Anxiety is the most common psychiatric symptom encountered in clinical practice and can lead to significant functional impairment. It represents a subjective experience of apprehension or dread in response to a real or imagined threat. The intensity of anxiety may range from mild discomfort to severe, incapacitating distress, which can sometimes be life-threatening.

Anxiety is a normal physiological response mediated by the autonomic nervous system (sympathetic and parasympathetic branches) aimed at preparing the body for purposeful action in the face of danger or stress. However, when anxiety is excessive, persistent, or unwarranted by situational demands, it often indicates an underlying psychological or medical disorder requiring professional evaluation and management.

Pathophysiology and Clinical Presentation

Anxiety activates multiple brain regions, including the amygdala and hypothalamus, leading to heightened arousal, vigilance, and somatic symptoms. Clinically, anxiety may manifest as:

• Psychological symptoms: fear, worry, irritability, difficulty concentrating.

• Physical symptoms: tachycardia, sweating, dyspnea, gastrointestinal upset, muscle tension.

Severity varies from mild (slight uneasiness) to severe (panic attacks or anxiety disorders) with corresponding impact on daily functioning.

History and physical examination

Initial assessment

• Acute severe anxiety: Rapid assessment of vital signs is crucial, as anxiety can mimic or mask life-threatening conditions (e.g., myocardial infarction, pulmonary embolism).

• Mild to moderate anxiety: Evaluate onset, duration, precipitating factors (stress, sleep deprivation, caffeine intake), and alleviating measures (rest, exercise, medication).

Clinical interview

• Explore the presence of psychological symptoms including mood disturbances, obsessive thoughts, or phobias.

• Assess for substance use (including stimulants or medications) that may provoke anxiety.

• Determine functional impairment and risk of self-harm or suicide.

Physical examination

• Conduct a thorough physical exam focusing on cardiovascular, respiratory, neurological, and endocrine systems.

• Observe the patient’s behavior, level of consciousness, and ability to communicate.

• Rule out secondary causes of anxiety with appropriate diagnostic investigations as indicated.

Medical causes of anxiety

Anxiety may present as a primary psychiatric symptom or secondary to various medical conditions summarized in table 1

Medical Causes of Anxiety – Summary table 1

Differential Diagnosis

Given the nonspecific nature of anxiety symptoms, differential diagnosis is critical to identify the underlying etiology:

Management

Supportive Care

• Create a calm, quiet environment to reduce external stressors.

• Use a reassuring, soothing tone to communicate.

• Encourage patient to verbalize fears and anxieties.

• Promote relaxation techniques such as deep breathing, guided imagery, and biofeedback.

Pharmacological Interventions

• Anxiolytics (e.g., benzodiazepines) may be used short-term in acute anxiety.

• Antidepressants (SSRIs, SNRIs) are indicated in chronic anxiety disorders.

• Address underlying medical conditions promptly.

Referral

• Patients with persistent, severe, or unexplained anxiety should be referred for psychiatric evaluation.

• Multidisciplinary approaches, including psychotherapy and behavioral interventions, improve outcomes.

Special Considerations

Pediatric Population

• Anxiety often relates to physical illness or hypoxia.

• Autonomic signs (tachycardia, diaphoresis) tend to be more prominent.

Geriatric Population

• Anxiety may present as agitation or confusion.

• Disruptions in routine or unfamiliar environments may exacerbate symptoms.

Patient education and counseling

• Teach patients relaxation and stress management techniques.

• Help patients identify and modify anxiety triggers.

• Encourage healthy lifestyle changes (adequate sleep, balanced diet, reduction of caffeine/stimulants).

• Promote adherence to treatment and follow-up.

Conclusion

Anxiety is a prevalent and complex clinical symptom with diverse etiologies ranging from benign transient stress responses to life-threatening medical emergencies. Accurate diagnosis through comprehensive history, examination, and targeted investigations is essential. Effective management requires both addressing underlying causes and providing symptomatic relief, with attention to psychological and social factors. Early recognition and intervention improve patient outcomes and quality of life.

References

1. Ferrari AJ, Charlson FJ, Norman RE, Patten SB, Freedman G, Murray CL, Whiteford HA. Burden of depressive disorders by country, sex, age, and year: Findings from the global burden of disease study 2010. PLoS Med. 2013;10(11):e1001547.

2. Gulliver A, Griffiths K, Christensen H. Perceived barriers and facilitators to mental health help seeking in young people: A systematic review. BMC Psychiatry. 2010;10(1):113.