What is the approach to assessing and managing anxiety?

Approach to Assessment of Anxiety

Definition

Anxiety disorders are characterized by excessive, uncontrollable worry about multiple life domains, accompanied by physical symptoms (restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbances), panic attacks, avoidance behaviors, and social fears that cause significant functional impairment. 1, 2

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Classification

Primary Anxiety Disorders

• Generalized Anxiety Disorder (GAD): Chronic, pervasive worry about multiple topics beyond cancer or medical concerns, with physical symptoms 3, 1
• Panic Disorder: Recurrent unexpected panic attacks with anticipatory anxiety 2, 4
• Social Anxiety Disorder: Fear and avoidance of social or performance situations 5, 2
• Specific Phobias: Circumscribed fears of specific objects or situations 1
• Separation Anxiety Disorder: Excessive fear of separation from attachment figures 6
• Agoraphobia: Fear of situations where escape might be difficult 2

Severity Stratification (Using GAD-7 Scores)

• None/Mild: 0-4 3
• Moderate: 5-9 3
• Moderate-Severe: 10-14 3
• Severe: 15-21 3

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Differential Diagnosis

Medical Conditions That Mimic Anxiety

• Thyroid disorders (hyperthyroidism) 1, 7
• Cardiac conditions (arrhythmias, coronary artery disease) 1
• Respiratory disorders (asthma, COPD) 1
• Metabolic conditions (hypoglycemia, electrolyte imbalances) 1, 7
• Caffeine excess or substance use 7
• Delirium (infection, electrolyte imbalance) 3
• Uncontrolled pain or other physical symptoms 3

Psychiatric Differential

• Major Depressive Disorder (50-60% comorbidity with anxiety) 3, 1, 7
• Bipolar Disorder 7
• Substance Use Disorders 1
• Obsessive-Compulsive Disorder 1
• Post-Traumatic Stress Disorder 1
• Personality Disorder features (especially with extreme anger bursts and projection) 7
• Psychosis 3

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History

Symptom Characteristics

• Worry pattern: Excessive, uncontrollable, about multiple domains (not just one topic) 3, 1
• Duration and chronicity: Symptoms present for weeks to months, beyond developmentally appropriate fears 1
• Physical manifestations: Palpitations, shortness of breath, dizziness, sweating, dry mouth, muscle tension 2, 8
• Panic symptoms: Discrete episodes of intense fear with autonomic symptoms 1, 2
• Avoidance behaviors: Social situations, specific triggers, places where escape is difficult 1, 5
• Sleep disturbances: Difficulty falling or staying asleep 3, 8
• Cognitive symptoms: Difficulty concentrating, feeling on edge, irritability 3, 1

Red Flags (Require Immediate Referral)

• Suicidal ideation or self-harm behaviors 1, 7
• Risk of harm to others 3, 1
• Severe anxiety or agitation 3
• Presence of psychosis 3
• Confusion or delirium 3

Risk Factors and Contextual History

• Developmental history: Age of onset, childhood anxiety 1
• Family psychiatric history: Anxiety, depression, substance use 1
• Stressors and precipitants: Recent life events, medical diagnosis, family crisis 3, 1
• Previous treatments: Response to prior medications or therapy 3, 1
• Cultural and spiritual factors: Impact on symptom expression and treatment preferences 3, 1
• Strengths and supports: Coping skills, social support network 3, 1

Functional Impairment Assessment

• Occupational/academic functioning: Ability to work, attend school, complete tasks 1
• Social relationships: Withdrawal from friends, family conflicts 3, 1
• Self-care and daily activities: Basic functioning, household responsibilities 1
• Quality of life: Overall life satisfaction and well-being 1

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Physical Examination (Focused)

Mental Status Examination Findings

• Appearance: Restless, fidgety, tense posture 1
• Behavior: Psychomotor agitation, poor eye contact 1
• Speech: Rapid, pressured, or hesitant 1
• Thought process: Rumination, racing thoughts 1
• Thought content: Excessive worry, catastrophic thinking, no delusions 1
• Mood and affect: Anxious, irritable, restricted or labile affect 1
• Cognition: Difficulty concentrating, intact orientation (unless delirium present) 1
• Insight and judgment: Variable awareness of excessive nature of worry 1

Vital Signs and Physical Findings

• Tachycardia, elevated blood pressure (may indicate autonomic arousal or medical cause) 2
• Tremor, sweating (anxiety vs. hyperthyroidism) 1
• Thyroid examination (goiter, nodules) 7

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Investigations

Screening Tools (Standardized)

Adults

• GAD-7 (Generalized Anxiety Disorder-7): First-line screening tool, scores 0-21 (sensitivity 57.6-93.9%, specificity 61-97%) 1, 2
• Hospital Anxiety and Depression Scale (HADS): 14 items, score ≥8 indicates caseness 3
• Penn State Worry Questionnaire (PSWQ): Assesses worry severity 3

Children and Adolescents

• SCARED (Screen for Child Anxiety Related Emotional Disorders): First-line for ages 6-18, parent version has superior sensitivity/specificity 6
• Preschool Anxiety Scale: For children under 6 years 6
• Spence Children's Anxiety Scale (SCAS): Alternative with similar psychometric properties 6

Laboratory Testing (When Indicated)

• Thyroid function tests (TSH, free T4): Rule out hyperthyroidism 7
• Glucose levels: Rule out hypoglycemia 7
• Electrolytes: If delirium suspected 3
• Urine drug screen: If substance use suspected 1

Structured Diagnostic Interviews (Research/Specialty Settings)

• ADIS (Anxiety Disorders Interview Schedule): Gold standard, covers all DSM anxiety disorders 6
• K-SADS-PL DSM-5: For pediatric populations, freely available 6

Expected Findings

• GAD-7 score ≥10: Indicates moderate-severe anxiety requiring intervention 3
• Elevated TSH or free T4: Suggests thyroid disorder as cause 7
• Normal laboratory values: Supports primary anxiety disorder diagnosis 7

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Empiric Treatment

Immediate Management (Based on Severity)

None/Mild Anxiety (GAD-7: 0-4)

• Education and active monitoring 3
• Nonfacilitated or guided self-help based on cognitive behavioral therapy principles 3

Moderate Anxiety (GAD-7: 5-9)

• Low-intensity interventions: Self-help, psychosocial group interventions 3
• Consider pharmacotherapy if symptoms persist 3

Moderate-Severe to Severe Anxiety (GAD-7: 10-21)

• Combination therapy: SSRI + Cognitive Behavioral Therapy (superior to either alone) 7
• Individual psychological therapy by licensed mental health professional 3

First-Line Pharmacotherapy

Initiate an SSRI as first-line treatment for GAD, panic disorder, and social anxiety disorder. 7, 2, 4

Sertraline (Preferred SSRI)

• Adults: Start 50 mg daily (morning or evening), titrate to 50-200 mg/day based on response 5
• Social anxiety disorder: May start at 25 mg/day for first week, then increase to 50 mg/day 5
• Children (ages 6-12): Start 25 mg daily for OCD 5
• Adolescents (ages 13-17): Start 50 mg daily for OCD 5
• Efficacy: Small to medium effect sizes vs. placebo (GAD: SMD -0.55; social anxiety: SMD -0.67; panic: SMD -0.30) 2

Alternative SSRIs/SNRIs

• Venlafaxine extended release: Alternative first-line SNRI 2, 4
• Other SSRIs: Paroxetine also FDA-approved for anxiety disorders 7

Monitoring

• Follow-up at 2 weeks, then monthly for first 3 months 7
• Assess for: Worsening anxiety/panic, suicidal ideation, medication adherence, side effects 7
• Response indicators: Reduced panic frequency, improved sleep, decreased worry, better functional capacity 7

Duration of Treatment

• Continue for 6-12 months after remission for GAD, panic disorder, social anxiety disorder 5, 4
• Maintenance treatment: May require several months or longer for chronic conditions 5

First-Line Psychotherapy

Cognitive Behavioral Therapy (CBT) is the psychotherapy with the highest level of evidence for anxiety disorders. 3, 2, 4

CBT Components

• Cognitive change: Identifying and challenging catastrophic thoughts 3
• Behavioral activation: Gradual exposure to feared situations 3
• Biobehavioral strategies: Relaxation training, breathing exercises 3
• Problem-solving skills 3
• Relapse prevention: Important as GAD is often chronic 3

Efficacy

• GAD: Large effect size (Hedges g = 1.01) 2
• Social anxiety disorder: Small-medium effect (Hedges g = 0.41) 2
• Panic disorder: Small-medium effect (Hedges g = 0.39) 2

Adjunctive Interventions

• Psychosocial group therapy: Stress reduction, positive coping, enhancing social support 3
• Supportive care services: Education, information provision 3

Medications NOT Recommended for Routine Use

• Benzodiazepines: Not recommended for routine use due to dependence risk 4
• Consider only for short-term duration in specific circumstances 3

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Indications to Refer

Immediate Psychiatric Referral Required

• Risk of harm to self or others 3, 1
• Severe anxiety or agitation 3
• Presence of psychosis 3
• Confusion or delirium 3

Referral to Psychology/Psychiatry for Diagnosis and Treatment

• Moderate to severe symptoms (GAD-7: 10-21) 3
• Symptoms not responding to initial treatment 3
• Functional impairment from mild to moderate 3
• Comorbid anxiety diagnoses (panic disorder, social phobia) 3
• Comorbid depression (treat depression first, then reassess anxiety) 3

Specialty Consultation

• Treatment-resistant cases 9
• Complex comorbidities (bipolar disorder, personality disorders) 7
• Need for structured diagnostic interview 6

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Critical Pitfalls

Diagnostic Pitfalls

• Never rely solely on screening scores for diagnosis—they identify concerns requiring clinical assessment, not definitive diagnoses 6
• Don't skip multi-informant assessment—gather information from patient, family, and when appropriate, teachers or other collaterals 6
• Failing to distinguish clinical anxiety from normal worry—clinical anxiety has excessive intensity, duration beyond developmental stage, significant distress, functional impairment, and uncontrollability 1
• Missing medical causes—always rule out thyroid disorders, cardiac conditions, hypoglycemia, caffeine excess, and substance use before confirming primary anxiety disorder 1, 7
• Overlooking comorbid depression—50-60% of patients with anxiety have comorbid depression; usual practice is to treat depression first 3
• Ignoring delirium—confusion and agitation may be delirium from infection or electrolyte imbalance, not primary anxiety 3

Treatment Pitfalls

• Delaying SSRI initiation in moderate-severe cases—combination of SSRI + CBT is superior to either alone and should be started promptly 7
• Inadequate duration of treatment—continue medications for 6-12 months after remission to prevent relapse 5, 4
• Routine use of benzodiazepines—not recommended due to dependence risk; reserve for short-term use only 4
• Failing to monitor for suicidal ideation—especially in first 2 weeks after starting SSRI 7
• Not addressing functional impairment—treatment success should include improved occupational, social, and daily functioning, not just symptom reduction 1, 9

Safety Pitfalls

• Missing red flags for immediate referral—suicidal ideation, harm to others, psychosis, severe agitation require urgent psychiatric evaluation 3, 1
• Inadequate safety planning—facilitate safe environment, one-to-one observation, and harm-reduction interventions when risk identified 3
• MAOI interactions—allow at least 14 days between discontinuing MAOI and starting sertraline, and vice versa 5
• Serotonin syndrome risk—do not start sertraline in patients receiving linezolid or IV methylene blue 5

Assessment Pitfalls

• Assuming anxiety is solely cancer-related—individuals with GAD have worries about multiple noncancer topics and life areas 3
• Ignoring cultural factors—use culturally sensitive assessments and treatments 3
• Not tailoring assessment for cognitive impairment—adjust approach for patients with learning disabilities or dementia 3
• Failing to assess duration and chronicity—anxiety disorders require persistent symptoms, not transient stress reactions 1, 8