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A 36-year-old woman comes to your office accompanied by her husband to discuss her "nervousness." She says she is nervous and worried almost all of the time. She also feels tired and does not sleep well at night.

  • What additional questions should you ask to learn more about her anxiety?
  • How would you classify her anxiety problem?
  • What are the possible causes of her anxiety?
  • How can you establish a presumptive diagnosis by asking open-ended questions followed by more focused history taking?
  • How can you use the patient's history to distinguish between anxiety as a normal phenomenon and other types of anxiety that are disabling?

Anxiety can be a normal and adaptive short-term, fear-based response to perceived threats of physical or psychological harm. An anxiety disorder exists when recurrent or persistent episodes of anxiety are so intense, frequent, or situationally inappropriate that they cause significant distress or impair normal functioning, activities, or relationships. Anxiety disorders are common but are underrecognized both by patients and providers.

Diagnosing anxiety disorders depends heavily on history taking, because physical examination and laboratory testing add little to the evaluation. An important starting point is to keep anxiety disorders in mind, particularly in patients who have a history of unexplained medical symptoms, high utilization of healthcare resources, major life stresses, prior physical or psychological trauma, depression or substance abuse, or disruptions in social or occupational functioning. Once recognized, anxiety disorders can be classified into one of the major categories listed below.

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AnxietyApprehension, uneasiness, or fear in response to a real or perceived threat.
Anxiety disorderExcessive anxiety and worry, recurring more days than not for at least 6 months.
Generalized anxiety disorder (GAD)Excessive anxiety, recurring more days than not for at least 6 months, associated with various objects, circumstances, or events.
PhobiaPersistent, irrational, intense anxiety and worry in response to specific external objects, activities, or situations.
AgoraphobiaAnxiety about being confined without easy egress or escape, causing avoidance or endurance with marked distress.
Social phobiaMarked and persistent fear of social activities or performances involving possible scrutiny or evaluation by others, resulting in avoidance or endurance with intense anxiety or stress. Recognized as excessive or unreasonable.
Specific phobiaMarked and persistent fear precipitated immediately and consistently by the presence or anticipation of a specific object or situation, resulting in avoidance or endurance with intense anxiety or stress. Recognized as excessive or unreasonable.
Panic attacksRapidly peaking (10 minutes), intense fear or alarm and at least 4 of the following 13 symptoms: abnormal heartbeat, chest discomfort, sweating, shakiness, dyspnea or choking, smothering sensation, abdominal symptoms, dizziness or faintness, sense of unreality, fear of going crazy or losing control, fear of dying, numbness or tingling, or hot flashes or chills.
Panic disorderRecurrent, unexpected panic attacks, followed by at least 1 month of persistent concern about additional attacks, worry about implications or consequences, ...

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