Diagnosis of Anxiety

Anxiety disorders have multiple subtypes each of which is characterized by unnecessary worry that can be distressing to the patient.

How is diagnosis of Anxiety made?

Diagnosis is made using the Diagnostic and Statistical Manual of Mental Disorders IV (Text Revision) also called DSM-IV-TR.

The manual lays down criteria for diagnosis of each of the types of anxiety disorders. If these criteria are fulfilled for at least 6 months, the diagnosis may be made.

Since anxiety disorders often coexist with other psychiatric disorders, diagnosis may be a challenge.

For example, nearly 60% of patients with generalized anxiety disorders have accompanying panic disorder or depressive disorders.

Further the condition may be accompanied with alcohol or drug abuse. (1, 2, 3, 4)

DSM IV-TR criteria for Generalized Anxiety Disorder

The DSM IV-TR Criteria for Generalized Anxiety Disorder include (1):

• Presence of excessive anxiety about events or activities occurring on most days for at least 6 months
• Losing control over the worry intensity
• At least three of the symptoms including restless or jumpiness, fatigue, lack of concentration, irritability, muscle tension and sleep problems
• Significant interference of symptoms with social and work related functioning or leading to significant distress
• No other mood disorder or psychiatric problem

DSM IV-TR criteria for Panic Disorder

The DSM IV-TR criteria for Panic Disorder include (1):

Frequent panic attacks without cause or warning.

There may be presence of agoraphobia (fear of large open spaces). There are no other psychiatric or medial ailments that explain the attacks.

At least a single attack is followed by fear of:

• Fear and concern regarding another attack
• Worry regarding the consequences of an attack
• Change in behavior with relation to the panic attacks

DSM IV-TR criteria for PTSD

The DSM IV-TR criteria for Post-traumatic stress Disorder include (1):

PTSD patients have a history of experiencing, witnessing or confronting an event that involved treat or actual risk of death or serious harm.

The experience may be accompanied with feelings of fear, helplessness or horror. The feelings of distress persist for at least 1 month.

On presentation the patient may re-live the event by:

• Recurrent recollections of the event with thoughts, perception or flashes of images
• Recurrent dreams
• Sense of reliving the incident with illusions, hallucinations and flashbacks
• Severe psychological distress on exposure to cues to the event and a physiological reaction to the cues

Patient avoids or feels at least three of the following:

• Thoughts, feelings and conversation associated with the event
• Activities, places, or people associated with the event
• Loss of recall of the event
• Decreased interest in significant activities
• Detachment or estrangement from others

There may be associated symptoms of anxiety like:

• Sleep problems
• Irritability and anger outbursts
• Lack of concentration
• Increased vigilance
• Increased jumpiness or startle response
• Interference with social and work functioning

DSM IV-TR criteria for Obsessive compulsive disorder

The DSM IV-TR Criteria for Obsessive compulsive Disorder include (1):

• Obsessions include recurrent and intrusive thoughts, impulses or ideas. There are usually no excessive worries about real-life problems.

  Patient has attempted to ignore or suppress such thoughts and recognizes that the obsessional thoughts are a product of his or her own mind.

• Compulsions are repeated behaviors and mental actions that the patient is driven to follow according to self-set rigid rules.

  The compulsions ease the anxiety and reduce distress. These are not realistic and are clearly excessive.

• The compulsions may be recognised as excessive and may take over 1 hour a day.

Diagnosing children with Anxiety

Diagnosing children with an anxiety disorder is difficult. Anxiety in children may manifest as behavioral problems or as a disruptive or rebellious nature.

Exclusion of medical conditions

Exclusion of medical conditions (3) –

• Heart disease – Since chest pain and shortness of breath are common symptoms, heart disease and heart attacks should be ruled out.

  Mitral valve prolapse is a disorder where the mitral valve that lies between two chambers of the heart does not close well. This leads to impaired blood flow from the heart and back flow into the left atrium.

  There may be symptoms like chest pain, difficulty breathing especially after exercise, fatigue, cough, palpitations etc. this needs to be ruled out.

• Asthma – Panic attacks may mask asthma attacks
• Over active thyroid may lead to palpitations and needs to be ruled out.
• Low blood sugar or hypoglycaemia manifests as sweating and palpitations.
• Substance abuse and caffeine over dose may lead to anxiety and similar symptoms.