Feeling Tense and Anxious

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

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 EventsPMT GADPanic DisorderDepression
Clear Causative EventYesNoNoNoPossible
Related to Menstrual Cycle in WomenNoYesPossibleNoPossible
Persistent Low MoodPossibleNoNoNoYes
Feeling of Tension is Short-LivedPossiblePossibleNoYesPossible
Sleep DisturbedYesPossiblePossibleNoYes

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.

Published: 2nd August 2022 Updated: 10th April 2024

Report errors, or incorrect content by clicking here.