Assessing a person with anxiety

Anxiety is an emotional state that is part of the general human condition. It can be useful in focusing attention during times of perceived threats (internal or external), stimulating appropriate and adaptive responses and ultimately improving function. If the anxiety becomes prolonged, excessive or out of proportion to the stimulus it can become maladaptive and impair function, becoming clinically significant.

Anxiety disorders are patterns of anxiety symptoms and signs that form syndromes with specific aetiology, clinical course, and response to treatments, and can be separated into a number of discrete conditions (see Common anxiety and associated disorders).

Comorbidity frequently exists between the different anxiety disorders, mood disorders and problem substance use. Anxiety is common during the perinatal period, including in partners, and is often associated with depression¹ .

Anxiety disorders can be difficult to diagnose. People may be hesitant to seek help because of embarrassment, a lack of awareness, or a misconception that their symptoms reflect flaws in their character rather than a treatable condition.

Patients with anxiety can have physical symptoms of anxiety (eg chest pain) and assume they are caused by another underlying condition. Careful examination, assessment and reassurance may reduce these anxiety symptoms.

Assess patients presenting with anxiety symptoms. The aim of assessing a patient with anxiety symptoms is to aid diagnosis, detect comorbid conditions and establish a robust patient–clinician relationship, which is central to the success of treatment.

When assessing a patient with anxiety symptoms:

• ask the patient about their worries, fears and traumas
• discuss their symptoms and fears, and the impact of these symptoms on their life—quantifying how the patient’s symptoms impact their day-to-day functioning can reassure the patient, help build rapport and establish a baseline by which to measure future improvements
• determine the severity and duration of symptoms
• determine why the patient has presented now, and not previously
• ask if they have tried any treatments before and if they helped
• determine if they are at risk of harm, including self-harm or harm inflicted by others.

Consider differential diagnoses and comorbid conditions—anxiety symptoms can be caused by an anxiety disorder, or be secondary to other psychiatric disorders (eg major depression) or, less commonly, medical conditions (eg hyperthyroidism).

If an anxiety disorder is suspected, specific questioning will help clarify the type of anxiety disorder, for example:

• asking about specific disturbance forms (eg blushing in social anxiety disorder or flashbacks in posttraumatic stress disorder [PTSD])
• key cognitions (eg fear of having a medical condition in panic disorder or embarrassment in social anxiety disorder)
• any commonly associated behaviours (eg agoraphobic avoidance in panic disorder or compulsive rituals in obsessive compulsive disorder).

If a somatic symptom disorder (hypochondriasis) is suspected, use health anxiety screening questions; for example:

• ask about any unexplained aches or pains
• ask if the person believes their symptoms have previously been treated appropriately
• assess if the person appears to spend excessive time or energy focusing on health symptoms or concerns.

When assessing a child with anxiety symptoms, also consider that:

• information should be obtained from the child, as well as their parents, carers or significant others (eg teachers)
• anxiety disorders are the most common mental health disorders experienced by children and have the earliest median age of onset
• anxiety in children can manifest as tantrums, crying, clinging or freezing
• the assessment should determine the impact of anxiety on life at home, at school and with friends, and whether they have difficulty communicating with people, or feel scared when doing things with other people or when others are watching
• the risk of suicidal behaviour increases sharply after the onset of puberty, especially for males.