Anxiety
Psychiatry
Introduction
Author: Iqra Bibi
When taking an anxiety history, a student should focus on key principles: onset, duration, and triggers of anxiety symptoms; severity and impact on daily life; associated physical and psychological symptoms (e.g., palpitations, sweating, avoidance behaviours); past mental health history, including previous diagnoses and treatments; family history of anxiety or psychiatric disorders; substance use, including caffeine, alcohol, and drugs; and social and occupational impact. As with all psychiatric histories, it is vital to rule out any signs of psychosis or suicidal/self harm ideation. Screening for comorbid conditions like depression and ruling out medical causes (e.g., hyperthyroidism) are also essential. A structured yet empathetic approach ensures a thorough and patient-centred assessment.
WIPER
W – Wash/Sanitise hands.
I – Introduce yourself and establish patient demographics
P- Permission, taking consent
E – Explanation and gain consent
R- Reposition
Presenting Complaint
Presenting symptoms
Feelings of worry or fear
Chest pain, nausea, palpitations/ feeling like your heart’s racing
Establish duration and progression – How long have you been feeling like this? How have things changed from when this first started to now?
Identify triggers/ significant life events – Has anything happened in your life recently that you think might have set these symptoms off? Do you feel worse in particular situations for example in crowded areas or when visiting a particular place or person (THINK safeguarding?
Other symptoms – Do you get any other symptoms when you feel like this?
Screen for panic attack - Have you noticed yourself getting sweaty, clammy, short of breath or tight chested when you’re feeling worried?
Sleep – Has your sleep been affected by these symptoms?
Appetite – Are you eating and drinking okay? Have you lost or put on any weight recently?
Cognition – Do you feel your concentration levels have changed since the onset of these symptoms?
Screen for depression - Do you have any feelings of worthlessness or guilt? How has your mood been?
Risk – In all psychiatry histories you must ALWAYS screen for risk of self harm and suicide.
Give a warning shot before asking the question as they can be quite distressing for some patients. I’m sorry things have been difficult for you recently. I’d like to ask you a few questions to keep you and the people around you safe if that’s okay?
Have you thought about harming yourself or ending your life recently? Have you had thoughts about harming others? Do you feel as though you may be at risk of harm from others?
Rule out physiological causes for symptoms
Hyperthyroidism can present with anxiety as the first symptoms - Ask specifically about recent weight loss, excess sweating, palpitations.
Cardio respiratory causes - take a thorough background history for any chest pains, shortness of breath and palpitations if indicated to make sure you’re not missing an organic cause for symptoms.
Use this opportunity to elicit Ideas, Concerns and Expectations
Be sure to summarise the history
Past Medical History
W – Wash/Sanitise hands.
I – Introduce yourself and establish patient demographics
P- Permission, taking consent
E – Explanation and gain consent
R- Reposition
Medications
Are you on any current medications?
Do you have any allergies to any medications/ have you ever had a reaction to a medication?
Family History
Do any medical conditions run in our family?
Has anyone in your family ever had a psychiatric condition?
Social History
Smoking (Pack-years history)
Alcohol intake
Recreational drug use
Ask about social circle and support systems
Who do you live with/ Who’s at home?
Do you work? What do you work as?
What are you hobbies? How often do you get to see your friends/family?
Differential Diagnosis
Generalised anxiety disorder
Phobic anxiety disorder
Panic attack
Post traumatic stress disorder
Hyperthyroidism
Management
Further investigations to consider:
Remember: Bedside --> Laboratory --> Imaging
Bedside examination involves a full mental state exam and a thyroid status exam if indicated
Laboratory investigations include bloods such as:
1- FBC
2- U&Es
3- LFTs (heart disease)
4 – TFTs
Imaging includes:
1- ECG
Management
Cognitive Behavioural Therapy (CBT)
Counselling
Lifestyle management
Beta blockers and SSRIs if symptoms are severe