What is the initial approach to a patient presenting with anxiety or anxious distress?

Differential Diagnoses for Anxiety or Anxious Distress

When a patient presents with anxiety or anxious distress, immediately rule out medical causes and substance-induced anxiety before diagnosing a primary anxiety disorder, then use the GAD-7 screening tool to stratify severity and guide treatment decisions. 1, 2

Immediate Safety Assessment

• Assess for imminent risk of harm to self or others - if present, refer immediately for emergency psychiatric evaluation, facilitate a safe environment with one-to-one observation, and initiate harm-reduction interventions 1
• Evaluate for psychosis, severe agitation, or delirium requiring urgent intervention 1

Medical and Substance-Induced Causes (Rule Out First)

Medical conditions must be excluded before diagnosing a primary anxiety disorder. The following conditions commonly present with anxiety symptoms 1:

• Endocrine disorders: Hyperthyroidism, hypoglycemia, pheochromocytoma, diabetes with hypoglycemic episodes 1
• Cardiovascular conditions: Arrhythmias, coronary artery disease, mitral valve prolapse 3
• Respiratory disorders: Asthma, chronic obstructive pulmonary disease, hypoxia 1
• Neurological conditions: Central nervous system disorders, migraine, seizure disorders 1
• Metabolic disturbances: Electrolyte imbalances, lead intoxication 1
• Chronic conditions: Chronic pain syndromes, chronic illness 1
• Substance-related: Caffeinism, substance intoxication or withdrawal, medication side effects 1, 4

Consider appropriate laboratory testing including thyroid function tests, glucose levels, and electrolytes in collaboration with primary care 5

Primary Anxiety Disorders (DSM-5 Criteria)

Once medical causes are excluded, evaluate for specific anxiety disorders 1:

• Generalized Anxiety Disorder (GAD) - excessive worry about multiple everyday situations or activities; most prevalent anxiety disorder and commonly comorbid with depression 1
• Panic Disorder - recurrent unexpected panic attacks with persistent concern about additional attacks 1
• Social Anxiety Disorder - marked fear or anxiety about social situations where scrutiny by others may occur 1
• Specific Phobia - marked fear about specific objects or situations (animals, natural environment, blood-injection-injury, situational) 1
• Agoraphobia - fear or anxiety about situations where escape might be difficult 1
• Separation Anxiety Disorder - excessive anxiety concerning separation from attachment figures 1
• Selective Mutism - consistent failure to speak in specific social situations 1
• Post-Traumatic Stress Disorder (PTSD) - anxiety following exposure to traumatic event 1
• Obsessive-Compulsive Disorder - presence of obsessions and/or compulsions 1

Structured Screening and Assessment Approach

Use the GAD-7 scale as the primary screening tool with the following severity stratification 2, 5:

• Mild anxiety (GAD-7: 0-9): Provide psychoeducation, active monitoring, self-help resources based on CBT principles, and structured physical activity 2
• Moderate anxiety (GAD-7: 10-14): Refer to educational and support services; consider low-intensity psychological interventions 2
• Moderate to severe/severe anxiety (GAD-7: 15-21): Implement high-intensity interventions including CBT, behavioral activation, structured physical activity, and consider pharmacotherapy 2

Alternative screening tools include the Distress Thermometer (score ≥4 indicates clinical significance) and the Patient Health Questionnaire-9 for comorbid depression 1

Comprehensive Diagnostic Interview Structure

Conduct interviews with both the patient and collateral sources (with consent) including family members, teachers, and primary care providers 5. The assessment should identify 1:

• Physical symptoms: Panic attacks, trembling, sweating, tachypnea, tachycardia, palpitations, sweaty palms 1
• Severity and duration of symptoms 1
• Functional impairment in major life areas 1
• Possible stressors and times of vulnerability 1
• Risk factors including prior psychiatric history, family history, and substance use 1

Conduct the evaluation in the patient's preferred language using interpreter services when necessary to avoid misdiagnosis 1

Comorbidity Assessment

Anxiety disorders frequently co-occur with other psychiatric conditions 5:

• Depression - present in majority of patients with anxiety; when both are present, prioritize treatment of depressive symptoms or use unified protocol 2
• Other anxiety disorders - GAD commonly comorbid with other anxiety disorders 1
• Substance use disorders - assess for current use and history of abuse 6

Patients with comorbid conditions typically experience greater impairment, earlier symptom onset, prolonged course, and increased suicide risk 6

Distinguishing Clinical Anxiety from Normal Worry

Clinically significant anxiety must be distinguished from everyday worries and normative developmental fears 1:

• Normal developmental fears vary by age: stranger anxiety in infants, separation anxiety in toddlers, supernatural creatures in preschoolers, physical well-being concerns in school-aged children, social and existential concerns in adolescents 1
• GAD worry is disproportionate to actual risk - for example, excessive fear of cancer recurrence beyond what is medically warranted 1
• Anxiety disorders cause clinically significant disturbance in cognition, emotion regulation, or behavior reflecting dysfunction in psychological, biological, or developmental processes 1

Common Pitfalls and Caveats

• Only 20% of people with anxiety disorders seek care, highlighting the need for proactive screening 2, 5
• Cautiousness and avoidance are cardinal features of anxiety, which may lead to poor follow-through with treatment recommendations 5
• Lack of appropriate linguistic support has been associated with misdiagnosis and adverse clinical outcomes 1
• Medical deterioration can be misidentified as primary anxiety - a patient with worsening cardiac or pulmonary function may present with anxiety symptoms that are actually secondary to the medical condition 4
• Medication side effects commonly cause anxiety symptoms in medically ill patients and must be considered 4

Initial Treatment Algorithm Based on Severity

For mild symptoms (GAD-7: 0-9) 2:

• Psychoeducation about anxiety
• Active monitoring with regular follow-up
• Self-help resources based on CBT principles
• Structured physical activity programs

For moderate symptoms (GAD-7: 10-14) 2:

• All interventions for mild symptoms
• Referral to educational and support services
• Low-intensity psychological interventions

For moderate to severe/severe symptoms (GAD-7: 15-21) 2:

• Cognitive Behavioral Therapy (CBT) as first-line psychological treatment with strongest evidence (effect size Hedges g = 1.01) 2, 3
• SSRIs (sertraline preferred) or SNRIs as first-line pharmacotherapy 2, 3
• Combined CBT plus SSRI shows superior outcomes compared to either alone for moderate-severe anxiety 3
• Behavioral activation and structured physical activity 2

Benzodiazepines (e.g., alprazolam starting 0.25-0.5 mg three times daily) may be used for acute symptom management but carry risk of dependence, cognitive impairment, and should be time-limited per psychiatric guidelines 1, 7

Follow-Up and Monitoring

Assess treatment response at regular intervals (4 weeks, 8 weeks, and end of treatment) using standardized measures 2. For pharmacotherapy, assess symptom relief, side effects, and patient satisfaction at 4 and 8 weeks 2. After 8 weeks of treatment with poor improvement despite good adherence, alter the treatment course by adding psychological or pharmacologic intervention, changing medication, or switching from group to individual therapy 1, 2