Assessing Anxiety Disorders
Screening Questions
Are you a worrier?
Have you ever had a panic or anxiety attack?
Are you uncomfortable in social situations?
Do you have any special fears, such as fear of insects or of flying?
Do you have symptoms of OCD, such as needing to wash your hands all the time because you feel dirty, constantly checking things, or having annoying thoughts pop into your head repeatedly?
Do you have PTSD, which means having painful memories or dreams of a terrible experience, such as being attacked by someone or surviving a natural disaster?
Recommended time: 3 minutes
Anxiety is a common symptom and can be a frustrating diagnostic issue for beginning interviewers because of the enormous number of disorders that can present with anxiety. For example, many patients with major depression, mania, and schizophrenia also report significant anxiety, even in the absence of a specific anxiety disorder (Boyd 1986).
Nonetheless, it is important to be systematic about diagnosing anxiety disorders, particularly because many disorder-specific psychotherapies have been developed. For example, the cognitive-behavioral approach to the treatment of panic disorder is very different from the cognitive-behavioral approach to social phobia (Barlow 1993).
You should develop a systematic approach to asking about the seven major DSM-IV-TR anxiety disorders:
Even if you ask all the right questions, distinguishing among these anxiety disorders, especially the first four, can be tricky. A useful aid is the DSM-IV Handbook of Differential Diagnosis (First et al. 1995), which contains excellent tables to guide you in differentiating one disorder from another.
Following are suggested questions for diagnosing the anxiety disorders, along with brief reminders of the diagnostic criteria for each disorder.
PANIC DISORDER
The first step in diagnosing panic disorder is establishing that your patient has had panic attacks. Remember, however, that a panic attack does not imply panic disorder. In fact, approximately 35% of healthy people report having had a panic attack within the past year (Norton et al. 1986), whereas only 3% of the population will ever develop fullblown panic disorder (Kessler et al. 1994). Panic attacks are often responses to specific situations that people can successfully avoid (e.g., claustrophobia, specific phobias). Panic may signal a disorder other than panic disorder, such as social phobia or PTSD. Finally, many people experience panic and anxiety that are not quite severe enough to meet criteria for a DSM-IV-TR disorder (Table 25.1).
TABLE 25.1. DSM-IV-TR criteria for panic disorder | ||||||
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The initial screening question for panic is straightforward:
Have you ever had a panic or anxiety attack?
Most people have heard the term panic attack. However, a positive response to this question requires verification, because many people define a subpanic level of anxiety as a panic attack. This seems especially true of patients with GAD. Such patients may respond, “I’m always having a panic attack. I’m having one right now.” Other patients will ask you what you mean by a panic attack. You need to provide a good definition in lay terms to effectively diagnose panic attack:
A panic attack is a sudden rush of fear and nervousness in which your heart pounds, you get short of breath, and you’re afraid you’re going to lose control or even die. Has that ever happened to you?
In my experience, this question is highly sensitive and specific for diagnosing true panic attack. Patients who hear this definition and say unequivocally, “Oh no, I’ve been nervous before, but I’ve never had anything like that,” are unlikely to have ever had a panic attack. For patients who answer “yes,” ask them to describe the experience:
When did you last have one of these attacks? Can you describe that attack for me? What were you doing when it started? How did it make you feel, and how long did it last?
The best way to assess the clinical significance of a panic attack is to listen to your patient describe one. You will find out which anxiety symptoms are present and whether the attacks have a specific precipitant.
When you have these attacks, do you notice any of the following symptoms: sweating, shaking, tingling in your hands or lips, shortness of breath, choking, your heart pounding, chest pain, nausea, or a feeling that you’re about to die or go crazy?
Although I’ve listed all these symptoms in one paragraph for convenience, you should ask about them one by one to give your patient time to think about each. Use the symptom cluster technique (heart, breathlessness, fear) to remember each of the symptoms.
When you have a panic attack, does it come out of the blue, or do you pretty much know what’s going to cause it?
Remember that to meet criteria for panic disorder, the panic attacks have to be unexpected (i.e., out of the blue). Otherwise, panic attacks may signify social phobia, if the trigger is a social situation; PTSD, if the trigger is a flashback; agoraphobia, if the trigger is a hard-to-escape place; or a specific phobia with a variety of possible triggers.
Has one of these attacks ever woken you up at night?
Do you remember when you had your first panic attack?
These two questions will increase the specificity of your exploration. If a patient is awakened at night by panic, it’s very likely a true, unexpected panic attack. (Some clinicians would also wonder about a history of sexual abuse.) In addition, people with true panic disorders often distinctly remember their first panic attack.
Beyond simply establishing the bare bones of the diagnosis, you should make some attempt to assess whether the patient might be a good candidate for cognitive-behavioral therapy (CBT). In many cases, CBT works better than medication for panic disorder, particular over the long haul (Barlow 2000). Patients who will respond well to CBT are those who can identify “catastrophic cognition” in response to the panic sensations. A typical interchange follows:
Interviewer: When you have panic attacks, what exactly goes through your mind?
Patient: I think I’m going to pass out, or worse.
Interviewer: Do you think you’re going to die?
Patient: Yes, that’s when I really get scared.
Interviewer: You mean the panic sensations become more intense when you have those thoughts?
Patient: Definitely.
Interviewer: But have you ever actually passed out?
Patient: No.
Interviewer: Do you think it’s possible that your thought process makes you feel even more anxious than you’d otherwise feel?
Patient: I never thought about it that way, but I guess you’re right.
Such a patient would likely be a good prospect for referral to a cognitive-behavioral therapist after you have finished your diagnostic interview.
AGORAPHOBIA
Agoraphobia (Table 25.2) usually develops as a complication of panic disorder (American Psychiatric Association
2000). Usually, the patient has a few panic attacks and gradually begins to avoid situations that he associates with those attacks, a process termed phobic avoidance. The agoraphobic avoids situations in which a quick escape would be difficult. Typical examples include crowded places (e.g., restaurants, stores, trains, buses) and driving a car, especially in heavy traffic or far from home.
2000). Usually, the patient has a few panic attacks and gradually begins to avoid situations that he associates with those attacks, a process termed phobic avoidance. The agoraphobic avoids situations in which a quick escape would be difficult. Typical examples include crowded places (e.g., restaurants, stores, trains, buses) and driving a car, especially in heavy traffic or far from home.
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