How should I evaluate and manage an adult with two weeks of generalized anxiety, palpitations, insomnia, mild hypotension, and tachycardia?

Evaluation and Management of Generalized Anxiety with Palpitations, Insomnia, and Hemodynamic Changes

This patient requires immediate exclusion of secondary medical causes—particularly hyperthyroidism, cardiac arrhythmia, and substance-induced anxiety—before confirming a primary anxiety disorder, followed by structured GAD assessment and initiation of combined SSRI therapy with cognitive behavioral therapy for moderate-to-severe symptoms.

Immediate Medical Evaluation Required

The combination of tachycardia, hypotension, palpitations, and anxiety mandates urgent exclusion of life-threatening conditions before attributing symptoms to a primary anxiety disorder:

• Check thyroid function (TSH, free T4) to rule out hyperthyroidism, which commonly presents with anxiety, palpitations, tachycardia, and weight loss 1, 2
• Obtain 12-lead ECG to exclude cardiac arrhythmias, particularly supraventricular tachycardia, which can present with palpitations and anxiety-like symptoms 1
• Assess for anemia (complete blood count), dehydration (orthostatic vital signs, electrolytes), and hyperparathyroidism (calcium level), all of which cause secondary tachycardia and anxiety symptoms 1, 3, 2
• Screen for substance use, including caffeine excess, stimulant medications (albuterol, decongestants), illicit drugs (amphetamines, cocaine), and alcohol withdrawal 1, 3
• Review all current medications for anxiety-inducing agents such as corticosteroids or bronchodilators 1, 3

The Heart Rhythm Society emphasizes that anxiety is an important trigger for inappropriate sinus tachycardia, but structural heart disease and secondary causes must be excluded first 1. The mild hypotension is concerning and atypical for primary anxiety alone, warranting careful cardiovascular assessment.

Structured Anxiety Assessment

Once medical causes are excluded, proceed with systematic GAD evaluation:

Use GAD-7 Screening Tool

• Administer the 7-item GAD-7 scale to quantify anxiety severity over the past 2 weeks, which has excellent reliability (Cronbach's alpha 0.92) and diagnostic accuracy (sensitivity 89%, specificity 82%) 1, 4, 5
• Interpret scores using validated thresholds: 0-4 (minimal), 5-9 (mild), 10-14 (moderate), 15-21 (severe) 1, 4, 6
• The GAD-7 assesses: feeling nervous/anxious/on edge, inability to control worry, excessive worry about different things, trouble relaxing, restlessness, irritability, and fear something awful will happen 1

Assess for Safety Concerns

• Screen immediately for suicidal ideation, self-harm thoughts, or intent to harm others—any positive response requires emergency psychiatric evaluation 4
• Evaluate for severe agitation, psychotic symptoms, or confusion/delirium, which warrant urgent specialist referral 1, 4

Determine Functional Impairment

• Ask specific questions about interference with work attendance, household task completion, social avoidance, and relationship functioning 1, 4
• Moderate GAD typically causes mild-to-moderate functional impairment, while severe GAD markedly interferes with daily activities 4

Screen for Comorbidities

• Administer PHQ-2 or PHQ-9 to screen for major depressive disorder, which co-occurs in approximately 31% of GAD cases 1, 4
• Assess alcohol and substance use/abuse, as these frequently complicate anxiety disorders and require concurrent treatment 1, 4
• Screen for other anxiety disorders including panic disorder (recurrent unexpected panic attacks) and social phobia, which have different treatment implications 1, 6

Treatment Algorithm Based on Severity

For GAD-7 Score 10-14 (Moderate Anxiety)

Refer to psychology/psychiatry for formal diagnosis and treatment, as guidelines recommend specialist involvement at this severity level 1, 4. While awaiting specialist evaluation:

• Initiate an SSRI (sertraline 25-50 mg daily preferred due to extensive evidence base and lower QT prolongation risk) or SNRI (venlafaxine extended-release) as first-line pharmacotherapy 7, 5, 8
• Provide education about GAD, including that it involves excessive worry about multiple life domains (not just health), is chronic and relapsing, but highly treatable 1, 6, 3
• Offer guided self-help based on cognitive behavioral therapy principles, including behavioral activation and problem-solving strategies 1
• Schedule follow-up in 2-4 weeks to reassess symptoms using GAD-7 and monitor for medication side effects 4, 7

For GAD-7 Score 15-21 (Severe Anxiety)

Immediate referral to mental health specialist is mandatory for combined pharmacotherapy and psychotherapy 1, 4, 6. Severe symptoms require:

• Start SSRI/SNRI immediately while arranging specialist care 5, 8
• Initiate cognitive behavioral therapy as soon as possible, which has large effect sizes for GAD (Hedges g = 1.01) and is the most strongly supported psychological treatment 5, 9
• Combined treatment (medication plus CBT) achieves superior outcomes compared to either modality alone 7, 5

For GAD-7 Score 5-9 (Mild Anxiety)

• Offer low-intensity interventions: education, active monitoring, guided self-help, or group psychosocial interventions 1, 6
• Reassess in 2-4 weeks with repeat GAD-7 to determine if symptoms are worsening 4

Pharmacotherapy Specifics

SSRIs and SNRIs are first-line agents with demonstrated efficacy in meta-analyses (GAD: SMD -0.55,95% CI -0.64 to -0.46) 5, 8, 9:

• Sertraline 25-50 mg daily is preferred initially, with titration to 50-200 mg daily based on response 7, 5
• Venlafaxine extended-release is an alternative SNRI with sustained long-term benefit and dual noradrenergic-serotonergic action 8, 3
• Continue medication for 6-12 months after symptom remission, then taper gradually over 2-3 months to prevent recurrence 7
• Avoid benzodiazepines for long-term treatment due to cognitive impairment, abuse potential, dependence risk, and severe withdrawal symptoms 1, 7, 3

Critical Pitfalls to Avoid

• Do not miss comorbid depression—always screen with PHQ-9, as GAD and major depression frequently co-occur and require combined treatment 1, 4
• Do not overlook substance use disorders, which complicate anxiety management and require concurrent treatment 1, 4
• Do not dismiss the hypotension and tachycardia as "just anxiety"—complete the medical workup first, as these findings may indicate inappropriate sinus tachycardia, dehydration, or other pathology 1, 7
• Do not prescribe SSRIs without concurrent psychotherapy when feasible, as combination therapy achieves superior outcomes 7, 5
• Do not restart benzodiazepines if the patient has prior use, given the high risk of dependence and severity of withdrawal 7

Ongoing Monitoring

• Reassess every 2-4 weeks using GAD-7 and PHQ-9 to track symptom response 4, 7
• Monitor for medication adherence, side effects, and adverse events at each visit 1
• After 8 weeks of treatment, if symptom reduction is poor despite good compliance, alter the treatment course by switching medications or intensifying psychotherapy 1
• Optimize psychotherapy engagement by addressing barriers to therapy adherence 7