How to diagnose and treat anxiety as part of a primary mental disorder?

Discerning Anxiety as Part of a Primary Mental Disorder

To diagnose anxiety as a primary mental disorder, you must confirm that excessive fear or worry causes clinically significant distress or functional impairment for at least 6 months, while systematically ruling out medical conditions (thyroid disorders, cardiac disease), substance-induced causes (caffeine, medications, alcohol withdrawal), and other psychiatric disorders that better explain the presentation. 1, 2

Core Diagnostic Requirements

The American Psychiatric Association requires that all anxiety disorders meet specific criteria that distinguish pathological anxiety from normal worry 2:

• Excessive fear or worry that is developmentally inappropriate and out of proportion to the actual threat 1, 2
• Duration of at least 6 months for most anxiety disorders in adults 1, 2
• Clinically significant distress or functional impairment in social, occupational, or academic functioning—normal developmental fears without impairment do not qualify for diagnosis 1, 2
• Exclusion of other causes including substance/medication effects, medical conditions, and other mental disorders 1, 2

Systematic Screening Approach

Begin with standardized screening tools rather than relying solely on spontaneous patient report 1:

• GAD-7 scale is the validated first-line screening tool for primary care, with scores ≥8-10 indicating moderate-severe anxiety requiring comprehensive evaluation 1, 3, 2
• GAD-2 (first two questions of GAD-7) serves as an ultra-short screen with a cutoff of ≥3 points (sensitivity 89%, specificity 82%) 1
• Mini-SPIN (3-item tool) screens specifically for social anxiety disorder with a cutoff of ≥6 points (sensitivity 89%, specificity 90%) 1
• For children and adolescents, use the APA Level 1 Cross-Cutting Symptom Measures or age-appropriate scales like SCARED or Spence Children's Anxiety Scale 1, 4

Distinguishing Primary Anxiety from Normal Worry

Clinical anxiety differs from developmentally normal fears by specific characteristics 1, 4:

• Excessive intensity beyond what is expected for the situation 1
• Duration beyond developmental stage—normal fears include stranger anxiety in infants, separation anxiety in toddlers, supernatural creatures in preschoolers, physical well-being concerns in school-aged children, and social concerns in adolescents 1
• Inability to control the worry despite reassurance 4
• Significant functional impairment in daily activities 2, 4

Specific Anxiety Disorder Patterns

Once screening is positive, identify the specific anxiety disorder subtype 1:

• Generalized Anxiety Disorder (GAD): Excessive, uncontrollable worries about multiple everyday situations with physical symptoms (muscle tension, restlessness, fatigue, concentration difficulties, irritability, sleep disturbance) 1, 3, 5
• Panic Disorder: Recurrent unexpected panic attacks with at least 4 of 13 symptoms (palpitations, sweating, trembling, shortness of breath, choking, chest pain, nausea, dizziness, derealization, fear of losing control, fear of dying, paresthesias, chills/hot flushes) 1, 5, 6
• Social Anxiety Disorder: Marked fear of social or performance situations involving scrutiny by others, with fears of humiliation or embarrassment 1, 6
• Specific Phobia: Marked, intense fear of a specific object or situation that is actively avoided or endured with intense distress 2
• Agoraphobia: Fear of situations where escape might be difficult or help unavailable 1, 2

Medical Differential Diagnosis (Critical Step)

You must systematically rule out medical conditions that mimic or cause anxiety before diagnosing a primary anxiety disorder 3, 2, 4:

Endocrine disorders:

• Hyperthyroidism (check TSH, free T4) 3, 4
• Hypoglycemia (check glucose) 2

Cardiac conditions:

• Arrhythmias (obtain ECG) 3, 2
• Coronary artery disease 3

Respiratory disorders:

• Asthma 2, 4
• Chronic obstructive pulmonary disease 4

Neurological conditions:

• Migraines 2
• Seizure disorders 4

Substance-induced causes:

• Caffeine excess 2, 4
• Medications (stimulants, corticosteroids, thyroid hormones) 1, 2
• Illicit drug use (cocaine, amphetamines) 2, 4
• Alcohol withdrawal 2, 4

Psychiatric Comorbidity Assessment

Anxiety disorders frequently co-occur with other psychiatric conditions that must be systematically evaluated 2, 4, 7:

• Major depressive disorder (most common comorbidity) 2, 4, 7
• Other anxiety disorders (patients often have multiple anxiety disorders) 2, 4
• Substance use disorders 2, 4, 8
• Post-traumatic stress disorder 4
• Obsessive-compulsive disorder 4
• Attention-deficit/hyperactivity disorder 2

The presence of comorbidity generally indicates more severe symptoms, greater clinical burden, and greater treatment difficulty 9

Functional Impairment Quantification

Document specific impairments to confirm clinical significance 2, 4:

• Occupational/academic functioning: missed work/school days, decreased productivity, inability to complete tasks 4
• Social relationships: avoidance of social situations, relationship conflicts, isolation 4
• Self-care and daily activities: difficulty with routine tasks, neglect of responsibilities 4
• Quality of life: overall distress and life satisfaction 3, 4

Structured Diagnostic Interview

After positive screening, conduct a comprehensive diagnostic interview 1:

Interview structure:

• Interview parent/guardian and patient separately and together as developmentally indicated 1
• Use multiple age-appropriate assessment techniques (direct questioning, symptom rating scales, behavioral observation) 1
• Gather collateral information from family members, teachers, primary care clinicians with appropriate consent 1

Key diagnostic questions:

• Specific nature and pattern of anxiety symptoms 4
• Worry characteristics (content, frequency, controllability) 4
• Physical manifestations (autonomic symptoms, muscle tension) 4
• Panic symptoms (frequency, triggers, duration) 4
• Avoidance behaviors (situations avoided, impact on functioning) 4
• Social fears (specific situations, degree of distress) 4

Safety Assessment

Evaluate immediate safety concerns in every patient with anxiety 4:

• Suicidal ideation (requires immediate psychiatric referral if present) 3, 4
• Self-harm behaviors 4
• Harm to others 3

Treatment Implications

Once primary anxiety disorder is confirmed, initiate evidence-based treatment 3, 7, 8:

First-line psychotherapy:

• Cognitive Behavioral Therapy (CBT) has the highest level of evidence with large effect sizes for GAD (Hedges g = 1.01) and small-to-medium effects for social anxiety disorder and panic disorder 3, 7

First-line pharmacotherapy:

• SSRIs (particularly sertraline) are first-line medications with small-to-medium effect sizes compared to placebo 3, 6, 7, 8
• SNRIs (venlafaxine extended release) are also first-line options 7, 8
• For moderate-severe anxiety (GAD-7 ≥10), combine SSRI with CBT as this is superior to either alone 3

Avoid benzodiazepines for routine use due to decreased long-term effectiveness, minimal treatment of psychic symptoms, and risk of dependence 8, 10

Common Pitfalls to Avoid

• Do not diagnose anxiety disorder based on screening tools alone—positive screens require comprehensive diagnostic interview to confirm DSM-5 criteria 1, 2
• Do not overlook medical causes—thyroid and cardiac conditions commonly present with anxiety symptoms 3, 2, 4
• Do not miss comorbid depression—present in the majority of anxiety disorder patients and requires concurrent treatment 2, 4, 7
• Do not attribute all anxiety to another psychiatric disorder—anxiety disorders can be primary even when other conditions are present 1, 2
• Do not dismiss developmentally appropriate fears as pathological—consider age and developmental stage when assessing symptom severity 1, 4