedure, by the need to attend an upcoming, scheduled procedure, or during the procedure. The elevated anxiety stems from concerns related to a clinical procedure. (See 'Focus of fear and anxiety' below.) The anxiety causes significant distress or avoidance of the procedure; avoidance includes delay in scheduling the procedure, early termination of the procedure, or the patients need for pre-medication in order to complete a procedure. Acute procedure anxiety is diagnosed as a specific phobia using DSM-5 criteria when the focus of the patients fear is specific to the procedure or its effects [11]. The diagnosis of a specific phobia is discussed in more detail separately. (See "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis", section on 'Diagnosis' and "Acute procedure anxiety in adults: Epidemiology and clinical presentation", section on 'Specific phobias'.) ASSESSMENT An assessment of a patient presenting with possible acute procedure anxiety should include: Focus of fear and anxiety The focus may be related to concerns about the potential risks and complications of the procedure; perceptions of pain and discomfort during the procedure; fears about implications and outcomes of the procedure; and/or uncertainty about illness and disability. (See "Acute procedure anxiety in adults: Epidemiology and clinical presentation", section on 'Clinical Manifestations'.) Understanding of procedure Patients may have an inaccurate perception of the risks, complications, pain, and discomfort associated with a procedure or preconceived negative notions of the procedure. Severity Determine the severity of anxiety (mild, moderate, severe) and the extent of avoidance behavior. Avoidance behavior can be manifested by avoidance of doctors appointments, delay in scheduling the procedure, missed appointment during the procedure day, or avoidance of follow-up of test results. (See 'Screening' above.) Past experience with procedure Past experience with a procedure may lead to lower [12-15] or higher [12,16] levels of anxiety when the patient undergoes the procedure again. Familiarity with a procedure may alleviate unwarranted fears about the pain or discomfort caused by the procedure. Increased fear upon repeating the procedure may be due to concerns about progression of the underlying illness, such as in a study of patients undergoing coronary angioplasty [16]. A past negative experience with a procedure can increase anxiety in patients who are repeating the procedure, as seen in patients undergoing gynecological exams [12]. History of acute procedure anxiety If the patient has previously experienced acute procedure anxiety, the clinician should inquire about previous coping strategies or past treatment. History of specific fears The clinician should ask whether the patient has previously experienced specific fears, in particular, fear of seeing blood, fear of injections, fear of dental treatments, and fear of being in small spaces. The patient should be asked about associated fainting if he or she has a history of blood-injection-injury phobia. Comorbid anxiety disorders Patients with a history of other anxiety disorders, such as generalized anxiety disorder, may be particularly vulnerable to the development of acute procedure anxiety. (See "Generalized anxiety disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Panic disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Obsessivecompulsive disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis" and "Specific phobia in adults: Epidemiology, clinical manifestations, course and diagnosis" and "Agoraphobia in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis".)

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Differential diagnosis Acute procedure anxiety should be differentiated from other mental disorders characterized by anxiety and avoidance of particular situations, or from a general medical condition in cases of fainting or panic attacks. Generalized anxiety disorder Generalized anxiety disorder (GAD) is characterized by excessive worries about a number of different areas that may include health or treatment-related concerns, but anxiety is not limited to worries about a specific procedure. GAD is also a chronic condition, whereas acute procedure anxiety is more acute and circumscribed. (See "Generalized anxiety disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".) Agoraphobia Agoraphobia is characterized by anxiety and avoidance of places and situations from which escape is difficult or embarrassing in the event of a panic attack. The focus of fear in agoraphobia is fear of losing control and consequences of having a panic attack. It is not about harm caused by the phobic situation or fear of suffocation or confinement as in MRI claustrophobia. An agoraphobia diagnosis requires anxiety and avoidance of multiple situations, rather than one type of situation, such as an enclosed space. (See "Agoraphobia in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis".) Panic disorder Patients with panic disorder may have a panic attack while undergoing a clinical procedure. However, in panic disorder, the focus of fear is the fear of the panic attack itself and concerns about the consequence or implication of a panic attack. Fear is not focused on aspects of the procedure, as in acute procedure anxiety. (See "Panic disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis".) Adjustment disorder with anxious mood Patients undergoing an extensive clinical evaluation for a severe medical illness may be anxious during a medical procedure. However, the anxiety experienced during the procedure is in response to the stressor illness and not limited to aspects of the procedure. General medical conditions In patients who faint during a medical procedure that involves exposure to injections or blood, it would be important to rule out underlying medical conditions before diagnosing a bloodinjection-injury phobia. Some causes of fainting can be readily identified with a brief history, such as: A vasovagal response Dehydration Hypoglycemia Orthostatic hypotension secondary to medication side effects A cardiac and neurological workup for syncope is recommended to rule out more severe medical conditions, such as a prolonged QT syndrome (eg, in a young patient with EKG abnormality), pre-existing cardiac diseases, CNS tumors, primary brain cancer, metastatic disease to the brain or a subdural hematoma (particularly in the elderly patient). The medical evaluation of syncope is described separately. (See "Evaluation of syncope in adults", section on 'Initial evaluation'.) In patients who experience an unexpected panic attack (especially associated with shortness of breath, palpitations, and chest discomfort) during an invasive procedure that may potentially compromise the cardiac or respiratory system, a medical work-up for an acute cardiac or respiratory condition should be completed before attributing the panic attack to acute procedure anxiety. Cardiac conditions that may present with panic-like symptoms include acute coronary syndrome or arrhythmia; respiratory conditions include pulmonary embolism (including air embolism), pneumothorax, or hemothorax. Air embolism to the lungs should be considered in any procedure that involves injections or central venous catheter placement. The evaluation for general medical conditions that may mimic a panic attack is described separately. (See "Panic disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis", section on 'General medical conditions'.) SUMMARY AND RECOMMENDATIONS Acute procedure anxiety is an excessive fear of medical, dental or surgical procedures, in anticipation of or during the procedure that results in acute stress or avoidance. (See 'Identification' above.) Acute procedure anxiety is diagnosed as a specific phobia using DSM-5 criteria when the focus of the

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patients fear is specific to the procedure or its effects. In most cases of acute procedure anxiety, the anxiety tends to peak prior to the procedure and decrease immediately after the procedure. (See 'Course' above.) Given the prevalence of acute procedure anxiety in response to certain procedures (eg, dentistry, prenatal testing, MRI examinations, colposcopy, breast and prostate biopsy, cardiac surgery, and neurosurgery), it can be useful to routinely screen these patients during the pre-procedural workup. (See 'Screening' above.) Screening instruments useful for specific phobias pertaining to procedures include the Dental Anxiety Scale Revised and the Claustrophobia Miniscreen. (See 'Screening' above.) Assessment of the patient with acute procedure anxiety includes: (See 'Assessment' above.) Identifying the focus of fear and anxiety Determining the severity of anxiety and the extent of avoidant behavior Assessing the patients understanding of the procedure Obtaining a history of prior procedure anxiety, specific phobias, or other anxiety disorders The differential diagnosis of acute procedure anxiety includes general anxiety disorder, agoraphobia, panic disorder, adjustment disorder with anxious features, and general medical conditions (eg, fainting secondary to dehydration). (See 'Differential diagnosis' above.) Use of UpToDate is subject to the Subscription and License Agreement. Topic 17123 Version 4.0

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