What is the best approach for evaluating and treating a possible anxiety disorder in an adult patient?

Evaluation of Possible Anxiety Disorder

Use the GAD-7 screening tool as your primary assessment instrument, with scores of 0-4 indicating none/mild symptoms, 5-9 indicating moderate symptoms, and 10-21 indicating moderate-to-severe/severe symptoms requiring escalated intervention. 1, 2

Initial Screening Approach

Screen all patients using a validated tool with established cut-offs that produce clinically meaningful scores. 1

• The GAD-7 is the recommended screening instrument because generalized anxiety disorder is the most prevalent anxiety disorder and commonly co-occurs with other anxiety and mood disorders 1, 2
• Alternative validated tools include the Hospital Anxiety and Depression Scale (HADS, with score ≥8 indicating significant anxiety), Penn State Worry Questionnaire (PSWQ), or Spielberger State-Trait Anxiety Inventory (STAI) 1, 2
• Screen at initial presentation and reassess at clinically appropriate intervals, particularly with changes in life circumstances or medical status 1

Critical Safety Assessment

Immediately assess for risk of harm to self or others before proceeding with further evaluation. 1

• If YES to harm risk: Refer immediately for emergency psychiatric evaluation, facilitate safe environment with one-to-one observation, and initiate harm-reduction interventions 1
• Emergency evaluation is also warranted for psychosis, severe agitation, or confusion/delirium 1

Comprehensive Clinical Evaluation

Identify specific risk factors and pertinent history that inform diagnosis and treatment planning: 1

• Family history of anxiety disorders with or without prior treatment 1
• Personal history of other psychiatric disorders, particularly mood disorders (50-60% of patients with depression have comorbid anxiety) 1
• Current or past alcohol/substance use or abuse 1
• Presence of other chronic medical illnesses 1

Rule out medical causes before confirming primary anxiety disorder: 2

• Unrelieved pain or fatigue 1, 2
• Endocrine disorders (thyroid dysfunction, pheochromocytoma) 2
• Infection or electrolyte imbalances causing delirium 1
• Medication side effects or withdrawal states 2

Symptom Characterization

Recognize that anxiety may present as "concerns," "fears," or "worries" rather than overt anxiety symptoms. 1

• Physical manifestations include panic attacks, trembling, sweating, tachycardia, palpitations, shortness of breath, and dizziness 2, 3
• Cognitive symptoms include excessive worry that is disproportionate to actual risk, difficulty concentrating, and anticipatory anxiety 1, 3
• Behavioral symptoms include avoidance of feared situations and functional impairment in social, occupational, or other important areas 4, 3
• Associated symptoms may include fatigue, sleep disturbances, irritability, and muscle tension 1, 3

Severity-Based Stratification

GAD-7 Score 0-4 (None/Mild): 1, 2

• No or minimal functional impairment 1
• Patient demonstrates effective coping skills and adequate social support 1
• Provide education about anxiety, stress reduction strategies, and when to seek further help 2

GAD-7 Score 5-9 (Moderate): 1, 2

• Worries extend beyond immediate medical concerns to multiple life areas 1
• Mild-to-moderate functional impairment present 1
• Fatigue, sleep disturbances, irritability, and concentration difficulties commonly present 1
• Consider psychological interventions using empirically supported treatment manuals, particularly cognitive behavioral therapy 2

GAD-7 Score 10-21 (Moderate-to-Severe/Severe): 1, 2

• Symptoms interfere moderately to markedly with daily functioning 1
• Refer to psychology and/or psychiatry for formal diagnosis and treatment 1, 2
• Combine psychological and pharmacological approaches, with first-line medications being SSRIs (e.g., sertraline) or SNRIs (e.g., venlafaxine extended-release) 2, 3
• SSRIs and SNRIs demonstrate small-to-medium effect sizes compared to placebo (SMD -0.55 for GAD) 3

Assessment of Comorbidity

Always screen for depression using validated instruments, as 50-60% of patients with anxiety have comorbid depressive disorders. 1

• Use PHQ-9 for depression screening alongside GAD-7 1
• When both conditions are present, typical practice is to treat depression first, though combined treatment may be necessary 1
• Consider other anxiety disorder subtypes including panic disorder (6.8% prevalence), social anxiety disorder (6.2% prevalence), specific phobias, and PTSD 1, 3

Treatment Selection Considerations

When selecting pharmacotherapy, consider adverse effect profiles, potential drug interactions with current medications, response to prior treatments, and patient preference. 1, 2

• Cognitive behavioral therapy demonstrates large effect sizes for GAD (Hedges g = 1.01) and small-to-medium effects for social anxiety and panic disorder 3
• Avoid benzodiazepines for routine or long-term use due to abuse potential, dependence risk, cognitive impairment, and increased mortality 2, 5
• Sertraline is FDA-approved for panic disorder, PTSD, social anxiety disorder, and PMDD, making it a versatile first-line option 4

Follow-Up Protocol

Assess treatment response at 4 weeks and 8 weeks after initiating treatment, then monthly until symptoms stabilize. 2

• Use standardized instruments (GAD-7, HADS, or BAI) at each assessment to objectively track progress 2
• Evaluate medication side effects, adherence, and patient satisfaction at each visit 2
• If minimal improvement occurs by 8 weeks despite good adherence, modify the approach by adding psychological intervention to medication, changing medication class, or switching therapy format 2
• Do not wait beyond 8 weeks to adjust inadequate treatment, as this delays recovery and increases suffering 2
• After achieving remission, continue medications for 6-12 months before considering discontinuation 6

Common Pitfalls to Avoid

• Do not dismiss patient concerns, as this increases anxiety and erodes trust 2
• Do not rely solely on clinical impression; always use standardized instruments to track progress objectively 2
• Do not assume patients follow through with referrals; actively verify attendance and identify barriers 2
• Do not overlook subthreshold anxiety symptoms, which are 2-4 times more common than full disorders and benefit from early intervention 1
• Do not use formal DSM diagnostic criteria as a prerequisite for treatment in primary care settings, where functional assessment is more practical 1