What is the initial assessment and treatment approach for a psychiatric patient complaining of anxiety?

Assessment Questions for Psychiatric Patients Complaining of Anxiety

Begin with standardized screening using the GAD-7 scale, then conduct a structured diagnostic interview covering symptom characteristics, medical differentials, psychiatric comorbidities, functional impairment, safety concerns, and contextual factors to distinguish clinically significant anxiety from normal worry. 1, 2

Initial Screening and Symptom Quantification

• Administer the GAD-7 (Generalized Anxiety Disorder-7) scale to quantify anxiety severity, with scores interpreted as: 0-4 (none/mild), 5-9 (moderate), 10-14 (moderate to severe), 15-21 (severe) 2, 3, 4
• For children and adolescents, use age-appropriate validated scales including SCARED (Screen for Child Anxiety Related Emotional Disorders), Spence Children's Anxiety Scale (SCAS), or Preschool Anxiety Scale for younger children 1
• The GAD-7 has demonstrated sensitivity of 57.6% to 93.9% and specificity of 61% to 97% for detecting anxiety disorders 4

Core Diagnostic Questions: Symptom Characteristics

Ask about the specific nature and pattern of anxiety symptoms:

• Worry characteristics: Is the worry excessive, uncontrollable, and focused on multiple life domains (work, health, family, finances) rather than a single concern? 3, 5
• Duration and chronicity: How long have symptoms been present? Are they persistent (present most days for at least 6 months for GAD)? 1
• Physical manifestations: Does the patient experience palpitations, shortness of breath, dizziness, tremor, fidgetiness, restlessness, gastrointestinal symptoms, headaches, or muscle tension? 1, 4
• Panic symptoms: Are there discrete episodes of abrupt, intense fear with physical symptoms (panic attacks)? Are these unexpected or triggered by specific situations? 1
• Avoidance behaviors: What situations, places, or activities does the patient avoid due to anxiety? 1, 4
• Social fears: Does the patient fear negative evaluation by others in social or performance situations? 1

Medical Differential Diagnosis

Rule out medical conditions that mimic or cause anxiety symptoms:

• Thyroid disorders: Ask about heat/cold intolerance, weight changes, tremor (consider thyroid function testing if clinically indicated) 1, 2
• Cardiac conditions: Inquire about chest pain, palpitations, history of arrhythmias or valvular disease 1, 6
• Respiratory disorders: Ask about asthma, chronic obstructive pulmonary disease, or episodes of hypoxia 1
• Metabolic conditions: Screen for diabetes, hypoglycemic episodes, electrolyte imbalances 1, 6
• Substance use: Document caffeine intake, alcohol use, illicit drug use, and recent medication changes (many medications cause anxiety as a side effect) 1, 6
• Other medical conditions: Ask about chronic pain, allergic reactions, lead exposure, pheochromocytoma, systemic lupus erythematosus, or central nervous system disorders 1

Psychiatric Comorbidities and Differential

Screen for other psychiatric conditions that commonly co-occur with or mimic anxiety:

• Depression: Assess for depressed mood, anhedonia, sleep changes, appetite changes, concentration difficulties, suicidal ideation (anxiety and depression co-occur in 56% of cases) 2, 7, 8
• Substance use disorders: Document alcohol, benzodiazepine, or other substance dependence (these must be treated concurrently) 8
• Other anxiety disorders: Distinguish between generalized anxiety, panic disorder, social anxiety, specific phobias, separation anxiety, agoraphobia, and selective mutism 1
• Trauma history: Ask about past traumatic experiences and symptoms of posttraumatic stress disorder 1, 6
• Obsessive-compulsive symptoms: Inquire about intrusive thoughts and compulsive behaviors 1

Functional Impairment Assessment

Quantify the impact of anxiety on daily functioning:

• Occupational/academic functioning: How does anxiety affect work performance, school attendance, or ability to complete tasks? 1
• Social relationships: Has anxiety impaired relationships with family, friends, or romantic partners? 1, 2
• Self-care and daily activities: Does anxiety interfere with basic self-care, sleep, eating, or routine activities? 1
• Quality of life: How much distress does the anxiety cause? 1

Safety Assessment

Evaluate immediate safety concerns:

• Suicidal ideation: Ask directly about thoughts of self-harm, suicide plans, intent, and access to means 1, 3
• Self-harm behaviors: Inquire about non-suicidal self-injury, risk-taking behaviors, or impulsivity 3
• Harm to others: Assess for thoughts or plans to harm others 1
• If positive: Facilitate emergency evaluation, ensure safe environment, initiate one-to-one observation, and implement harm-reduction interventions 1

Contextual and Historical Factors

Gather information to develop a clinical formulation:

• Developmental history: Ask about childhood anxiety, separation difficulties, school refusal, or developmental delays 1
• Family psychiatric history: Document anxiety disorders, depression, or other psychiatric conditions in first-degree relatives (individuals with GAD are significantly more likely to have family members with anxiety) 3
• Stressors and precipitants: Identify recent life changes, losses, conflicts, or traumatic events 1
• Previous treatments: Document prior psychotherapy, medications tried, response to treatment, and reasons for discontinuation 1
• Cultural and spiritual factors: Consider how cultural background influences anxiety expression and treatment preferences 1, 2
• Strengths and supports: Identify coping skills, social support systems, and protective factors 1

Mental Status Examination Findings

Observe for signs of anxiety during the interview:

• Appearance: Note if fastidious or disheveled 1
• Behavior: Look for poor eye contact, clinginess, tremor, fidgetiness, restlessness, "nervous" habits, hypervigilance 1
• Speech: Assess for poverty of speech or pressured speech 1
• Thought process: Note perseverative or ruminative patterns 1
• Thought content: Identify worry- or fear-laden content 1
• Mood and affect: Document irritability, agitation, or anxious affect 1
• Cognition: Assess for distractibility 1
• Insight and judgment: Evaluate patient's understanding of their condition 1

Collateral Information

Obtain information from multiple sources when possible (with patient consent):

• Interview family members, teachers, primary care providers, or other treating clinicians to gather comprehensive diagnostic information 1, 2
• Review medical records, previous psychiatric evaluations, and school reports 1
• For children and adolescents, obtain both parent and child perspectives, as they may differ 1

Distinguishing Clinical Anxiety from Normal Worry

Differentiate pathological anxiety from developmentally normal fears:

• Normal developmental fears include: stranger anxiety in infants, separation anxiety in toddlers, fears of supernatural creatures in preschoolers, concerns about physical well-being in school-aged children, and social/existential concerns in adolescents 1, 3
• Clinical anxiety is distinguished by: excessive intensity, duration beyond developmental stage, significant distress, functional impairment, and inability to control the worry 1

Common Pitfalls to Avoid

• Do not dismiss anxiety as purely psychological without ruling out medical causes, as conditions like hyperthyroidism, cardiac arrhythmias, or medication side effects can present identically to primary anxiety disorders 1, 6
• Do not overlook comorbid depression, which co-occurs in over half of anxiety cases and may require prioritized treatment 2, 7
• Do not rely solely on mental status examination findings, as signs of anxiety are nonspecific and may be absent even in severe cases 1
• Do not assume patient will follow through with referrals, as cautiousness and avoidance are cardinal features of anxiety pathology; plan for active follow-up 1, 2
• Do not conduct evaluation in a language the patient is not proficient in, as this is associated with misdiagnosis and adverse outcomes 1