Anxiety: Differential diagnosis
Adjustment disorder is a psychological response to an identifiable stressor or stressors that results in clinically significant emotional or behavioural symptoms. These are short-duration conditions, with symptoms developing within three months of the onset of the stressor and usually resolving within six months.
An adjustment disorder with anxious mood is typified by nervousness, worry or jitteriness, and in children, by fear of separation from significant people in their lives. The acute onset of anxiety symptoms following a major stressor such as marital separation, significant employment problems or threat to housing stability may all be followed by adjustment disorder with anxious mood.
Screening for the disorders described in Table 4.1 is necessary to rule out the presence of anxiety, mood or organic disorders.
Organic states such as hyperthyroidism can present with anxiety symptoms (e.g., tremulousness and palpitations). The clinician should determine:
- Is the clinical picture secondary to an organic state, such as the intense agitation and fear that appear in the early stages of dementia?
- Is the use of stimulants (e.g., coffee, amphetamines) responsible for the occurrence of the symptoms?
Substance use disorders
People with anxiety may seek quick relief by using commonly available substances. It is important to determine with all patients whether withdrawal from benzodiazepines or alcohol is responsible for the patient's symptoms.
Stimulants can trigger significant anxiety symptoms and panic attacks. Three or four coffees, teas or caffeinated soft drinks a day can precipitate anxiety attacks. Cocaine and amphetamines are also powerful anxiety-producing agents. Although marijuana use is usually accompanied by feelings of relaxation, some people are very sensitive to the occurrence of depersonalization and suffer marked panic, usually on one of the first few occasions that they try it.
Depression often presents with anxiety symptoms that may be new or that may be an exacerbation of pre-existing anxiety conditions that only come to attention as the mood state worsens. The combination of depression and severe anxiety symptoms is cause for concern because of increased suicidality.
Lifelong mood instability as seen in Cluster B (borderline, histrionic and narcissistic) personality disorders may present with severe anxiety symptoms at times of increased instability.
Generalised anxiety disorder and panic disorder in adults: management (NICE guideline CG113 2011)
Social anxiety disorder: recognition, assessment and treatment (NICE guidelines CG159, 2013)