Feeling Tense and Anxious
Differential Diagnosis
Common Diagnoses
- Life Events (May be Underlying ‘Anxious Personality’)
- Pre-Menstrual Tension
- Generalised Anxiety Disorder
- Panic Disorder
- Depression
Occasional Diagnoses
- Obsessive–Compulsive Disorder
- Phobias
- Drug Side Effect (e.g. in the Early Stages of SSRI Treatment)
- Hyperthyroidism
- Drug/Alcohol Use or Withdrawal
- Somatisation Disorder
- Post-Traumatic Stress Disorder
Rare Diagnoses
- Psychotic Illness
- Any Cause of Palpitations (May be ‘Misinterpreted’ by the Patient or Others as Anxiety)
- Organic Brain Disease (e.g. Tumour)
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Life Events | PMT | GAD | Panic Disorder | Depression | |
|---|---|---|---|---|---|
| Clear Causative Event | Yes | No | No | No | Possible |
| Related to Menstrual Cycle in Women | No | Yes | Possible | No | Possible |
| Persistent Low Mood | Possible | No | No | No | Yes |
| Feeling of Tension is Short-Lived | Possible | Possible | No | Yes | Possible |
| Sleep Disturbed | Yes | Possible | Possible | No | Yes |
Possible Investigations
- It would be very unusual for the 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 LFT, if alcohol was thought to be playing a significant part. Investigations in the rare event of suspected organic brain disease would usually 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, as this may significantly alter the management.
- Do not overlook an alcohol or drug history – abuse or withdrawal may be the cause of the symptoms, or a significant contributor.
- It may be worthwhile carefully reviewing the patient’s old records to establish patterns of symptoms or attendance, and to check previous response to treatment.
- Whenever possible, life events should not be ‘medicalised’ – otherwise this may, in the future, encourage re-attendance and foster dependence on treatment
- Apparent pre-menstrual 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 pre-menstrual 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.