Generalised Anxiety Disorder History Taking

Panda’s Top Tip 🐼

In a history taking station, there is a lot to cover and many differentials to rule out, so practice asking questions in a concise manner.

Key Knowledge

●Excessive, uncontrollable worry about multiple everyday concerns
●Worry is difficult to control and causes significant distress
●Physical symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
●Duration: at least several months (ICD-11: typically 6 months or more)
●Onset often in early adulthood, but can occur at any age
●Commonly coexists with depression, other anxiety disorders, substance use
●Responds to CBT and/or antidepressants (SSRIs, SNRIs)

What is Generalised Anxiety Disorder?

ICD-11 defines generalised anxiety disorder (6B00) as marked symptoms of anxiety accompanied by either general apprehensiveness (i.e., “free-floating anxiety”) or excessive worry focused on multiple everyday events, most often concerning family, health, finances, and school or work.
Core features:
●Excessive anxiety and worry about a number of events or activities (work, school, health, finances, family, minor matters like appointments or household tasks)
●Difficult to control the worry: The person finds it hard to stop worrying once they start
●Worry is persistent: Present more days than not for at least several months
Associated with several of the following: 
●Restlessness or feeling on edge
●Being easily fatigued
●Difficulty concentrating or mind going blank
●Irritability
●Muscle tension
●Sleep disturbance (difficulty falling asleep, staying asleep, or restless, unsatisfying sleep)
Significant distress or functional impairment
Typical pattern:
●Worry shifts from topic to topic
●Anticipatory anxiety: “What if…?” thinking
●Person recognises worry is excessive but struggles to control it
●Reassurance-seeking is common but provides only brief relief

Differential Diagnosis for Generalised Anxiety Disorder

1. Other anxiety disorders
Key distinctions:
Panic disorder: Anxiety is episodic (panic attacks), not persistent worry
Social anxiety disorder: Worry is specifically about social situations and negative evaluation
Specific phobia: Fear is limited to a specific object or situation
OCD: Anxiety is driven by obsessions and temporarily reduced by compulsions
In GAD, worry is generalised across multiple domains
2. Hypochondriasis (illness anxiety disorder)
Key distinctions: Worry is specifically focused on having a serious illness. In GAD, health may be one of several worry domains, but preoccupation with illness is not dominant.
3. Depression
Key distinctions: Depression involves low mood, anhedonia, hopelessness. Worry in depression tends to be more ruminative and negative (“everything’s hopeless”) rather than anticipatory (“what if something bad happens?”). However, GAD and depression commonly coexist.
4. Adjustment disorder
Key distinctions: Anxiety develops in response to an identifiable stressor and does not meet full criteria for GAD. Symptoms resolve within six months of the stressor ending. 
5. Substance use or withdrawal
Key distinctions: Caffeine, stimulants, or cannabis can cause anxiety symptoms. Alcohol or benzodiazepine withdrawal can mimic GAD. Temporal relationship to substance use helps differentiate.
6. Medical conditions causing anxiety
Key distinctions: Examples of physical health conditions that may present with similar symptoms include hyperthyroidism, phaeochromocytoma, cardiac arrhythmias and hypoglycaemia. Investigations (TFTs, ECG, glucose levels etc.) can help differentiate.
7. PTSD
Key distinctions: Anxiety in PTSD is related to trauma reminders, with re-experiencing, avoidance, and hypervigilance. In GAD, worry is not trauma-focused.

Risk Assessment in Generalised Anxiety Disorder

Communication Tips

Communication Tips
Think CASC: GAD assessments involve exploring worry content, controllability, physical symptoms, and impact on daily functioning.
Exploring worry:
●”What sorts of things do you worry about?”
●”Do you find yourself worrying about everyday things like work, money, health, family?”
●”How much of your day would you say you spend worrying?”
●”Does the worry shift from topic to topic?”
●”Do you worry about minor things, like being late, making mistakes, what people think?”
Exploring controllability:
●”Can you control the worry, or does it feel like it takes over?”
●”Once you start worrying, can you stop?”
●”Do you try to distract yourself or push the thoughts away? Does that work?”
Exploring physical symptoms:
●”How do you feel anxiety affects you physically?”
●”Do you feel restless, on edge, or wound up?”
●”Do you get tired easily?”
●”How’s your concentration?”
●”Do you feel irritable or snappy?”
●”Do you experience any muscle tension in your body (shoulders, neck, jaw)?”
●”How’s your sleep, do you have trouble falling asleep, staying asleep, or waking up tired?”
Impact on functioning:
●”How do your worries affect your daily life, such as work, relationships, and enjoying things?”
●”Do you avoid situations or activities because of anxiety?”
Timeline:
●”How long have you been feeling this way?”
●”Has it been pretty constant, or does it come and go?”
Screen for comorbidities:
●Depression: “How’s your mood been, have you felt low or hopeless at all?”
●Panic attacks: “Do you get sudden, intense episodes of anxiety?”
●Social anxiety: “Do you worry particularly about social situations?”
●Substance use: “Do you use alcohol or anything else to cope?”
●Suicidal ideation
Reassurance-seeking:
●”Do you ask others for reassurance from others when you’re worried?”
●”Does that help, or does the worry come back?”

CASC Practice Scenarios

Scenario 1: History Taking

Candidate Instructions:
You are the SpR in the general adult psychiatry outpatient clinic. You have been asked to see Mrs Emily White, a 38-year-old accountant, who has been referred by her GP following a 6-month period of persistent anxiety. She has no previous psychiatric history.
Your tasks are to:
●Take a psychiatric history
●Perform a risk assessment

Scenario Summary:
Emily White is a 38-year-old accountant with generalised anxiety disorder. For the past eighteen months, she has experienced persistent, excessive worry about several aspects of her life: work performance, money, her children’s safety and future, her husband’s health, her own health, minor daily matters, and world events. The worry is difficult to control, present most days, and accompanied by multiple physical symptoms: restlessness, fatigue, poor concentration, irritability, muscle tension (particularly neck and shoulders), and disrupted sleep. The anxiety began gradually during a stressful period at work (deadline pressure, fear of redundancy) but has persisted and generalised beyond the initial trigger. She is experiencing secondary depression with low mood, anhedonia, and hopelessness. She is drinking alcohol (2-3 glasses of wine a night) to manage her anxiety and help her get to sleep. There is significant functional impairment at work and home. Her husband David is supportive but exhausted by her constant need for reassurance.

Actor Brief:
You are Emily White, a 38-year-old senior accountant. You live with your husband David, 36, who’s a part-time manager at a different accounting firm, and your two children, Lydia (8) and Jack (5). You’ve always been someone who worries a bit, but over the past 18 months, it’s completely spiraled out of control.

You worry about everything. At work, you’re constantly anxious that you’ve made a mistake, that you’ll miss a deadline, that your manager doesn’t think you’re performing well enough. The nature of your work means there’s always pressure, but you used to cope. Now, you check and re-check your work obsessively, stay late most evenings, and still feel like it’s not good enough. You worry that the firm will make redundancies and you’ll lose your job. There’s no actual indication of this, but you can’t shake the thought. If you lose your job, how will you pay the mortgage? What will happen to your family?

You worry about your children constantly. Are they safe? Are they happy? Will they do well at school? What if something happens to them? When Lydia is at school, you sometimes have intrusive worries about accidents or abduction. You know it’s irrational, but you can’t stop. You’ve started texting David during the day asking if the kids are okay, even though you know they’re fine.

You worry about Lydia’s health. She’s perfectly healthy, but what if something happens to her? What if she gets ill? You’ve noticed she looks tired lately, and you’ve been googling symptoms of serious illnesses late at night. You worry about your own health too. Any minor ache or pain and you’re convinced it’s something serious.

You worry about money, even though objectively you’re financially stable. What if interest rates go up? What if the boiler breaks? What if there’s an unexpected expense you can’t cover? You check your bank account multiple times a day.

You even worry about small things; whether you locked the door (you go back to check), whether you’ve upset someone with something you said, whether you’ve replied to an email correctly. Your mind is constantly racing with “what if” thoughts. You try to push them away, but they just come back stronger.

Physically, you feel terrible. You’re tense all the time, particularly your neck and shoulders, they’re constantly tight and painful. You’re exhausted, but it’s not from lack of sleep, it’s from the mental effort of worrying all day. You can’t concentrate at work, you read the same paragraph multiple times and still don’t take it in. You’re irritable and snappy with David and the kids, which makes you feel guilty, which makes you worry more.

Sleep is awful. You lie awake for hours with your mind racing, worrying about everything on your mental list. When you do sleep, you wake at 4am and can’t get back to sleep. You’ve started drinking 2-3 glasses of wine every evening to help you relax and sleep. It helps a bit, but you’re aware it’s becoming a habit.

Your mood has dropped over the past few months. You feel low, flat, hopeless. You used to enjoy playing football on Sunday mornings with a group of mates—you’ve stopped going because you’re too tired and anxious. You don’t enjoy much anymore. Everything feels like an effort.

You haven’t had thoughts of harming yourself, but you’ve had thoughts like “I can’t keep living like this” and “What’s the point if I’m always going to feel this anxious?”

You’ve never had psychiatric treatment before. You have had no previous episodes of depression or anxiety, or at least, nothing like this. Your mum has always been a “worrier,” but she’s never seen anyone about it. No one else in the family has had psychiatric treatment.
Your GP started you on propranolol three months ago for the physical symptoms ( muscle tension, palpitations). It’s helped a tiny bit with the physical side, but the worry is still there. The GP suggested an antidepressant, but you’re hesitant, you’re worried about side effects and about becoming dependent on medication.

Feedback for Scenario 1

Authors/Reviewers

Dr Damir Rafi is a Psychiatry Speciality registrar in forensics, currently working in London.
Dr Rebecca Goodall is a Psychiatry Specialty Registrar, specialising in children & adolescents.

References and Resources

World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th ed.). https://icd.who.int/browse11/l-m/en
National Institute for Health and Care Excellence. (2011). Generalised anxiety disorder and panic disorder in adults: Management (CG113). https://www.nice.org.uk/guidance/cg113
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
 
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.

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