Feeling Tense and Anxious

The patient complaining of feeling tense and anxious may induce similar feelings in the GP – because there are many possible underlying and contributory causes, the consultation may be lengthy, and the patient may well present in a crisis. A calm, methodical approach, possibly stretching over more than one consultation, will pay dividends.

Published: 2nd August 2022 | Updated: 9th September 2022

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 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.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.