What is the recommended approach for an initial anxiety workup?

Recommended Approach for Initial Anxiety Workup

A comprehensive diagnostic evaluation is essential for the treatment of anxiety disorders, requiring specialized clinical assessment to identify symptoms, their frequency, severity, onset, duration, associated distress, and functional impairment. 1

Initial Screening and Assessment

• Use standardized screening instruments to identify anxiety concerns in primary care settings, such as the Generalized Anxiety Disorder-7 (GAD-7) scale, which categorizes anxiety severity as mild (0-9), moderate (10-14), and moderate to severe/severe (15-21) 2

• Consider using freely available general social-emotional screening instruments like the Pediatric Symptom Checklist or Difficulties Questionnaire for systematic identification of anxiety concerns in primary care or school settings 1

• For psychiatric evaluations, the American Psychiatric Association's Level 1 Cross-Cutting Symptom Measures (parent and self-rated versions) can be included in intake packets to efficiently gather information about presenting problems 1

Diagnostic Evaluation Structure

• Conduct interviews with both the patient and parent/guardian (if applicable), either separately or together as clinically indicated 1

• Use developmentally sensitive approaches that may include direct and indirect questioning, interactive techniques, and symptom rating scales 1

• Obtain input from collateral sources (with patient consent) including family members, teachers, primary care providers, and other relevant individuals to add depth to diagnostic information 1

• Consider conducting the evaluation in the language in which the patient is most proficient, using interpreter services when necessary 1

Differential Diagnosis

• Distinguish clinically significant anxiety from everyday worries and fears that are common to human experience and normative in specific developmental stages 1

• Rule out medical conditions that can present with anxiety symptoms, including: 1, 2

  • Thyroid disorders (particularly hyperthyroidism)
  • Cardiac conditions (arrhythmias, valvular disease)
  • Respiratory disorders (asthma)
  • Metabolic disorders (hypoglycemia, diabetes)
  • Substance use or withdrawal (including caffeinism)
  • Neurological conditions
  • Chronic pain/illness

• Consider appropriate laboratory testing (e.g., glucose, thyroid function) in collaboration with primary care if medical conditions are suspected 1

• Assess for comorbid conditions, particularly depression, as anxiety disorders frequently co-occur with depressive disorders 2, 3

Specific Anxiety Disorders to Consider

• Evaluate for the following anxiety disorders according to DSM-5 criteria: 1
  • Separation Anxiety Disorder (ICD F93.0)
  • Selective Mutism (ICD F94.0)
  • Specific Phobia (various ICD codes based on type)
  • Social Anxiety Disorder (ICD F40.10)
  • Panic Disorder (ICD F41.0)
  • Agoraphobia (ICD F40.00)
  • Generalized Anxiety Disorder (ICD F41.1)

Treatment Planning Based on Assessment

• For mild anxiety symptoms (GAD-7 score 0-9): provide education, active monitoring, self-help resources based on cognitive behavioral therapy principles, and structured physical activity 2

• For moderate anxiety symptoms (GAD-7 score 10-14): refer to educational and support services and consider low-intensity psychological interventions 2

• For moderate to severe/severe anxiety symptoms (GAD-7 score 15-21): implement high-intensity interventions including cognitive behavioral therapy, behavioral activation, structured physical activity, and consider pharmacotherapy 2

First-Line Treatment Options

• Cognitive Behavioral Therapy (CBT) is the psychological treatment with the strongest evidence of efficacy for anxiety disorders and should be considered first-line treatment. 2, 3, 4

• For pharmacotherapy, selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are first-line medications: 2, 3, 4

  • Sertraline: Initial dose of 25-50 mg once daily, may increase up to 200 mg/day at intervals of at least 1 week 5
  • Fluoxetine: For panic disorder, start with 10 mg/day for 1 week, then increase to 20 mg/day 6

Follow-Up and Monitoring

• Establish regular follow-up appointments to monitor treatment response, as patients with anxiety may not follow through on referrals or treatment recommendations 2

• Monthly assessment is recommended until symptoms have subsided to evaluate compliance with psychological interventions, assess medication adherence and side effects, and monitor symptom relief 2

• For patients on medication, continue treatment for 6-12 months after remission 4

Common Pitfalls and Caveats

• Only about 20% of people with anxiety disorders seek care for these conditions, highlighting the importance of proactive screening 2, 1

• Cautiousness and avoidance are cardinal features of anxiety, which may lead to poor follow-through with treatment recommendations 2

• Anxiety disorders are often underrecognized and undertreated in primary care settings 4

• Benzodiazepines are not recommended for routine use in anxiety disorders due to risk of dependence and other adverse effects 4