Anxiety Disorders ____________________________________________________________________________
with anxiety. Careful measurement and recording of resting pulse rate and blood pressure (including postural effect) are important. Patients may be uncomfortable discussing their anxiety, but physical signs of heightened sympathetic nervous system activity (e.g., tachycardia, hyperventilation, sweating, flushing) are absent in the context of a reassuring clinical encounter (excepting acute examination of a patient follow- ing panic attack). Routine examination of adolescents and young adults with recent-onset anxiety should prompt careful assessment for signs of hyperthyroidism (e.g., the stare of early proptosis; fine tremor of outstretched hands; tachycardia; brisk deep tendon reflexes). Patients with observed (or history of) vasovagal fainting, especially those suspected of specific pho- bia disorder, should be assessed for other medical conditions associated with fainting risk (including blood glucose levels and orthostatic hypotension) [2]. Diagnosis is made through self-report, clinical interview, and behavioral observation of impairments in personal, social, or occupational domains; no laboratory testing is necessary. Several empirically validated self-report questionnaires are available to assess baseline functioning and track treatment response. Assessment of anxiety symptoms and associated impairments optimally includes key informant interviews with family members or close friends [2]. DIFFERENTIAL DIAGNOSIS Differential diagnosis is performed to eliminate potential underlying causes that, if present, would better account for patient anxiety complaints. As noted, screening for other anxi- ety, mood, and substance-related disorders should be routinely conducted due to high comorbidity rates. Other Mental Disorders To confirm or rule out the presence of comorbid anxiety or related disorders, determine the nature and focus of patient apprehension/anxiety. It may be [2]: • Diffuse, non-specific (GAD) • Discrete, intense anxiety episodes (panic disorder) • Fear of one’s panic attacks and avoidance of places or situations where they may occur (agoraphobia) • Embarrassment in public (SAD) • Fear of specific objects or situations (specific phobia) • Attachment figure separation (separation anxiety) • Contamination (OCD) • Weight gain (anorexia nervosa) • Multiple physical complaints (somatization disorder)
If an adult with possible social anxiety disorder finds it difficult or distressing to attend an initial appointment in person, the National Collaborating Centre for Mental Health recommends making the first contact by phone or Internet, but aiming to see the person face to face for subsequent assessments and treatment. (https://www.nice.org.uk/guidance/cg159/resources/ social-anxiety-disorder-recognition-assessment-and- treatment-pdf-35109639699397. Last accessed April 27, 2025.) Level of Evidence : Expert Opinion/Consensus Statement PATIENT HISTORY A patient history is performed to assess patient and family history for clinically relevant information. Patients should be assessed for onset of anxiety symptoms, duration (remission or persistent), association with life events or trauma, level of distress, and effect on current functioning (academic, occu- pational, relationships, leisure activities, role functioning). Also inquire about a personal history of physical or emotional trauma, anxiety or mood disorders, medications or therapies, and patient response. Family history should be assessed for anxiety, mood, and substance use disorders [2]. Screening for depression is very important, given its high comorbidity rate and associated risk of suicidal behavior [129]. A thorough list of prescribed, over-the-counter, and herbal medications should be obtained [2]. Furthermore, substance use should be assessed, including: • Current and past tobacco use • Current and past alcohol use • Current and past use of illicit drugs (e.g., cannabis, cocaine, heroin, methamphetamine) • Current and past use of pharmaceutical drugs (e.g., opioids, stimulants, benzodiazepines) • Current and past use of “legal high” or novel drugs (e.g., club drugs, “bath salts,” “synthetic cannabis”) • Having been told their substance use is a problem • Having received counseling or treatment for a substance use problem PHYSICAL EXAMINATION The physical examination of most patients evaluated for anxiety is usually unrevealing but necessary in order to assess the possibility of primary disorders and conditions associated
• Serious illness (hypochondriasis) • Strictly trauma-related (PTSD)
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