Anxiety disorders: Assessment and diagnosis​

Key points

• The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR or DSM-5) criteria are used to make a formal diagnosis. 
• People being assessed for anxiety disorders should also be assessed for suicide risk, particularly if they have co-occurring depression.

Assessment

Determining whether a person has an anxiety disorder should involve the following components:

• Take a full history and conduct an examination, including a mental status examination. Consider organic causes of anxiety, such as stimulant use, endocrine disorders, asthma or congestive heart failure.

Download a pdf of the Mental Status Examination.

• Review related functional, interpersonal and social difficulties the person is experiencing. Obtain a third-party history from family members if the client provides consent and family involvement is appropriate. Also consider cultural factors.
• Take a psychiatric history, noting past episodes of anxiety, response to treatments and comorbid mental health conditions.
• Assess the person's safety and risk regularly because suicidal intent may be present, particularly if the person also has depression.

Diagnosis

DSM-5 criteria for anxiety disorders

Anxiety disorders share features of excessive fear and anxiety and related behaviour disturbances and tend to be highly comorbid. However, they can be differentiated by close examination of the types of situations that are feared and the content of the associated thoughts.

Note that the DSM-5 classification of anxiety no longer includes obsessive-compulsive disorder (now included with the obsessive-compulsive and related disorders) or posttraumatic stress disorder and acute stress disorder (now included with the trauma-and stressor-related disorders). Also, the DSM-5 now classifies separation anxiety disorder and selective mutism disorder as anxiety disorders. In the DSM-IV-TR, they were classified as disorders usually first diagnosed in infancy, childhood or adolescence.

Generalized anxiety disorder

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):

1. restlessness or feeling keyed up or on edge
2. being easily fatigued
3. difficulty concentrating or mind going blank
4. irritability
5. muscle tension
6. 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.

Panic disorder

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:

1. palpitations, pounding heart or accelerated heart rate
2. sweating
3. trembling or shaking
4. sensations of shortness of breath or smothering
5. feelings of choking
6. chest pain or discomfort
7. nausea or abdominal distress
8. feeling dizzy, unsteady, light-headed or faint
9. chills or heat sensations
10. paresthesias (numbness or tingling sensations)
11. derealization (feelings of unreality) or depersonalization (being detached from oneself)
12. fear of losing control or "going crazy"
13. 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:

1. persistent concern or worry about additional panic attacks or their consequences.
2. 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.

Agoraphobia

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

1. using public transportation (e.g., automobiles, buses, trains, ships, planes)
2. being in open spaces (e.g., parking lots, marketplaces, bridges)
3. being in enclosed places (e.g., shops, theatres, cinemas)
4. standing in line or being in a crowd
5. 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.

Social phobia (social anxiety disorder)

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.

Specific phobia

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.

Substance/medication-induced anxiety disorder

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:

1. the symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication
2. 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.

Evidence summary

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.

Swinson, R. (2011). The patient who is anxious. In D. Goldbloom & J. Davine (Eds.), Psychiatry in Primary Care: A Concise Canadian Pocket Guide (pp. 45–60). Toronto, ON: Centre for Addiction and Mental Health.