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Diagnosing Anxiety

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Monday, 24 September 2007

Physical Examination and History

A physical examination and medical and personal history is essential. Because anxiety accompanies so many medical conditions, some serious, it is extremely important for the physician to uncover any medical problems or medications that might underlie or be masked by an anxiety attack.

The patient should describe any occurrence of anxiety disorders or depression in the family and mention any other contributing factors, such as excessive caffeine use, recent life changes, or stressful events.

It is very important to be honest with the physician about all conditions, including excessive drinking, substance abuse, or other psychological or mood states that might contribute to, or result from, the anxiety disorder.

Diagnosing children is very difficult, since often anxiety results in disruptive behaviors that overlap with attention-deficit hyperactivity or oppositional disorder. Parents and children may report different symptoms.

Ruling Out Conditions That Accompany or Resemble Anxiety Disorders

People with anxiety disorders are more likely to see a family physician first rather than a mental health specialist, since so often their symptoms are physical. They can include muscle tension, trembling, twitching, aching, soreness, cold and clammy hands, dry mouth, sweating, nausea or diarrhea, and urinary frequency. Anxiety attacks can mimic or accompany nearly every acute disorder of the heart or lungs, including heart attacks and angina (chest pain). In fact, nearly all individuals with panic disorders are convinced that their symptoms are physical and possibly life-threatening.

Depression. Depression is very common in people with anxiety disorder, and it is sometimes difficult to distinguish o­ne from the other because either or both can be accompanied by anxious feelings, agitation, insomnia, and problems with concentration. Because of the confusion in making a diagnosis between the two disorders, the American Psychiatric Association is considering a new classification, mixed anxiety and depression.

Heart Problems. One study reported that 25% of patients entering the emergency room with chest pain were actually suffering from panic attacks, which were diagnosed correctly by cardiologists in o­nly 2% of cases. It is often difficult to distinguish between a number of heart conditions and a panic attack:

  • Women who are having an actual heart attack or acute heart problem are much more likely to be misdiagnosed as having an anxiety attack than men with similar symptoms.

  • Mitral valve prolapse, a common and usually mild heart problem, may have symptoms that are nearly identical to those of panic disorder. The two conditions, in fact, frequently occur together.

  • Two-thirds of people with a heart-rhythm disturbance called paroxysmal supraventricular tachycardia have the same symptoms as those with panic attacks.
Asthma. Asthma attacks and panic attacks have similar symptoms and can also coexist.

Hyperthyroidism. Hyperthyroidism can cause many of the same symptoms of generalized anxiety disorder and must be ruled out.

Epilepsy. The symptoms of partial seizures and panic attacks often overlap, although partial seizures are usually very short (one to two minutes).

Other Medical Conditions. In addition, anxiety-like symptoms are seen in many other medical problems, including hypoglycemia, recurrent pulmonary emboli, and adrenal-gland tumors. Women can also experience intense anxiety attacks with hot flashes during menopause.

Medication Side Effects. Many drugs, including some for high blood pressure, diabetes, and thyroid disorders, can produce symptoms of anxiety. Withdrawal from certain drugs, often those used to treat sleep disorders or anxiety, can also precipitate anxiety reactions.

Substance Abuse. People with anxiety disorders often drink alcohol or abuse drugs in order to conceal or ameliorate symptoms, but substance abuse and dependency can also cause anxiety. In addition, withdrawal from alcohol can produce physiologic symptoms similar to panic attacks. Clinicians often have difficulty determining whether alcoholism or anxiety is the primary disorder. Overuse of caffeine or abuse of amphetamines can cause symptoms resembling a panic attack.
Screening Tests

Although most family physicians can identify panic disorder, very few (10% in o­ne study) recognize social phobias. Clinicians can use various tests to determine the causes, type, severity, and frequency of anxiety. Such tests include the Beck Anxiety Inventory, the Hamilton Anxiety Rating Scale, and the Anxiety Disorders Interview Schedule. Screening tests for children may include Child Behavior Checklist, which measures a child's ability to function, or for OCD the Leyton Obsessional Inventory-Child Version


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