How is anxiety assessed?

Assessment of Anxiety

Anxiety should be assessed using a structured, multi-method approach that combines validated screening tools (GAD-7 as the primary instrument), structured diagnostic interviews, mental status examination, and collateral information from multiple sources to establish diagnosis, severity, and functional impairment. 1

Primary Screening Tool

• Use the GAD-7 (Generalized Anxiety Disorder-7) as your first-line screening instrument for adults, which is a 7-item self-report scale assessing nervousness, inability to control worry, excessive worry, trouble relaxing, restlessness, irritability, and fear over the past 2 weeks. 1, 2

• Interpret GAD-7 scores as follows: 0-4 indicates none/mild anxiety, 5-9 indicates moderate anxiety, 10-14 indicates moderate to severe anxiety, and 15-21 indicates severe anxiety. 1

• The GAD-7 demonstrates excellent psychometric properties with 89% sensitivity and 82% specificity at the optimal cut-point, and performs well for screening multiple anxiety disorders beyond just GAD (area under the curve 0.80-0.91). 3, 2

• For rapid screening, the GAD-2 (first two items of GAD-7) can be used initially, with positive screens followed by the full GAD-7. 3

Pediatric-Specific Assessment Tools

• For children and adolescents, use the SCARED (Screen for Child Anxiety Related Emotional Disorders) or SCAS (Spence Children's Anxiety Scale), both available in parent and child versions with acceptable psychometric properties. 1

• The GAD-7 can be used for adolescents, while the Preschool Anxiety Scale should be used for younger children. 1

• For children ages 8-18, consider the ASICA (Anxiety Severity Interview for Children and Adolescents) with a cut-off score of 13, which assesses physical response, avoidant behavior, and anxious thoughts. 4

Structured Diagnostic Interviews

• When enhanced diagnostic accuracy is needed, use the Anxiety Disorders Interview Schedule (ADIS), which is considered the gold standard in research settings and addresses all DSM anxiety disorders plus screening sections for comorbidities. 1

• The K-SADS-PL DSM-5 interview guide is a freely available alternative that includes sections for panic, agoraphobia, separation anxiety, social anxiety, selective mutism, specific phobia, and generalized anxiety disorders. 1

• Structured interviews substantially enhance diagnostic reliability over unstructured clinical interviews, though they require more time and resources. 1

Additional Validated Instruments

For comprehensive assessment, consider these disorder-specific tools:

• Beck Anxiety Inventory (BAI): 21-item self-report scale assessing somatic symptoms of anxiety; scores ≥10 suggest mild anxiety, ≥19 suggest moderate anxiety. 1

• Hospital Anxiety and Depression Scale (HADS): 14-item self-report with separate anxiety and depression subscales; score ≥8 on anxiety scale indicates probable disorder. 1

• Penn State Worry Questionnaire (PSWQ): 16-item scale (or 8-item abbreviated form) assessing worry severity, the primary symptom of GAD. 1

• Spielberger State-Trait Anxiety Inventory (STAI): 40-item measure (20 state, 20 trait) assessing cognitive, behavioral, and physiologic anxiety symptoms. 1

• GAD-Q-IV: 9-item self-report assessing generalized anxiety disorder symptoms per DSM-IV criteria, covering uncontrollable worry, functional impairment, physical symptoms, and subjective distress. 1

Mental Status Examination

Look for these specific anxiety-related signs during examination:

• Appearance: fastidious or disheveled presentation, poor eye contact, shy demeanor, clinginess. 1

• Motor signs: tremor, fidgetiness, restlessness, "nervous" habits, hypervigilance. 1

• Speech: poverty of speech or pressured speech. 1

• Thought process: perseverative or ruminative patterns, worry- or fear-laden content. 1

• Affect: distractibility, irritability, agitation, poor insight and judgment. 1

• Note that these signs are nonspecific and may be absent, so they serve as adjunctive rather than primary diagnostic information. 1

Multi-Informant Assessment

• Systematically gather information from the patient, family members, teachers (for children), and review medical records to obtain a comprehensive picture. 1

• Conduct diagnostic interviews with both the patient and family members, separately or together, using developmentally appropriate techniques. 1

• Use problem checklists to assess possible stressors, risk factors, and times of vulnerability. 1

Critical Safety Assessment

Immediately evaluate for:

• Risk of harm to self or others, including suicidal ideation, self-harm behaviors, and impulsivity. 1

• Severe depression, severe agitation, psychosis, or confusion (delirium) requiring immediate psychiatric referral. 1

• Any patient identified as at risk requires immediate referral to appropriate emergency services, with facilitation of a safe environment and one-to-one observation. 1

Differential Diagnosis and Medical Workup

Rule out medical causes that can mimic or cause anxiety:

• Hyperthyroidism, caféinism, asthma, diabetes, hypoglycemia, cardiac disorders, migraines, and chronic pain. 1

• Medication-induced or substance-induced anxiety (e.g., interferon administration, stimulants). 1

• Delirium from infection or electrolyte imbalance. 1

Assess for psychiatric comorbidities:

• 50-60% of individuals with depression have comorbid anxiety disorders, with generalized anxiety being most prevalent. 1

• Screen for other anxiety disorders, depression, ADHD, conduct disorders, and learning/language disorders. 1

• The HADS is particularly useful as it excludes physical symptom items, making it less affected by medical comorbidities. 1

Functional Impairment Assessment

• Document specific impairments in home, relationship, social, educational, or occupational functioning using standardized measures like the Medical Outcomes Study Short Form. 1, 3

• Assess disability days and healthcare utilization patterns. 3, 2

• Increasing anxiety severity is strongly associated with progressive functional impairment across multiple domains. 3, 2

Clinical Formulation

Develop a biopsychosocial formulation identifying:

• Biological factors: family history of anxiety disorders, autonomic hyperreactivity, temperament (negative affectivity, behavioral inhibition), chronic medical conditions. 1

• Psychological factors: maladaptive cognitive schemas, information-processing errors, negative self-evaluations, insecure attachment. 1

• Social/environmental factors: stressful or traumatic life events, anxiogenic parenting behaviors (overprotection, overcontrol, high criticism), social skills deficits, peer rejection. 1

Reassessment Schedule

Re-screen at these critical timepoints:

• Initial diagnosis/start of treatment. 1

• Regular intervals during treatment (every 4-6 weeks). 1, 5

• At 3,6, and 12 months after treatment initiation. 1

• With diagnosis of recurrence or progression. 1

• During times of personal transition, family crisis, or disease status changes. 1, 5

Common Pitfalls to Avoid

• Don't rely solely on self-report without corroborating information from multiple sources, especially in pediatric populations. 1

• Anxiety disorders are highly prevalent (19.5% in primary care) but frequently undetected, with 41% of patients reporting no current treatment. 3

• Physical symptoms of anxiety (headaches, gastrointestinal distress, palpitations) may be misattributed to medical causes without proper screening. 6

• Don't assume rating scales alone establish diagnosis—they support but don't replace clinical diagnostic assessment. 1

• In children, distinguish pathological anxiety from developmentally normal fears and worries. 5