The frame
Anxiety is an adaptive threat‑response with cognitive (catastrophic appraisal), physical (autonomic arousal), and behavioural (avoidance, reassurance‑seeking) components. Fear = response to present threat; anxiety = anticipation of future threat. Pathology = excessive, persistent, hard‑to‑control, impairing (D‑I‑R‑E‑C‑T).
Map the pattern (don't diagnose "anxiety")
| Pattern | Core |
|---|---|
| GAD | Free‑floating, multi‑domain worry ≥6 months + somatic tension |
| Panic disorder | Recurrent unexpected panic + anticipatory worry/behaviour change |
| Social anxiety | Fear of scrutiny/negative evaluation |
| Specific phobia | Circumscribed object/situation |
| Agoraphobia | Situations where escape/help is difficult |
| Separation anxiety | Attachment‑figure separation |
The mandatory exclusions 🚩
Anxiety is a great mimic — and is mimicked. Exclude hyperthyroidism, phaeochromocytoma, arrhythmia, hypoglycaemia, asthma/COPD, stimulant/caffeine use, and sedative/alcohol withdrawal before settling on a primary anxiety disorder, especially with late onset or prominent physical symptoms.
Management logic
First‑line SSRI/SNRI + CBT; benzodiazepines only short‑term/bridging (dependence). Set expectations: anxiolytic response takes weeks, and an initial activation/jitteriness is common — start low.
Pitfalls
- Anchoring on "anxiety" and missing thyrotoxicosis or an arrhythmia.
- Long‑term benzodiazepine prescribing.
Pearls
- 🎯 Diagnose the pattern, not the affect.
- 🩺 New anxiety in an older patient or with prominent autonomic signs → screen the body first.
Next → The pattern with the highest medical‑mimic stakes (Concept 21).