Unlocking Behaviors: Symptoms of Anxiety

Over the prior six months, Charlie's episodes have become more frequent.

By Ley Linder, MA, M. Ed, BCBA and Craig Escudé, MD, FAAFP, FAADM

This article is part of a co-authored series on behavioral presentations in which a physician and a behavior analyst provide insight into real-life case studies to share their expertise on how behavioral issues can be addressed in an interdisciplinary fashion. Dr. Escudé and Ley are recipients of the 2024 AADMD Excellence in IDD Journalism Award for this ongoing series. 

Charlie is a 64-year-old gentleman with a history of hypertension, Type 2 diabetes mellitus, severe intellectual disability, and anxiety. He lives in a group home with two other gentlemen and has around-the-clock support staff in the home. He doesn't use words to communicate, but he can often indicate his wants and needs through gestures or specific behaviors that people who know him understand. For example, when he wants something to drink, he touches his hands to his mouth or goes to the kitchen and looks for a glass.

Over the years, Charlie’s anxiety has manifested in different ways. When anxious, he often paces around the room, wringing his hands, and his respiratory rate increases. His anxiety is usually provoked by being in crowds of unfamiliar people and noisy areas. His anxiety causes some challenges for his support staff because his episodes can occur randomly and are often in public places such as a busy grocery store or a doctor’s waiting room. Some of his staff have begun to expect these actions and not let them interfere with whatever the task at hand is.

“Anxiety is a common problem that can be provoked by many different situations and events, or sometimes seemingly none at all. A change in someone’s anxiety symptoms and presentation can indicate something new is happening. It’s easy to overlook slight differences, but when a pattern of behaviors becomes evident, it should trigger another evaluation. ”

Over the prior six months, Charlie's episodes have become more frequent. His physician saw him, and his anxiety medication was increased, but it did not help. He began having anxiety symptoms when walking around the block for exercise, when watching television, and sometimes early in the morning before breakfast. He also seemed to have new symptoms associated with these episodes. Staff noted he was a little sweaty and scratching at his chest and neck. They checked it up to his worsening anxiety at first, but one morning, the nurse was there and witnessed one of the episodes. She felt it was more than anxiety and sent him to the emergency room for further evaluation.

Medical Discussion

Anxiety is a common problem that can be provoked by many different situations and events, or sometimes seemingly none at all. A change in someone’s anxiety symptoms and presentation can indicate something new is happening. It’s easy to overlook slight differences, but when a pattern of behaviors becomes evident, it should trigger another evaluation.

In Charlie’s case, the addition of being sweaty and scratching at his chest and neck were different, and the nurse recognized that these could be symptoms of something more serious: cardiac chest pain.

Angina, or cardiac-related chest pain, can look like an anxiety attack, especially when someone cannot verbally tell others their chest is hurting. A person may appear anxious, nervous, sweaty, and short of breath. They may also grab the areas that are hurting. This type of pain is often described as a heaviness in the chest and can also present with neck and left arm pain. In a person who has Type 2 diabetes, the pain can feel less intense or a bit different than the usual type of pain because diabetes can damage the nerves’ ability to transmit pain signals.

Behavioral Discussion

Anxiety symptoms can be challenging to identify in any person, particularly in people with more severe intellectual disabilities and/or limited expressive verbal communication. For these people, changes in their behavioral presentations are often the primary indicators of concerns. In Charlie’s experience, having a robust understanding of what caused his anxiety and how it presented was critical to identifying other underlying medical issues.

From a behavioral standpoint, there are times when simply stating a person’s diagnosis is not enough information. Colloquially, there is a general understanding of anxiety. However, we need more specific information about what anxiety means for Charlie. We need to know the antecedents for his anxiety (e.g., crowded areas, loud noise) and what his anxiety behaviors look like (e.g., pacing and wringing his hands). Being able to identify the specific characteristics of Charlie’s anxiety is necessary to recognize when changes in behavior can be indicative of other concerns. When Charlie was exhibiting signs of anxiety in non-crowded places (e.g., walking in the neighborhood, watching TV) and the behavior changed (e.g., scratching his chest/neck), we need to explore why the behavior changed. 

When discussing the behavioral presentations of anxiety symptoms, it is also important to note the occurrence of autonomic symptoms that can accompany behavior presentations. An increased respiratory rate, itchiness, sweating, and even pacing can all be the body's involuntary response to an internal stimulus, leading to behaviors “coming out of nowhere.” As service providers, it is essential to recognize these involuntary symptoms as equally, if not more important, than behavior presentations, as they provide additional information to medical professionals. 

Outcome

Charlie was evaluated in the emergency room. The attending physician did not think much of Charlie’s presentation at first because he was not well-trained in the different presentations of illness in people with intellectual or developmental disabilities (IDD). The nurse who sent Charlie to the ED called the ED and spoke with the doctor. She explained that Charlie had anxiety, but these symptoms were new, and he appeared to be in much more distress than usual. The physician then ran additional tests and found that Charlie had some EKG abnormalities. Charlie was admitted to the hospital and evaluated by a cardiologist who found that Charlie had a significant blockage in one of his cardiac arteries and required stent placement. Charlie went home after a few days and returned to his usual self, and all of the new symptoms of his “anxiety” disappeared.

About the Authors

Ley Linder is a Board-Certified Behavior Analyst with an academic and professional background in gerontology and applied behavior analysis. Ley’s specialties include behavioral gerontology and the behavioral presentations of neurocognitive disorders, in addition to working with high-management behavioral needs for dually diagnosed persons with intellectual disabilities and mental illness. He works closely with national organizations such as the National Down Syndrome Society and the National Task Group on Intellectual Disabilities and Dementia Practices, and is the Founder/CEO of Crescent Behavioral Health Services based in Columbia, SC. 

Dr. Craig Escudé is a board-certified Fellow of the American Academy of Family Physicians and the American Academy of Developmental Medicine and President of IntellectAbility. He has more than 20 years of clinical experience providing medical care for people with IDD and complex medical and mental health conditions. He is the author of “Clinical Pearls in IDD Healthcare” and developer of the “Curriculum in IDD Healthcare,” an eLearning course used to train clinicians on the fundamentals of healthcare for people with IDD.