Assess and Confirm Diagnosis of an Anxiety Disorder

On this page

• Assess
• Anxiety vs Depression?
• Screen for the following conditions associated with anxiety 
  • Generalized Anxiety Disorder
  • Social Anxiety Disorder
  • Panic Disorder
  • Post-traumatic Stress Disorder
  • Obsessive-compulsive disorder
  • Rule out contributory medical conditions or medications and use of caffeine
  • Rule out main psychiatric differential and/or co-morbid diagnoses
• Which disorder to treat?
• DSM-5 Criteria for your reference
  • Generalized Anxiety Disorder
  • Social Anxiety Disorder
  • Panic Disorder
  • Post-traumatic Stress Disorder
  • Obsessive-compulsive disorder

Assess

• Offer the person an opportunity to talk, preferably in a private space. Ask for the person’s subjective understanding of his or her symptoms.
• Ask about
  • Nature, severity and duration of anxiety symptoms - "When do you tend to feel anxious?"
  • Underlying cognitions associated with anxiety
  • Degree of avoidance associated with anxiety
  • Precipitants for anxiety
• Also important to obtain other important information including:
  • Current psycho-social stressors
  • Suicidal ideation, if present go to Assess severity of suicidal ideation
  • Assess and manage any situation of maltreatment, abuse (e.g. domestic violence) and neglect
  • Past psychiatric history, including a history of depression
  • Substance use including caffeine
  • Current medical status and medications
  • Family history of psychiatric illness
  • Social supports and coping strategies
• Consider assessing functioning using the Workplace and Social Adjustment Scale
• Check for accompanying or primary depressive disorder using the PHQ-9.pdf

For those with more minor anxiety condition expected to be time-limited go to Patient Resources for assistance with management.

Anxiety vs Depression?

If PHQ-9 score 10 or more and one of the following are present then consider treating depression as the primary disorder:

1. Depressive symptoms appear to be causing more functional impairment
2. Depressive symptoms precede or begin at the same time as the anxiety symptoms
3. Previous history of depression
4. Age greater than 35 when symptoms of anxiety began

If based on your assessment you consider depression to be the primary condition then go to the Ottawa Depression Algorithm for further assistance.

Screen for the following conditions associated with anxiety

Generalized Anxiety Disorder

• Screening questions
  • "Have you been bothered by nerves or feeling anxious or on edge for the last six months?
  • "Do you tend to be a worrier?"
• If answers yes to either question then consider doing the GAD-7.pdf

Social Anxiety Disorder

• Screening questions
  • "Do you find yourself anxious or uncomfortable around people?"
  • "When you are in a situation where people can observe you, do you feel nervous and worry they may judge you?"
• If answers yes to either then consider doing the Liebowitz social anxiety scale (lsas-sr)

Panic Disorder

• Screening questions
  • "In the past six months did you ever have a spell or an attack when all of a sudden you felt frightened, anxious or very uneasy?
  • "In the past six months did you ever have a spell or attack when for no reason your heart suddenly began to race, you felt faint, or you couldn't catch your breath?"
• If answers yes to either then consider doing the Panic Disorder Self-Report (PDSR)

Post-traumatic Stress Disorder

• Screening questions
  • "Have you had recurrent dreams or nightmares of trauma or avoidance of trauma reminders?"
  • "Have you experienced a trauma that still haunts you?"
• If answers yes to either then consider doing either or both of the following scales:
  • Primary Care PTSD screen pc-ptsd-5 (1).pdf
  • if score is 3 or greater on pc-ptsd-5 then for more comprehensive assessment proceed to PCL5.pdf

  • for people who have experienced prolonged trauma consider assessing for Complex PTSD using the International Trauma Questionnaire (ITQ)

Obsessive-compulsive disorder

• Screening questions:
  • "Have you had repeated uncomfortable thoughts, images or urges that you did not want and found hard to ignore?"
  • "Have you repeated a behaviour or thought over and over again in order to reduce anxiety or prevent something bad from happening?"
• If answers yes to one or both of these questions then consider doing the OCI-r.pdf

Rule out contributory medical conditions or medications and use of caffeine, that might better explain the symptoms of anxiety*:

• Do physical exam
• Consider doing CBC, lytes, BUN, Cr, Glucose, calcium, albumen, B12, folate, TSH
  • CT/MRI if there are focal neurologic symptoms suggesting focal lesions
  • consider ECG or EEG depending on clinical presentation
• review medication list (e.g. bronchodilators, steroids, stimulants) and use of caffeine

*higher index of suspicion of organic cause for anxiety with new onset anxiety in patients over 35 especially with absence of history of anxiety in past and no significant recent life events

Rule out main psychiatric differential and/or co-morbid diagnoses such as:

• Substance Abuse
  • For alcohol Consider using Audit-C
  • For drug use ask "How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?" (response of 1 or greater is considered positive)
    • if positive response Consider using DAST-10
  • ask about cannabis use
• Bipolar Disorder
  • Consider using MDQ
    • Note: this is a screening not a diagnostic tool

Which disorder to treat?

• It is very common for a patient to have more than one anxiety disorder
• Focus initial treatment on the disorder causing the most distress and/or functional impairment

DSM-5 Criteria for your reference

Generalized Anxiety Disorder

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B. The individual finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months): Note: Only one item required in children.

1. Restlessness, feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

E. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

F. The disturbance is not better explained by another medical disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder

Social Anxiety Disorder

A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g. giving a speech). Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.

B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).

C. The social situations almost always provoke fear or anxiety.  Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug abuse, a medication) or another medical condition.

I. The fear, anxiety, or avoidance is not better explained by symptoms or another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Panic Disorder

A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

• Palpitations, pounding heart, or accelerated heart rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breath or smothering
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, light‐headed, or faint
• Chills or heat sensations
• Paresthesias (numbness or tingling sensations)
• Derealization (feelings of unreality) or depersonalization (being detached from oneself)
• Fear of losing control or “going crazy”
• Fear of dying

>Note: Culture‐specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

1. Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).
2. A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).

C. The disturbance is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).

D. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phonic objects or situations, as in specific phobia; in response to obsessions, as in obsessive‐compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).

Posttraumatic Stress Disorder

A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

1. Directly experiencing the traumatic event(s).Witnessing, in person, the event(s) as it occurred to others.

2. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

3. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse). Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s). Note: In children, there may be frightening dreams without recognizable content.

3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.) Note: In children, trauma-specific reenactment may occur in play.

4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia, and not to other factors such as head injury, alcohol, or drugs).

2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).

3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.

4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

5. Markedly diminished interest or participation in significant activities.

6. Feelings of detachment or estrangement from others.

7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

1. Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects.

2. Reckless or self-destructive behavior.

3. Hypervigilance.

4. Exaggerated startle response.

5. Problems with concentration.

6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

F. Duration of the disturbance (Criteria B, C, D and E) is more than 1 month.

G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Specify whether:

With dissociative symptoms: The individual’s symptoms meet the criteria for posttraumatic stress disorder, and in addition, in response to the stressor, the individual experiences persistent or recurrent symptoms of either of the following:

1. Depersonalization: Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).

2. Derealization: Persistent or recurrent experiences of unreality of surroundings (e.g., the world around the individual is experienced as unreal, dreamlike, distant, or distorted). Note: To use this subtype, the dissociative symptoms must not be attributable to the physiological effects of a substance (e.g., blackouts, behavior during alcohol intoxication) or another medical condition (e.g., complex partial seizures).

Specify whether:

With delayed expression: If the full diagnostic criteria are not met until at least 6 months after the event (although the onset and expression of some symptoms may be immediate).

Obsessive Compulsive Disorder

A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize hem with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

Note: Young children may not be able to articulate the aims of these behaviors or mental acts.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).