GPs Dr Keith Hopcroft and Dr Vincent Forte advise a calm approach to anxiety consultations in the latest in their series on symptom sets
Patients complaining of feeling tense and anxious may induce similar feelings in the GP because of the many possible underlying and contributory causes.
A calm, methodical approach, possibly stretching over more than one consultation, will pay dividends.
Differential diagnosis
Common
• Life events (may be underlying ‘anxious personality')
• Premenstrual tension
• Generalised anxiety disorder
• Panic disorder
• Depression
Occasional
• Obsessive-compulsive disorder
• Phobias
• Drug side-effect – for example, in the early stages of SSRI treatment
• Hyperthyroidism
• Drug/alcohol use or withdrawal
• Somatisation disorder
• Post-traumatic stress disorder
Rare
• Psychotic illness
• Any cause of palpitations – which may be ‘misinterpreted' by the patient or others as anxiety
• Organic brain disease, such as tumour
Possible investigations
It would be unusual for a GP to require any investigations when dealing with this symptom. Thyroid function tests would be indicated in suspected hyperthyroidism and a blood screen, to include LFTs, if alcohol was thought to be playing a part. Investigations in the event of suspected organic brain disease would be left to the specialist.
Top tips
• It is tempting to lump many of these scenarios under a catch-all label of ‘tension' or ‘anxiety'. But attempts at making a more precise diagnosis are worthwhile.
• Do not overlook an alcohol or drug history; abuse or withdrawal may be the cause of, or contributor to, the symptoms.
• Carefully review the patient's old records to establish patterns of symptoms or attendance and to check previous treatment.
• Whenever possible, life events should not be ‘medicalised' to avoid fostering dependence on treatment.
• Apparent premenstrual tension may be a sign of some other underlying disorder – the patient may be suffering generalised anxiety disorder, for example, but may tend to focus on the premenstrual phase, when the symptoms are at their worst.
• Do not accept a self-diagnosis of ‘panic attacks' at face value – the patient may actually mean any one of a number of possible symptoms.
Red flags
• If the underlying diagnosis turns out to be depression, assess for any suicidal ideas or intent.
• Check for any psychotic features – anxiety can occasionally be a presenting feature of serious psychotic illness.
• New onset of tension or anxiety without any obvious explanation – especially in the context of personality change, neurological features or new headaches – could, rarely, reflect organic brain disease.
• It's important to make diagnoses such as somatisation disorder when appropriate – otherwise the patient may suffer years of unnecessary tests and treatment.
Dr Keith Hopcroft is a GP in Basildon, Essex
Dr Vincent Forte is a GP in Gorleston, Norfolk
quick sorter on feeling tense and anxious Patient in a consultation about anxiety and depression Anxiety and depression
