What history questions should be asked for a patient presenting with apprehension (anxiety)?

History Taking for Apprehension (Anxiety)

When evaluating a patient presenting with apprehension or anxiety, begin with open-ended questions about current concerns, then systematically assess for specific anxiety symptoms, risk factors, functional impairment, and safety concerns using validated screening tools like the GAD-7. 1

Initial Approach

Start with general, non-threatening inquiries that allow patients to present concerns in their own terms, as this approach is associated with more complete problem presentations and higher patient satisfaction 2, 3:

• "What can I do for you today?" or "How have you been doing?"
• "What kinds of things have been on your mind or stressing you lately?" 4
• "How have things been going with [school, work, relationships, family]?" 4

Immediate Safety Assessment

First and foremost, assess for risk of harm to self or others 1:

• "Have you ever thought about killing yourself or wished you were dead?" 4
• "Have you ever done anything on purpose to hurt or kill yourself?" 4
• If positive responses: inquire about specific plans, access to firearms, and timeline 4
• Screen for psychosis, severe agitation, or confusion (delirium) that may warrant emergency evaluation 1

Core Anxiety Symptom Assessment

Use the GAD-7 scale to systematically assess symptoms over the past 2 weeks 1, 5:

• Feeling nervous, anxious, or on edge
• Not being able to stop or control worrying
• Worrying too much about different things
• Having trouble relaxing
• Being so restless that it is hard to sit still
• Becoming easily annoyed or irritable
• Feeling afraid, as if something awful might happen 5

Important caveat: Patients with generalized anxiety disorder may not present with overt "anxiety" but rather describe "concerns," "fears," or "worries" that are disproportionate to actual risk 1

Pertinent Risk Factors and History

Systematically inquire about the following risk factors 1:

Psychiatric History

• Personal history: Prior anxiety disorders with or without treatment 1
• Family history: Familial history of anxiety disorders 1
• Comorbid conditions: Other psychiatric disorders, particularly mood disorders (depression commonly co-occurs with anxiety) 1

Substance Use

• Current alcohol or substance use or abuse 1
• History of alcohol or substance use or abuse 1

Medical History

• Presence of other chronic medical illnesses 1
• Medical causes of anxiety symptoms (hyperthyroidism, cardiac conditions, medication side effects) 6

Functional Impairment Assessment

Determine the impact on daily functioning, as this guides treatment intensity 1, 6:

• Home and relationship functioning
• Social functioning and interactions
• Occupational or academic performance
• Duration of symptoms and their progression 6
• Presence of associated symptoms: fatigue, sleep disturbances, irritability, concentration difficulties 1

Characterization of Worries

Distinguish between situational concerns and generalized anxiety disorder 1:

• Are worries focused on a single issue or multiple areas of life?
• Are the worries disproportionate to actual risk?
• Do worries extend beyond the immediate presenting concern to other life domains? 1

Comorbid Anxiety Disorders

Screen for other anxiety disorder presentations 1:

• Panic disorder: Unexpected panic attacks with physical symptoms (palpitations, sweating, trembling, shortness of breath) 6, 7
• Social anxiety disorder: Fear of social or performance situations 1
• Specific phobias: Excessive fear of specific objects or situations 1
• PTSD: History of trauma with re-experiencing, avoidance, and hyperarousal symptoms 1

Severity Stratification

Based on GAD-7 scores, categorize symptom severity 1, 5:

• None/mild (0-4 points): Minimal functional impairment, effective coping skills
• Moderate (5-9 points): Mild to moderate functional impairment, may present as multiple worries
• Moderate to severe/severe (10-21 points): Marked interference with functioning, requires referral for formal diagnosis and treatment 1

Common Pitfalls to Avoid

• Don't dismiss vague complaints: Patients may present with somatic symptoms (palpitations, dizziness, shortness of breath) rather than explicitly stating they feel anxious 7
• Don't overlook substance-induced anxiety: Always assess for medical and substance-related causes before attributing symptoms to primary anxiety disorder 6
• Don't skip safety assessment: Even if anxiety seems mild, always screen for suicidality, as anxiety disorders increase suicide risk 4
• Don't use closed-ended confirmatory questions initially: Starting with "You're here for anxiety, right?" limits patient disclosure compared to open-ended inquiries 2, 3