Assessment

Assessment of a person presenting with anxiety begins with a full psychiatric history. The history of the presenting complaint should establish whether the symptoms of generalised anxiety or panic attacks are present. It is often helpful to ask about a recent time when symptoms were severe and then enquire about the events leading up to it, the environment in which it occurred, who was present, what thoughts accompanied the anxiety and how it was resolved. This can help establish whether there is a phobic element or other triggers and maintaining factors for the anxiety, which will be relevant when considering psychological treatment.

The differential diagnosis of anxiety disorders is shown in Figure 1. It is important to exclude depressive disorder in every case by asking questions about mood, suicidal thoughts, sleep, appetite and energy. Alcohol and substance misuse often occurs as a result of ‘self-medication’ for anxiety disorder and withdrawal states are often accompanied by anxiety. A full blood count and liver function test may reveal covert alcohol problems. Schizophrenia should also be considered. A person with agoraphobia may be unable to go to a supermarket because of the fear of having a panic attack there. In contrast, a patient with schizophrenia may avoid the supermarket because of the delusional belief that their movements in shops are monitored on video cameras by terrorists.

Fig. 1 Differential diagnosis of anxiety disorders.

As anxiety can present with symptoms in virtually any system of the body, the potential list of physical differential diagnoses is long. The majority can be excluded by the history and physical examination alone. There is a tendency to over-investigate these patients, and it is important to limit the investigations to those needed to exclude a real diagnostic possibility based upon positive findings on history and examination.

Treatment

Drug, psychological and social treatments should be discussed with the patient. The anxiety disorder in itself can place limitations on the treatment options – people with severe social phobia will avoid group treatments and asking someone with agoraphobia to attend a clinic two bus rides away from their home is unlikely to be successful! A collaborative approach to treatment is therefore vital.