Anxiety Disorders: Clinical Features, Assessment and Evidence-Based Management

Anxiety is a normal alarm response that becomes a disorder when fear, worry or avoidance is excessive, persistent, difficult to control and associated with clinically significant distress or impairment. Anxiety symptoms can also signal cardiac, respiratory, endocrine, neurological, toxicological or medication-related illness. A safe clinician treats both the mind and the body.

Learning objectives

• Differentiate generalised anxiety, panic disorder, agoraphobia, social anxiety, specific phobia and trauma-related anxiety.
• Assess symptoms, avoidance, comorbidity, substances, medical causes and risk.
• Use brief tools such as GAD-7 without replacing clinical judgement.
• Apply psychoeducation, CBT, exposure, stress management and safe pharmacotherapy.
• Recognise why long-term benzodiazepines are unsafe and when emergency referral is required.

1. Anxiety symptom domains

2. Common anxiety disorders

Generalised anxiety disorder (GAD)

Excessive worry about several everyday domains on most days, difficult to control and accompanied by restlessness, fatigue, tension, irritability, poor concentration or sleep disturbance. Assess duration, functional effect, depression, trauma, substances and medical illness.

Panic disorder

Recurrent unexpected panic attacks with sudden intense fear and autonomic symptoms, followed by persistent concern or avoidance. Panic attacks can occur in other disorders; panic disorder requires the characteristic recurrent and anticipatory pattern.

Agoraphobia

Fear/avoidance of situations where escape or help may be difficult, such as crowds, public transport, open spaces or being outside alone. Clarify whether avoidance is driven by panic, trauma or social evaluation.

Social anxiety disorder

Marked fear of scrutiny, embarrassment or negative evaluation, causing avoidance or endurance with intense distress. Distinguish shyness, autism, psychosis and culturally appropriate modesty.

Specific phobia

Marked fear of a particular object or situation, such as animals, heights, injections or blood. Graded exposure is usually the key treatment.

3. Assessment

1. Clarify the episode: trigger, onset, duration, peak, symptoms, thoughts, behaviour, avoidance and recovery.
2. Measure impact: work/school, relationships, sleep, self-care, travel, finances and substance use.
3. Assess mood and risk: depression, bipolarity, self-harm, suicide, psychosis, trauma and domestic violence.
4. Review medical causes: thyroid disease, arrhythmia, asthma, anaemia, hypoglycaemia, seizures, menopause, pregnancy and medication effects.
5. Ask about substances: caffeine, stimulants, cannabis, alcohol withdrawal, decongestants, steroids and herbal products.
6. Use collateral and a culturally appropriate interpreter when needed.

4. Screening and investigations

GAD-7, PHQ-4, panic questionnaires and symptom diaries can quantify burden and response. A score is not a diagnosis and should not rule out serious disease. For a new or atypical presentation consider vitals, glucose, ECG, pregnancy test, FBC, thyroid function, electrolytes, oxygenation and targeted tests guided by symptoms. Chest pain, syncope, wheeze, focal neurology, fever or reduced consciousness needs a medical pathway.

5. Psychological treatment

• CBT: identify catastrophic thoughts, safety behaviours and avoidance; test predictions and build graded exposure.
• Applied relaxation and breathing: teach slow, comfortable breathing without encouraging hyperventilation or excessive monitoring.
• Exposure: gradual, planned and repeated practice in feared situations; never forced and not used until medical stability is established.
• Stress management: sleep routine, exercise, mindfulness/relaxation, problem-solving and reduction of caffeine/stimulants.
• Guided self-help and group/online formats: useful where specialist access is limited, with safety and follow-up.

6. Medication treatment

SSRIs are often first-line when anxiety is persistent, moderate/severe or psychotherapy is unavailable/insufficient. Start low because initial activation can occur, explain delayed benefit and review early.

Benzodiazepines

WHO advises against benzodiazepines for routine GAD or panic treatment. For acute, severe anxiety they may be considered only briefly, generally no more than 3–7 days, with a clear stop plan. Risks include dependence, withdrawal seizures, falls, cognitive impairment, disinhibition and respiratory depression, especially with opioids, alcohol or other sedatives.

7. Panic attacks in the emergency setting

1. Assess ABCDE, glucose, oxygenation, pulse, BP, temperature and ECG when indicated.
2. Exclude acute coronary syndrome, arrhythmia, asthma, pulmonary embolism, hypoglycaemia, thyroid disease, seizure, stimulant toxicity and withdrawal according to presentation.
3. Use calm explanation, reduce stimulation, sit with the patient and coach comfortable slow breathing.
4. Avoid repeated reassurance tests that reinforce health anxiety; arrange appropriate follow-up and CBT.
5. Assess suicide risk, depression, substance use and domestic violence before discharge.

8. Comorbidity

• Depression and anxiety commonly coexist; treat both and monitor suicide risk.
• Substance use may be an attempt to self-medicate but can worsen panic and withdrawal.
• PTSD requires trauma-informed assessment and may need a separate therapy pathway.
• OCD, psychosis, bipolar disorder, ADHD, autism and personality-related difficulties can change treatment choice.

9. Special populations

• Pregnancy/breastfeeding: balance untreated illness and medicine exposure; use specialist guidance and discuss therapy/support first where appropriate.
• Older adults: check falls, cognition, polypharmacy, hyponatraemia and anticholinergic burden.
• Young people: assess safeguarding, school, family, self-harm and developmental factors; use age-appropriate pathways.
• Medical disease: do not assume anxiety is psychological when symptoms are new, exertional or atypical.

10. Relapse prevention

• Identify triggers, early warning signs, avoidance cycles and coping skills.
• Agree a graded activity/exposure plan, sleep routine and exercise target.
• Plan medicine adherence, tapering and what to do if activation or suicidal thoughts emerge.
• Give emergency contacts and define when chest pain, syncope, severe breathlessness or suicidality needs urgent care.

11. Worked cases

First panic-like episode

A young adult develops palpitations, chest tightness and dizziness on a bus. Check vital signs, glucose, ECG and clinical red flags before diagnosing panic; then address avoidance with CBT and graded exposure.

GAD with benzodiazepine dependence

A patient takes diazepam daily and becomes anxious when a dose is missed. Assess withdrawal and substance risk, avoid abrupt cessation, create a supervised taper and offer CBT/SSRI-based treatment.

Stimulant-related anxiety

Severe tremor, sweating and insomnia follow stimulant use. Manage intoxication/withdrawal and cardiovascular risk; do not label primary GAD until the substance timeline is clear.

12. Quick self-test

1. What makes anxiety a disorder?
2. Name four physical causes that can resemble panic.
3. Why can GAD-7 not replace assessment?
4. What is the main psychological treatment for panic and GAD?
5. Why are benzodiazepines not routine long-term treatment?
6. What must be checked before discharging a patient after a panic-like episode?

Answers

1. Persistent/excessive fear or worry with difficulty controlling it, avoidance/distress and meaningful functional impairment.
2. Arrhythmia, asthma, hypoglycaemia, thyroid disease, pulmonary embolism, seizure, stimulant toxicity, anaemia and medication effects.
3. Scores do not exclude medical disease, bipolarity, psychosis, substance use or suicide risk.
4. Structured CBT principles, including cognitive work, exposure, behavioural change, stress management and relapse prevention.
5. Dependence, tolerance, withdrawal, falls, cognitive impairment, disinhibition, respiratory depression and interaction with alcohol/opioids.
6. Medical red flags, observations/ECG when indicated, suicide risk, substances, domestic safety, follow-up and a clear return plan.

References

• NICE: Generalised anxiety disorder and panic disorder in adults.
• WHO mhGAP evidence centre: anxiety.
• WHO: benzodiazepines in GAD/panic.
• WHO mhGAP guideline 2023.
• Use Uganda Ministry of Health and hospital protocols for emergency chest pain, toxicology, pregnancy, safeguarding and referral.