Troubles anxieux : Évaluation et diagnostic

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Troubles anxieux : Évaluation et diagnostic

Notions essentielles

Les critères du Manuel diagnostique et statistique des troubles mentaux (DSM-IV-TR ou DSM-5) servent à l'établissement d'un diagnostic formel.
Les personnes évaluées pour des troubles anxieux doivent aussi être évaluées pour le risque de suicide, surtout lorsqu'elles ont également une dépression concomitante.

Évaluation

Les éléments suivants permettent d'établir la présence d'un trouble anxieux chez un individu :

Établissez les antécédents médicaux complets et procédez à un examen, y compris de son état mental. Considérez les causes organiques de l'anxiété comme la consommation de stimulants, des troubles endocriniens, l'asthme ou l'insuffisance cardiaque congestive.

Télécharger The Mental Status Examination (fichier PDF en anglais).

Examinez les difficultés fonctionnelles, interpersonnelles et sociales apparentées que l'individu peut avoir. Obtenez les antécédents médicaux d'une tierce personne comme un membre de la famille lorsque le client accorde son consentement et l'implication de la famille est appropriée. Considérez également les facteurs culturels.
Établissez les antécédents psychiatriques, en prenant note des épisodes précédents d'anxiété, de la réaction aux traitements et des conditions concomitantes de santé mentale.
Évaluez régulièrement la sécurité de la personne ainsi que ses risques parce qu'une volonté de se suicider pourrait être présente, surtout si elle est déprimée.

Diagnostic

Critères du DSM-5 pour les troubles anxieux

Les troubles anxieux ont en commun une crainte et une anxiété excessive ainsi que des perturbations apparentées du comportement, et ils ont tendance à être fortement concomitants. Toutefois, il est possible de distinguer les troubles anxieux en examinant de près les types de situations qui suscitent des craintes ainsi que le contenu des pensées à ces moments.

Veuillez noter que la classification du DSM-5 de l'anxiété ne comprend plus le trouble obsessionnel-compulsif (qui figure maintenant parmi les troubles obsessionnels-compulsifs et non spécifiques) ni le trouble de stress post-traumatique et le trouble de stress aigu (maintenant inclus parmi les troubles traumatiques ou reliés aux facteurs de stress). De plus, le DSM-5 classifie le trouble d'anxiété de séparation et le trouble de mutisme sélectif en tant que troubles anxieux. Dans le DSM-IV-TR, ils étaient catégorisés en tant que troubles habituellement diagnostiqués au cours de la petite enfance, l'enfance ou l'adolescence.

[translator: don't translate the DSM criteria. We are clearing permission from the French language rights holder to reproduce the criteria]

Trouble d'anxiété généralisée

A. Excessive anxiety and worry, occurring more days than not for at least six months, about a number of events or activities (such as work or school performance).

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three or more of the following six symptoms (with at least some symptoms having been present for more days than not for the past six months):

Remarque : Un seul critère chez les enfants.

restlessness or feeling keyed up or on edge
being easily fatigued
difficulty concentrating or mind going blank
irritability
muscle tension
sleep disturbances.

D. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance or another medical condition.

F. The disturbance is not better explained by another mental disorder.

Trouble panique

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or discomfort that reaches a peak within minutes, and during which four or more of the following symptoms occur:

palpitations, pounding heart or accelerated heart rate
sweating
trembling or shaking
sensations of shortness of breath or smothering
feelings of choking
chest pain or discomfort
nausea or abdominal distress
feeling dizzy, unsteady, light-headed or faint
chills or heat sensations
paresthesias (numbness or tingling sensations)
derealization (feelings of unreality) or depersonalization (being detached from oneself)
fear of losing control or "going crazy"
fear of dying.

B. At least one of the attacks has been followed by one month or more of one or both of the following:

persistent concern or worry about additional panic attacks or their consequences.
a significant maladaptive change in behaviour related to the attacks (such as avoidance).

C. The disturbance is not attributable to the physiological effects of a substance or another medical condition.

D. The disturbance is not better explained by another mental disorder.

Agoraphobie

A. Marked fear or anxiety about two or more of the following five situations:

using public transportation (e.g., automobiles, buses, trains, ships, planes)
being in open spaces (e.g., parking lots, marketplaces, bridges)
being in enclosed places (e.g., shops, theatres, cinemas)
standing in line or being in a crowd
being outside of the home alone.

B. The individual fears or avoids these situations because of thought that escape might be difficult or help might not be available in the event of developing panic-like symptoms.

C. The agoraphobic situations almost always provoke fear or anxiety.

D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.

F. The fear, anxiety or avoidance is persistent, typically lasting for six months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. If another medical condition is present, the fear, anxiety, or avoidance is clearly excessive.

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder.

Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If a person's presentation meets criteria for panic disorder and agoraphobia, both diagnoses should be assigned.

Phobie sociale (trouble d'anxiété sociale)

A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions, being observed, performing in front of others. In children, the anxiety must occur in peer settings and not just during interactions with adults.

B. The individual fears that he or she will act in a a way or show anxiety symptoms that will be negatively evaluated.

C. The social situations almost always provoke fear or anxiety.

D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance or another medical condition.

I. The fear, anxiety or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

J. If another medical condition is present, the fear, anxiety or avoidance is clearly unrelated or is excessive.

Phobie spécifique

A. Marked fear or anxiety about a specific object or situation (e.g., flying, heights, animals, receiving an injection, seeing blood)

B. The phobic object or situation almost always provokes immediate fear or anxiety.

C. The phobic object or situation is actively avoided or endured with intense anxiety.

D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.

E. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

F. The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

G. The disturbance is not better explained by the symptoms of another mental disorder.

Trouble anxieux induit par une substance ou un médicament

A. Panic attacks or anxiety is predominant in the clinical picture.

B. There is evidence from the history, physical examination or laboratory findings of both:

the symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication
the involved substance/medication is capable of producing the symptoms in Criterion A.

C. The disturbance is not better explained by an anxiety disorder that is not substance/medication-induced.

D. The disturbance does not occur exclusively during the course of a delirium.

E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Note: This diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and they are sufficiently severe to warrant clinical attention.

Sommaire des données probantes

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5^e édition). Washington (DC).

Swinson, R. (2011). « The patient who is anxious ». Dans D. Goldbloom et J. Davine (réd.), Psychiatry in Primary Care: A Concise Canadian Pocket Guide (p. 45–60). Toronto Ontario) : Centre de toxicomanie et de santé mentale.