What is the best approach to assess and manage a middle-aged adult patient with symptoms of anxiety, including feeling on edge, trouble sleeping, muscle tension, and excessive worrying that interferes with concentration, and potentially has a history of stress or anxiety disorders?

Interview Script for Assessing Generalized Anxiety Disorder

Begin with the GAD-7 screening tool to systematically assess anxiety symptoms and determine severity, as this validated instrument guides treatment intensity and is recommended by the American College of Physicians for primary care settings. 1

Opening and Chief Complaint

• Start by asking: "Over the past two weeks, how often have you been bothered by feeling nervous, anxious, or on edge?" and "How often have you been unable to stop or control worrying?" 1
• These two questions comprise the GAD-2 ultra-short screen, with a score ≥3 indicating need for full GAD-7 assessment 1
• Document the patient's own words describing their worry and how it feels uncontrollable 1

Complete GAD-7 Assessment

Administer all seven questions using the standardized format, asking about the past two weeks 1:

• "How often have you been bothered by worrying too much about different things?" 1
• "How often have you had trouble relaxing?" 1
• "How often have you been so restless that it is hard to sit still?" 1
• "How often have you become easily annoyed or irritable?" 1
• "How often have you felt afraid, as if something awful might happen?" 1

Score each item as: 0 (not at all), 1 (several days), 2 (more than half the days), 3 (nearly every day). 1

Immediate Safety Assessment

Before proceeding further, screen for safety concerns that require immediate psychiatric referral: 2

• "Have you had any thoughts of hurting yourself or ending your life?" 2
• "Have you had thoughts of harming anyone else?" 2
• "Have you experienced any confusion, seeing or hearing things that others don't, or feeling like people are out to get you?" 2

Any positive response requires immediate psychiatric evaluation or emergency department referral 2

Assess Functional Impairment

• Ask: "How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?" 1
• Request specific examples: "Can you give me examples of times when anxiety prevented you from doing something important?" 2
• Document concrete instances such as missing work, avoiding social situations, difficulty completing household tasks, or relationship conflicts 2

Duration and Pattern Assessment

• "How long have you been experiencing these symptoms of worry and anxiety?" 1
• "Do you worry about multiple different things, or is it focused on one specific concern?" 1
• GAD requires worry about multiple domains for at least 6 months, distinguishing it from adjustment disorder which has a clear precipitating stressor within 3 months 1

Screen for Comorbid Depression

Administer the PHQ-2 at minimum, as depression co-occurs in approximately 31% of anxiety disorder patients: 1, 3

• "Over the past two weeks, how often have you had little interest or pleasure in doing things?" 1
• "How often have you been feeling down, depressed, or hopeless?" 1

If either scores ≥1, complete the full PHQ-9 to assess for major depressive disorder 1

Substance Use Screening

Systematically assess substance use, as it frequently complicates anxiety disorders and requires concurrent treatment: 2

• "How many alcoholic drinks do you have per week?" 2
• "Have you used alcohol or any substances to help manage your anxiety or help you sleep?" 2
• "Do you use marijuana, prescription medications not prescribed to you, or other substances?" 2

Medical and Psychiatric History

• "Do you have any chronic medical conditions like thyroid problems, heart disease, or chronic pain?" 2
• "Have you been diagnosed with anxiety or depression in the past?" 2
• "Has anyone in your family been diagnosed with anxiety, depression, or other mental health conditions?" 2
• "What medications are you currently taking, including over-the-counter and supplements?" 1

Screen for Other Anxiety Disorders

Assess for panic disorder: 1

• "Have you experienced sudden episodes of intense fear or discomfort that reach a peak within minutes?" 1
• "During these episodes, do you experience symptoms like racing heart, sweating, shaking, shortness of breath, or fear of dying?" 1

Screen for social anxiety: 4

• "Do you experience significant anxiety in social situations or when you might be observed or judged by others?" 4

Assess for PTSD if relevant: 1

• "Have you experienced or witnessed a traumatic event that continues to cause distressing memories, nightmares, or flashbacks?" 1

Assess Current Coping and Support

• "What have you tried so far to manage your anxiety?" 2
• "Do you have family or friends you can talk to about your concerns?" 2
• "Have you tried therapy, counseling, or medications for anxiety in the past? What was helpful or unhelpful?" 2

Interpretation and Next Steps Based on GAD-7 Score

Score 0-4 (minimal): Provide reassurance and education about stress management; no treatment indicated 2

Score 5-9 (mild): Offer low-intensity interventions including psychoeducation, guided self-help, and active monitoring with follow-up in 2-4 weeks 2

Score 10-14 (moderate): Refer to psychology/psychiatry for formal diagnosis and treatment; if access is limited, consider initiating SSRI/SNRI while awaiting specialist evaluation 2

Score 15-21 (severe): Immediate referral to mental health specialist for comprehensive evaluation and treatment initiation 2

Common Pitfalls to Avoid

• Do not miss comorbid depression—always screen with PHQ-9 when GAD is suspected, as treatment approach differs with comorbidity 2, 3
• Do not overlook substance use disorders, which require concurrent treatment and complicate anxiety management 2
• Do not attribute all somatic symptoms to anxiety without medical evaluation—muscle tension, fatigue, and sleep disturbance can indicate underlying medical conditions 1
• Do not confuse GAD with adjustment disorder—GAD involves worry about multiple domains for ≥6 months, while adjustment disorder has a clear stressor within 3 months 1