What are the clinical manifestations of anxiety?

Signs and Symptoms of Anxiety

Anxiety disorders manifest through three primary domains: psychological symptoms (excessive worry, fear-laden thoughts, rumination), physical symptoms (palpitations, tremor, sweating, muscle tension, shortness of breath), and behavioral signs (avoidance, restlessness, irritability, functional impairment). 1

Psychological and Cognitive Symptoms

• Excessive, uncontrollable worry about everyday situations is the hallmark psychological symptom, particularly when it persists most days for at least 6 months 1, 2
• Worry- or fear-laden thought content with perseverative or ruminative thinking patterns 1
• Fear of negative evaluation by peers, especially prominent in social anxiety presentations 1
• Difficulty concentrating or distractibility 1, 3
• Anticipatory anxiety about future events or potential threats 4

Physical and Somatic Symptoms

The physical manifestations of anxiety are often what drive patients to seek medical attention:

• Cardiovascular symptoms: palpitations, tachycardia, chest discomfort 4
• Respiratory symptoms: shortness of breath, feeling of choking 4
• Neurological symptoms: dizziness, tremor, paresthesias 4
• Musculoskeletal symptoms: muscle tension, restlessness, being easily fatigued 3
• Autonomic symptoms: sweating, hot flashes or chills 2
• Sleep disturbance: difficulty falling or staying asleep 3
• Gastrointestinal distress and nausea 5

Observable Behavioral Signs

During mental status examination, clinicians should look for these nonspecific but supportive findings:

• Poor eye contact, shy demeanor, or clinginess 6
• Tremor, fidgetiness, restlessness, or "nervous" habits (nail-biting) 6, 1
• Hypervigilance and exaggerated startle response 6
• Poverty of speech or pressured speech patterns 6
• Irritability and agitation, which may be the predominant presentation rather than overt anxiety 6, 3
• Avoidance behaviors of anxiety-provoking situations 1, 4

Important caveat: These observable signs are nonspecific to anxiety and may be absent even in severe cases; they should never be used in isolation for diagnosis 6

Functional Impairment Indicators

Clinically significant anxiety must cause distress or functional impairment across multiple domains:

• Declining academic or occupational performance 1
• Withdrawal from peer relationships and social isolation 1
• Interference with family functioning and daily activities 1, 4
• School refusal or work avoidance 1

Disorder-Specific Presentations

Generalized Anxiety Disorder (GAD)

• Chronic, pervasive worry about multiple topics (health, finances, family, work) with physical symptoms dominating 1, 2
• Difficulty controlling the worry despite recognizing it as excessive 2

Panic Disorder

• Recurrent unexpected panic attacks with abrupt surge of intense fear 1, 7
• Physical manifestations include palpitations, sweating, trembling, chest pain, nausea, dizziness 7
• Anticipatory anxiety about future attacks leading to avoidance 7

Social Anxiety Disorder

• Excessive fear of negative evaluation by others 1
• Marked avoidance of social or performance situations 1
• May present as selective mutism in severe cases 1

Separation Anxiety Disorder

• Developmentally inappropriate distress about separation from attachment figures 1
• School refusal and reluctance to be alone 1

Critical Red Flags Requiring Immediate Attention

• Suicidal ideation or self-harm behaviors (present in approximately 24% of anxious adolescents, with 6% having made suicide attempts) 1
• Severe agitation or psychotic symptoms 8
• Comorbid depression, especially GAD with depression, which carries the greatest suicide risk 1, 7
• Substance use as self-medication 1

Common Diagnostic Pitfalls to Avoid

Before confirming an anxiety disorder diagnosis, always rule out medical conditions that mimic anxiety:

• Hyperthyroidism: causes anxiety, palpitations, tremor, sweating, heat intolerance 8, 7
• Hypoglycemia/diabetes: triggers panic-like symptoms with autonomic activation 7
• Cardiac arrhythmias: can initiate or mimic panic attacks 7
• Substance intoxication (stimulants, caffeine, cannabis) or withdrawal states 8
• Other endocrine, respiratory, and neurological disorders 8

Order thyroid function tests and glucose levels when clinical presentation suggests these conditions 8

Screening and Assessment Tools

• GAD-7: validated for patients ≥8 years; scores of 10-14 indicate moderate-severe anxiety, 15-21 indicate severe anxiety requiring immediate intervention 1, 7
• SCARED (Screen for Child Anxiety Related Emotional Disorders): parent and child versions available for comprehensive assessment 6, 1
• Spence Children's Anxiety Scale (SCAS): captures broader range of anxiety symptoms across subtypes 6

Systematic screening is recommended for all adolescents 8 years and older using these validated tools 1