What are the steps to diagnose anxiety?

How to Diagnose Anxiety

The diagnosis of anxiety requires a systematic screening approach using validated tools like the GAD-7, followed by a comprehensive clinical assessment to confirm diagnostic criteria according to DSM-5 standards. 1

Screening Process

Step 1: Initial Screening

• Use the GAD-7 questionnaire as the primary screening tool:
  • 7 questions rated 0-3 (0 = not at all, 3 = nearly every day)
  • Measures symptoms over the past two weeks
  • Content includes: feeling nervous/anxious, inability to control worry, excessive worry, trouble relaxing, restlessness, irritability, and feeling afraid 1

Step 2: Interpret Screening Results

• GAD-7 score interpretation:
  • 0-4: None/minimal anxiety
  • 5-9: Mild anxiety
  • 10-14: Moderate anxiety
  • 15-21: Severe anxiety 1
• Consider using the ultra-brief GAD-2 (first two questions of GAD-7) for initial rapid screening:
  • Score ≥3 has sensitivity of 89% and specificity of 90% for anxiety disorders 1

Diagnostic Assessment

Step 3: Clinical Interview

• Assess for DSM-5 diagnostic criteria for specific anxiety disorders:
  • Generalized Anxiety Disorder: Excessive worry about multiple events/activities, difficult to control, lasting ≥6 months
  • Panic Disorder: Recurrent unexpected panic attacks with fear of future attacks
  • Social Anxiety Disorder: Fear of social situations where scrutiny is possible
  • Specific Phobia: Excessive fear of specific objects or situations 1, 2

Step 4: Evaluate Symptom Patterns

• Assess for physical symptoms:
  • Motor tension: Trembling, muscle tension, restlessness, fatigue
  • Autonomic hyperactivity: Shortness of breath, palpitations, sweating, dry mouth, dizziness
  • Vigilance: Feeling on edge, exaggerated startle response, concentration difficulties, sleep problems 3

Step 5: Determine Functional Impact

• Evaluate impairment in:
  • Social functioning
  • Occupational performance
  • Daily activities
  • Quality of life 1

Differential Diagnosis

Step 6: Rule Out Medical Conditions

• Medical conditions that can mimic anxiety:
  • Hyperthyroidism
  • Cardiac arrhythmias
  • Respiratory disorders (asthma, COPD)
  • Caffeine intoxication
  • Medication side effects
  • Substance use/withdrawal 1, 2

Step 7: Assess for Comorbidities

• Common comorbidities to evaluate:
  • Depression (often co-occurs with anxiety)
  • Substance use disorders
  • Other anxiety disorders
  • Chronic medical conditions 1, 2

Special Considerations

Risk Assessment

• Always evaluate for risk of self-harm or harm to others
• If risk identified, provide immediate referral for emergency evaluation 1

Cultural Factors

• Use culturally sensitive assessments
• Consider cultural variations in symptom presentation
• Use interpreter services when language barriers exist 1

Common Pitfalls to Avoid

• Misattributing physical symptoms: Many anxiety symptoms are somatic and may be mistaken for medical conditions 2
• Missing comorbidities: Anxiety often co-occurs with depression and substance use disorders 4
• Inadequate assessment of functional impairment: Anxiety must cause significant distress or impairment to meet diagnostic criteria 1
• Relying solely on screening tools: Screening tools should be followed by clinical assessment to confirm diagnosis 1

By following this systematic approach to diagnosing anxiety, clinicians can accurately identify patients with anxiety disorders and initiate appropriate treatment to improve morbidity, mortality, and quality of life outcomes.