Anxiety disorders cover a wide spectrum of illness including presentations of acute overwhelming anxiety (e.g. panic attacks) or more generalised persistent anxiety (e.g. generalised anxiety disorder). Panic attacks may be related to specific situations or stimuli (e.g. phobias) or may have no obvious precipitant (e.g. panic disorder).

Panic disorder (PD; see also Chapter 38) is where the patient experiences regular panic attacks without any obvious precipitant, in the absence of any other psychiatric illness. Generalised anxiety disorder (GAD) refers to patients who have persistent anxiety symptoms (>6 months) without panic attacks, agoraphobia or other marked phobic symptoms.

These are all common in primary care. The impact of anxiety disorders is significant for both the affected individual and society in terms of distress, loss of work and productivity and use of NHS resources. There is a genetic predisposition for both GAD and PD.

History

The challenge in taking a history is to disentangle ‘the chaos of the first presentation’ into a clinical syndrome that allows a management plan to be developed (NICE). There are no validated screening tools that reliably identify anxiety disorder so you need high level consulting skills to make an accurate diagnosis. Patients with anxiety disorders often fear they are suffering from a physical illness and it may take many consultations to arrive at a proper diagnosis. Panic attacks are usually relatively easy to diagnose although more generalised anxiety may be harder to identify (see Figure 58).

As with all psychological problems, the therapeutic alliance between patient and clinician is critical. Start with open questions to establish the nature of the problem.

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