Anxiety disorders: Screening and referral​

Key points

• Primary caregivers should screen for anxiety disorders because they are common.
• Panic disorder and generalized anxiety disorder are the most common types of anxiety disorder seen in primary care settings.
• Rule out possible causes of anxiety, such as a heart attack or major depressive disorder.

Why screen? Prevalence

• Anxiety disorders are the most common mental illnesses and affect 12% of Canadians at some time in their lives.
• About 16% of women and 9% of men have an anxiety disorder.
• About 25% of people experience significant problems related to an anxiety disorder.
• The average age of onset for an anxiety disorder is 12 years. Anxiety disorders often may show up in later adolescence or early adulthood.

Screening in primary care

• In primary care, people may present with medical problems and anxiety symptoms at the same time.
• Screening should determine whether anxiety symptoms are due to distressing events, to an anxiety disorder or another emotional disorder such as depression, or to an organic state such as hyperthyroidism or the use of stimulants such as coffee.
• Determine the specific anxiety disorder the person has.
• Diagnosis requires that the person is experiencing significant distress or functional impairment.

Conditions with similar symptoms

Organic conditions

Many medical illnesses can cause anxiety symptoms, but they generally also feature symptoms associated only with the primary disease. These medical illnesses include:

• endocrine conditions such as hyperthyroidism, hypothyroidism, hypoglycemia, menopause
• cardiovascular conditions such as congestive heart failure, pulmonary embolism, angina
• respiratory conditions such as asthma, chronic obstructive pulmonary disease, pneumonia
• metabolic conditions such as diabetes
• central nervous system or neurological conditions such as migraine, early dementia
• gastrointestinal disorders such as peptic ulcers, irritable bowel syndrome
• chronic fatigue
• other serious illnesses such as cancer
• drug-related symptoms from excessive caffeine, nicotine, alcohol, illegal drugs.

Response to stress (adjustment disorder)

• An adjustment disorder occurs in response to a common stressor, such as a job loss or divorce. Distress must occur within three months of the event and persist only if the stressor continues. Watchful waiting may help to determine whether symptoms worsen or lead to an anxiety disorder.

Co-occurring disorders

Anxiety disorders may co-occur with several psychiatric disorders:

• major depressive disorder: 51% of people with an anxiety disorder also have a major depressive disorder. Anxiety disorders typically precede major depressive disorder.
• another anxiety disorder
• substance use disorders, including alcohol abuse or dependence
• personality disorders.

Screening protocols

When screening for anxiety disorders, screen for specific disorders, remembering that the symptoms must cause significant distress or functional impairment.

Generalized anxiety disorder

• Ask if the person has been bothered by feeling worried, tense or anxious most of the time. About 90% of people with generalized anxiety disorder (GAD) will respond positively.
• If the person responds positively, use the WHAT IF mnemonic to explore further whether the person has GAD:

Worry

Hard-to-control headache

Anxiety

Tension

Insomnia/irritability/irritable bowel

Fatigue

Panic disorder

• Ask the person about sudden unexpected episodes with a rush of uncomfortable feelings, such as a racing heart or dizziness accompanied by panic or fear.
• Ask whether the person avoids or hesitates to approach new situations expected to bring on anxiety symptoms.

Agoraphobia

• Ask the person about avoiding crowds, lines or bridges; going outside the home alone; travelling on a bus, train or highway; or needing to have a companion as a safe person.

Social phobia (social anxiety disorder)

• Ask whether the person is overly anxious or concerned about feeling embarrassed or humiliated while doing things in front of people or interacting with others.

Specific phobia

• Ask whether any of these objects or situations make the person anxious or fearful, and whether the fear interferes with the person's life:
  • animals, snakes, insects
  • heights, storms, being near water
  • seeing blood, getting an injection
  • being in enclosed spaces
  • flying, elevators.

Separation anxiety disorder

• For children, use the Screen for Child Anxiety Related Disorders (SCARED) – Child version, which the child completes.

Selective mutism

• For children, use the Screen for Child Anxiety Related Disorders (SCARED) – Child version, which the child completes.

Substance/medication-induced anxiety disorder

• Appropriate laboratory testing will likely be necessary to identify substance/medication-induced anxiety. Lab tests may include:
  • complete blood count
  • chemistry panels
  • serum and/or urine screens for drugs.

Diagnostic questionnaires

Diagnostic questionnaires for anxiety (e.g., GAD-7) can be practical for making a diagnosis, assessing severity and monitoring treatment response.

 

To screen for anxiety disorders in children, have parents complete the Screen for Child Anxiety Related Disorders (SCARED) – Parent version. The child completes the Screen for Child Anxiety Related Disorders (SCARED) – Child version.

Specialist referral

Refer to a specialist in cases of:

• complicating comorbidity (substance use or dependence, major depressive disorder, suicidality)
• poor response to standard treatment (cognitive-behavioural therapy, two or more medication trials), or if the person is significantly impaired
• anxious children/adolescents who are too fearful to attend school or to socialize
• adults who cannot get to work or maintain usual activities.

Evidence summary

Laposa, J, (2012). Anxiety disorders. In A. Khenti, J. Sapag, S. Mohamound & A. Ravindran (Eds.), Collaborative Mental Health: An Advanced Manual for Primary Care Professionals (pp. 115–126). Toronto, ON: Centre for Addiction and Mental Health.

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.