Diagnosing Anxiety Disorders
Understanding the extent and nature of a disorder is essential in order to provide the correct intervention or treatment. Mental health professionals often use a variety of approaches to diagnosis which aim to gather as much information about a person's situation as possible in order to develop a formulation. A formulation is a term used to describe making sense of a person’s difficulties in the context of their lives, and the sense that they themselves have made of them. This information will enable the professional to reach a conclusion as to the severity of symptoms and associated functional impairment and in turn, whether it meets diagnostic criteria. Further, accurate diagnosis of a person's specific difficulties can enable them to understand their condition and ensure that they can access the most appropriate treatment as soon as is possible.
Therapists need to understand the extent and nature of an individual's disorder. It is important to asses how it interacts with other areas of a patient's life, as this is crucial for careful diagnosis and successful treatment. The process of understanding this begins during the screening process, which helps match the individual with appropriate services. In order to ensure that all important information is gleaned, it is now considered good practice to use standardized screening and assessment instruments and interview protocols. These are typically studied at length for their sensitivity, validity, and accuracy in identifying the specific problem prior to being used.
There are a wide array of screening instruments and assessment tools in existence. Some may be used to determine if further assessment is necessary, to establish the nature and extent of a person's difficulties, whether a client has any underlying or co-morbid health or psychiatric problems, background information relevant to their current situation and treatment-related factors that may determine the person's response to any treatment or intervention.
The Difference Between Screening And Assessment
Screening typically involves asking questions that have been carefully designed to determine whether a more thorough evaluation is required but they require little or no special training to be able to carry out. Screening differs from assessment in the following ways:
- Screening is about detecting the possible presence of a problem and the outcome is generally yes or no.
- Assessment is a process designed to clarify the exact nature of the problem, if it meets diagnostic criteria, and formulating specific treatment recommendations for addressing the issue.
Screening is usually the first point of contact someone has with support and can be hugely influential on the trajectory of events. It can be very difficult for someone to acknowledge that they have difficulty and to seek out help, therefore services need to be mindful that the way screening is carried out can be as important as the information you collect.
In the past, a psychiatric assessment was typically carried out on the basis of observation and discussion by a psychiatrist and psychometrics (screening tools or diagnostic measures) were more the remit of intelligence testing. However, over time, the pressure for validity, pressure on services, alongside the use of a wider pool of professionals (social workers, nurses, psychologists etc) than just psychiatrists has meant that screening tools and assessment measures are now widely in use.
Assessment Of Anxiety Disorders
Assessment of anxiety disorders covers the person's life in more detail than screening measures. Usually, a clinical assessment examines current experiences as well as physical, psychological, and socio-cultural history. A comprehensive assessment needs to be carried out by a qualified professional and should include the nature, duration and severity of the presenting disorder and associated impact on daily life. It should also include an evaluation of the ways in which the following areas may have shaped the disorder:
Mental health history.
Physical health history including questions around substance use.
Previous experience of a similar problem and response to treatments.
Personal relationships (considering social isolation).
Environmental factors such as socio-economic issues.
Family history (especially in relation to mental health or physical conditions that may have a mental health component).
History of trauma - such as domestic violence or sexual abuse or assault.
Employment (current and past) and immigration status.
This list is by no means exclusive and the specific areas to be explored might differ depending on the specific anxiety disorder, as research increasingly finds associations and increased risks between mental health and other factors. In addition, while it begins with an assessment interview, the process does not end there as it should be ongoing throughout treatment.
Psychometric Measures: Questionnaires
While the clinical interview remains the foundation of assessments, there is now widespread use of specific measures, scales and inventories to support that process. Some measures used in the USA to diagnose generalized anxiety include:
- The Hamilton Anxiety Rating Scale (HAM-A)
- The Beck Anxiety Inventory (BAI)
- Trait Anxiety subscale of the State-Trait Anxiety Inventory (STAI-T)
- The Generalized Anxiety Disorder Questionnaire IV (GADQ-IV)
- The Generalized Anxiety Disorder 7 (GAD-7)
- Overall Anxiety Severity and Impairment Scale (OASIS)
- Hospital Anxiety and Depression Scale (HADS)
- Patient Health Questionnaire 4 (PHQ4)
- Penn State Worry Questionnaire (PSWQ)
- Depression, Anxiety, Health Scales (DASS-21)
- The General Health Questionnaire 12 (GHQ-12)
- The Anxiety Disorder Diagnostic Questionnaire (ADDQ)
This list is by no means exhaustive and there are many more used for specific diagnoses (such as social anxiety or panic disorder). However, all are recommended for general use in screening for anxiety and are seen as a part of the diagnostic process.
Diagnostic Criteria of DSM-5
Alongside assessment interview and the use of measures, the clinician assessing for anxiety disorder will also look to the diagnostic criteria of the DSM-5 - The Diagnostic and Statistical Manual, 5th Edition, for an evaluation of symptom criteria to assist the process. These criteria will differ according to the disorder in question but general diagnostic indicators of an anxiety disorder that clinicians will be looking for include the presence of excessive fear and anxiety and associated behavioral disturbances, such as possible widespread avoidance behaviors. They will be generally be looking for reports of autonomic arousal, expressions of thoughts of immediate danger and escape behaviors; and hyper-vigilance to future danger such as cautious behaviors.