How to document and manage a client with severe anxiety and social anxiety?

Documentation and Management of Severe Anxiety with Social Anxiety Disorder

Document the diagnosis using validated screening tools with established cutoffs, specifically the GAD-7 for generalized anxiety symptoms and the Mini-SPIN for social anxiety disorder, recording both the numerical scores and the specific symptoms that meet DSM-V criteria for social anxiety disorder. 1, 2

Initial Documentation Requirements

Screening and Assessment Tools

• Use the GAD-7 scale to quantify overall anxiety severity, with scores of 10-14 indicating moderate to severe symptoms and scores of 15-21 indicating severe symptomatology requiring immediate referral to mental health specialists 1
• Use the Mini-SPIN screening tool specifically for social anxiety disorder, with a cutoff score of ≥6 points demonstrating 89% sensitivity and 90% specificity in primary care populations 2
• Document the exact numerical scores from both instruments at baseline, as these provide clinically meaningful data for monitoring treatment response 1

Core Diagnostic Features to Document

• Marked and persistent fear of social situations where scrutiny by others may occur, including public speaking, work performance, eating in front of others, or meeting new people 2, 3, 4
• Physical symptoms during social exposure, such as panic attacks, trembling, sweating, tachypnea, tachycardia, palpitations, hyperhidrosis, flushing, and sweaty palms 1, 4
• Avoidance behaviors or endurance with intense anxiety when facing feared social situations 3, 4
• Duration of symptoms lasting typically 6 months or more 2
• Functional impairment in occupational, academic, social, or family domains—document specific examples of how the disorder affects daily functioning 1, 5

Critical Safety Assessment

• Immediately assess for risk of harm to self or others before proceeding with any other documentation or treatment planning 1
• If risk is present, document this as requiring emergency psychiatric evaluation and implement one-to-one observation with harm-reduction interventions 1

Comprehensive Clinical Documentation

Symptom Characterization

• Document whether the patient recognizes that the fear is excessive or unreasonable relative to the actual threat 3, 4
• Note if anxiety symptoms present as "concerns" or "fears" that may be disproportionate to actual risk (e.g., excessive fear of negative evaluation) 1
• Record associated symptoms including fatigue, sleep disturbances, irritability, and concentration difficulties 1
• Document any comorbid conditions, particularly other anxiety disorders (panic disorder, generalized anxiety disorder), mood disorders, or substance use disorders 1, 6

Historical and Risk Factors

• Family history of anxiety disorders with or without prior treatment 1
• History of other chronic illnesses 1
• Presence or history of alcohol or substance use or abuse 1
• Early onset and chronicity of symptoms 7
• Prior treatment history and response 1

Differential Diagnosis Considerations

• Rule out medical causes of anxiety symptoms (uncontrolled pain, infection, electrolyte imbalance, delirium) 1
• Rule out substance-induced anxiety 1
• Consider other anxiety disorders that may be comorbid, including panic disorder, specific phobias, obsessive-compulsive disorder, and post-traumatic stress disorder 1
• Document if symptoms overlap with avoidant personality disorder, which may lie on the social anxiety disorder spectrum 7

Treatment Documentation and Monitoring

First-Line Treatment Options

• Cognitive Behavioral Therapy (CBT) is the psychotherapy with the highest level of evidence, delivered by a skilled therapist over approximately 12 sessions, including cognitive restructuring, gradual exposure to feared social situations, and relapse prevention 2, 6, 8
• SSRIs (sertraline, paroxetine, or escitalopram) are first-line pharmacotherapy, with sertraline dosed at 50-200 mg/day for social anxiety disorder 2, 3, 6, 8
• Document the rationale for treatment selection based on symptom severity, patient preference, prior treatment response, comorbidities, and access to care 1, 6

Monitoring Schedule and Documentation

• Reassess using the same validated tools (GAD-7, Mini-SPIN) at 0,8, and 16 weeks to monitor treatment response 1
• Document symptom improvement or treatment dropout at each assessment point 1
• For pharmacotherapy, continue medications for 6-12 months after remission 8
• For social anxiety disorder specifically, maintenance treatment efficacy is demonstrated for up to 24 weeks following initial 20-week treatment response 3

Stepped-Care Documentation

• For mild to moderate symptoms (GAD-7: 5-9), document management with usual supportive care or single-modality treatment 1
• For moderate to severe symptoms (GAD-7: 10-14), document referral to mental health specialist for CBT or initiation of SSRI monotherapy 1
• For severe symptoms (GAD-7: 15-21), document immediate referral to psychiatry or psychology for diagnostic confirmation and combination treatment 1

Common Pitfalls to Avoid

• Never write work excuse letters or provide accommodations that reinforce avoidance behavior, as avoidance is the core maintaining factor in social anxiety disorder 2
• Avoid using the GAD-7 alone for social anxiety disorder diagnosis, as it may miss performance-focused anxiety that is not generalized worry 2
• Do not delay appropriate treatment by failing to use validated screening tools with established cutoffs 1
• Avoid benzodiazepines for routine long-term use due to risk of abuse, dependence, and cognitive impairment 1, 8
• Do not implement immediate immersion therapy without proper psychoeducation and graduated exposure, as this can be premature and potentially traumatizing 2