Anxiety & Adjustment Disorder
Diagnoses
Generalised Anxiety Disorder (GAD)
Definition
Symptoms
At least 3 of the following (mnemonic BESKIM):
Symptoms cause clinically significant distress or functional impairment (e.g. social, occupational).
Exclusions
Adjustment Disorder
Definition
The development of emotional or behavioural symptoms (e.g. anxiety, low mood) in response to an identifiable stressor within 3 months of the stressor’s onset.
Symptoms do not meet full criteria for another mental disorder (e.g. GAD, major depression).
Symptoms resolve within 6 months after the stressor or its consequences end.
Exclusions
Does not meet criteria for other mental health conditions (e.g. major depressive episode, PTSD).
Not merely an exacerbation of a pre-existing disorder.
Key Steps in Evaluation
Thorough history and mental state examination: Identify triggers, stressors, timeline, functional impairment.
Rule out physical causes mimicking anxiety (e.g. thyroid disorders, anaemia, cardiac arrhythmias).
Assess for risk factors: family history of anxiety, substance use, co-morbid depression, suicidality.
Investigations
Depending on clinical judgment:
ECG
Blood Tests
FBC (Full Blood Count): Exclude anaemia, infection.
FBG (Fasting Blood Glucose): Screen for hyperglycaemia or diabetes.
TFTs (Thyroid Function Tests): Exclude hyperthyroidism or hypothyroidism.
Electrolytes if indicated (e.g. if diuretic use, suspicion of electrolyte imbalance).
Management
Non-Pharmacological Interventions
Consider these interventions first (especially in adjustment disorder and mild-to-moderate GAD):
Pharmacological Therapy
Generalised Anxiety Disorder (GAD)
SSRIs (e.g. escitalopram, sertraline) are first-line.
SNRIs (e.g. venlafaxine, duloxetine) may be considered if SSRIs are not tolerated or ineffective.
Benzodiazepines (e.g. diazepam) should generally be short-term (e.g. ≤2 weeks) for severe acute anxiety or while waiting for SSRIs to take effect; avoid long-term use due to dependence risk.
Adjustment Disorder
Pharmacotherapy is not routinely required if symptoms are mild and stressor is time-limited.
Short-course benzodiazepines (e.g. diazepam 2–5 mg BD PRN for up to 2 weeks) may be used cautiously if anxiety is severe.
SSRIs are not typically first-line for pure adjustment disorder but may be considered if the patient’s symptoms persist or evolve into GAD or major depression.
Monitoring & Follow-Up
Regular reviews to assess treatment response, adherence, and side effects.
Adjust treatment as needed (e.g. switch SSRIs if intolerable side effects, increase psychosocial support if stressors intensify).
In GAD, check for long-term improvement in anxiety levels, sleep, functioning (work, relationships).
In adjustment disorder, ensure resolution of symptoms typically within 6 months. If not, reassess diagnosis or consider more intensive therapy.
