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Anxiety: Screening, assessment and diagnosis

When anxiety is a presenting symptom, screen to determine the specific anxiety disorder, if any. Diagnosis requires that the symptoms cause significant distress or functional impairment. 

Note: the DSM-5 Anxiety chapter does not include obsessive-compulsive disorder (moved to a new chapter: obsessive- compulsive and related disorders) and posttraumatic stress disorders (moved to a new chapter: trauma-and-stressor-related disorders). Highlights of Changes from DSM- IV-TR to DSM-5 notes that the sequential order of the Anxiety chapter and the two new chapters "reflects the close relationships among them".

Table 4.1: Brief diagnostic criteria for anxiety disorders summarizes the key criteria for specific anxiety disorders as well as OCD and PTSD.

Screening for anxiety disorders

Panic disorder

Ask the patient about:

  • sudden unexpected episodes, with a rush of symptoms or uncomfortable feelings such as racing heart or dizziness, as well as panic or fear
  • avoiding or hesitating to approach situations that the patient expects will bring on symptoms (e.g., crowds, enclosed spaces, driving, leaving the house alone)

Individuals with panic disorder often avoid places where they have had panic attacks or fear that they might occur. This is called agoraphobia.

Agoraphobia (without panic)

Ask the patient about:

  • avoiding certain situations or places, for example, crowds, lines, bridges, going outside the home alone, travelling on bus, train or highway, or the need to have a companion as a safe person

Note that complete houseboundedness is rare but is a strongly negative prognostic factor.

Social anxiety disorder (SAD)

This common anxiety disorder is characterized by fear of embarrassment or of negative evaluation by other people. It usually has very early onset and commonly begins in childhood or adolescence. People with SAD are often embarrassed about the condition and do not readily volunteer information about their anxieties.

Ask the patient:

  • In general, are you overly anxious or concerned about embarrassing or humiliating yourself while doing things in front of people or interacting with others?

The severity of SAD can be assessed by asking the three questions that make up the Mini-SPIN (Connor et al., 2001).

Specific phobia

Specific phobias are the most prevalent anxiety disorders. They usually are not diagnosed because people learn to manage their anxiety by avoidance. Specific phobias can be very disabling if they involve situations that cannot be avoided such as having to attend a physician's office for blood tests or needing to take an elevator to the 25th floor to get to work.

Ask the patient:

  • Do any of the following make you anxious or fearful?
    • animals, snakes, insects
    • heights, storms, being near water
    • the sight of blood, getting an injection
    • being in enclosed spaces, flying, elevators
  • Does this fear interfere with your life?

Generalized anxiety disorder (GAD)

GAD is very common and occurs throughout the lifespan. The main symptoms are excessive, uncontrollable worry accompanied by muscle tension, fatigue, insomnia, impaired concentration and irritability. It is often comorbid with major depression.

Ask the patient:

  • During the past four weeks, have you been bothered by feeling worried, tense or anxious most of the time? (Of people with GAD, 90 per cent will respond yes to this question.)

If positive, explore further symptoms. The WHAT IF mnemonic is useful:

Worry

Hard-to-control headache

Anxiety

Tension

Insomnia/irritability/irritable bowel

Fatigue

Obsessive-compulsive disorder (OCD)

OCD can have its onset as early as age four or five, but is often concealed. The person recognizes the thoughts and impulses as unrealistic, but feels shame about the content of, and the inability to control, the thoughts. The person feels an intense compulsion to continue the thoughts and rituals and experiences severe distress if they are resisted. This contrasts with "addictive" behaviours that produce pleasure or gratification.

Symptoms of OCD include washing, checking, counting, hoarding, seeking reassurance and having religious preoccupations.

Ask the patient:

  • Do you experience repeated unwanted thoughts that you cannot easily control?
  • Do you feel compelled to carry out repetitive acts, such as washing, counting or checking?

Posttraumatic stress disorder (PTSD)

PTSD is precipitated by severe trauma in which the patient experienced, saw or heard of someone's physical or mental integrity being threatened. Feelings of horror and helplessness often occur at the time of the trauma. The onset of symptoms maybe delayed by months or even years and is triggered by another traumatic episode. The memories of the trauma remain very clear and are accompanied by intense emotion.

Ask the patient:

  • Are you bothered by memories, thoughts or images of a very upsetting event that happened to you or to someone close to you in the past? (Offer examples such as being in an accident, having been sexually assaulted or seeing someone get badly injured.)

Underlying organic pathology

Specific investigations for organic pathology depend on the patient's clinical presentation, age, sex, health history and other individual and familial factors. The Canadian Anxiety Disorders Treatment Guidelines (2014) suggest the following baseline laboratory investigations in patients with anxiety disorders:

  • complete blood count
  • urinalysis
  • fasting glucose
  • fasting lipid profile (total cholesterol, very low-density lipoprotein, low-density lipoprotein, high-density lipoprotein, triglycerides)
  • 24-hour creatinine clearance (if history of renal disease)
  • electrolytes
  • thyroid-stimulating hormone
  • liver enzymes
  • electrocardiogram (if over 40 years old or if indicated)
  • serum bilirubin
  • pregnancy test (if relevant)
  • serum creatinine
  • prolactin
  • urine drug screening for substance use

Psychiatry in primary care toolkit

A powerful mobile app packed with features that will streamline screening and assessment in primary care.

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Frequently asked questions