Feeling Anxious
Feeling anxious is a normal emotional response characterized by apprehension, worry, and physiological arousal in anticipation of perceived threats or stressful situations, which becomes clinically significant when disproportionate and functionally impairing.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Generalised Anxiety Disorder (GAD) [1] | Excessive worry about multiple topics ≥6 months + somatic symptoms + functional impairment | 「你係咪覺得成日擔心好多唔同嘅嘢，停唔到？持續咗幾耐？」 |
| Adjustment disorder with anxious mood [6] | Clear precipitant, onset within 3 months of stressor, < 6 months duration | 「呢啲緊張嘅感覺係咪喺某件事之後先開始？」 | |
| Mixed anxiety and depressive disorder [1] | Anxiety + low mood, neither severe enough alone for full diagnosis | 「除咗緊張，有冇同時覺得好唔開心？」 | |
| Serious Not To Miss | Suicidal ideation / self-harm | Active plan, access to means | 「有冇諗過傷害自己或者唔想生存落去？」 |
| Hyperthyroidism | Weight loss, heat intolerance, tremor, tachycardia, goitre [5] | 「有冇消瘦、怕熱、心跳快？」→ P/E: fine tremor, lid lag, tachycardia | |
| Cardiac arrhythmia | Palpitations with syncope/presyncope [2] | 「心跳快嘅時候有冇暈低或者差啲暈低？」 | |
| Phaeochromocytoma | Episodic headache, sweating, hypertension, palpitations | 「你嗰陣會唔會頭痛、面紅、出好多汗？血壓有冇試過好高？」 | |
| Pitfalls | Panic disorder | Discrete episodes peaking in ~10 min with ≥4 somatic symptoms, fear of dying [1] | 「嗰陣緊張嘅感覺係咪好快好強烈，之後又慢慢退？有冇覺得自己快要死？」 |
| Social anxiety disorder | Fear specifically of social situations / scrutiny [1] | 「你係咪特別驚人哋點睇你？」 | |
| OCD | Intrusive thoughts + compulsive rituals [6] | 「有冇重複嘅諗法令你好困擾，要做某啲嘢先舒服啲？」 | |
| PTSD | Re-experiencing, avoidance, hyperarousal after trauma [6] | 「有冇經歷過好驚嘅事件之後，成日會閃返嗰啲畫面出嚟？」 | |
| Masquerades | Depression | Low mood, anhedonia, guilt, worthlessness – anxiety may be presenting symptom [1][3] | 「你有冇覺得好攰、做嘢冇動力、覺得自己冇用？」 |
| Hypoglycaemia | Sweating, tremor, anxiety, hunger – especially in diabetics on SU/insulin [7] | 「你有冇糖尿病？食緊咩藥？有冇試過手震出汗好肚餓嗰種感覺？」 | |
| Drug-related (caffeine, stimulants, benzodiazepine withdrawal) [4] | Temporal relationship with substance use/cessation | 「你一日飲幾多杯咖啡？有冇食過安眠藥最近停咗？」 | |
| Anaemia | Fatigue, palpitations, pallor | 「有冇覺得好攰、面青口白？」 | |
| Trying to Tell Me Something? | Work/academic stress | Excessive workload, bullying, exam pressure | 「工作或者讀書壓力大唔大？有冇俾人欺負？」 |
| Relationship/family problems | Conflict, domestic violence, carer stress | 「同屋企人或者伴侶關係點？有冇人對你唔好？」 | |
| Health anxiety | Fear of specific disease (cancer, heart disease) | 「你係咪擔心自己有咩嚴重嘅病？」 | |
| Financial stress | Debt, job loss | 「經濟方面有冇壓力？」 |
Minute-by-Minute 6-Minute Consultation
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好，我係X醫生，今日由我幫你睇症。可唔可以問你點稱呼？」「今日咩嘢令你嚟睇醫生呢？」 | Establishes rapport; patient-centred opening scores interpersonal marks |
| 0:30–2:00 | HPI – characterise anxiety symptoms | 「你話覺得好緊張，可唔可以同我講吓係幾時開始？」「係成日都咁定係一陣陣嚟？」「有冇咩嘢特別會引起呢種感覺？」「有冇心跳快、手震、出汗、透唔到氣、頭暈？」 | Defines chronology, pattern (GAD vs panic vs situational), associated somatic symptoms |
| 2:00–3:00 | Red flags, DDx screening, psych screening | 「你有冇諗過唔想生存落去？」「有冇食過任何藥或者健康產品？」「有冇飲咖啡、酒或者食其他提神嘢？」「有冇體重變化、怕熱、手震？」（thyroid）「最近瞓得點？食嘢點？」 | Screens suicide, substance use, thyroid, depression comorbidity – these are must-not-miss |
| 3:00–4:00 | ICE – uncover hidden agenda | 「你自己覺得呢啲症狀係咩嘢原因呢？」（Idea）「你最擔心嘅係咩嘢？」（Concern）「你今日嚟最希望醫生可以幫到你啲咩嘢？」（Expectation） | ICE is directly scored on the Case Report Form; hidden agenda often = stressor like work/relationship |
| 4:00–5:00 | Psychosocial & functional impact, PMH, FHx | 「呢個問題影唔影響到你做嘢或者同人相處？」「屋企人有冇情緒病嘅病史？」「你而家做咩工作？壓力大唔大？」「屋企情況點？」 | Biopsychosocial problems; functional impact needed for CRF |
| 5:00–5:30 | Summarise & check understanding | 「等我總結返：你最近兩個月不斷覺得好緊張、瞓唔好、擔心好多嘢，影響到你做嘢。我有冇理解錯？」 | Demonstrates active listening; scores summarising marks |
| 5:30–6:00 | Signpost plan, empathy, safety-net, close | 「好多謝你同我講咁多，我明白呢段時間對你嚟講好辛苦。」「我想幫你做少少檢查排除身體嘅問題，然後我哋再傾吓點樣幫到你。」「如果你有任何時候覺得頂唔順或者有傷害自己嘅諗法，記住去急症室或者打熱線。」 | Empathy statement + safety-net = essential interpersonal and safety marks |
Uncovering the hidden agenda: The patient presenting with "feeling anxious" may actually be coming because of a specific stressor (job loss, relationship breakdown, family illness, exam pressure), fear of a serious disease (e.g. "Am I having a heart attack?"), or substance withdrawal. Ask 「其實今日嚟，除咗緊張之外，仲有冇其他嘢困擾緊你？」 This separates the symptom from the reason for consultation.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Onset & Duration | When did this start? Sudden or gradual? | 「幾時開始？係突然間定慢慢嚟？」 | Acute = adjustment/panic; chronic ≥6 months = GAD [1] | GAD if ≥6 mo; adjustment disorder if < 6 mo with clear stressor |
| Pattern | Is it constant worry or sudden attacks? | 「係成日都擔心定係突然間一陣好驚嘅感覺？」 | Constant = GAD; episodic = panic disorder [1] | Panic disorder if discrete episodes with peak in ~10 min |
| Triggers | Any specific situation that triggers it? | 「有冇特定嘅情況會引發？例如人多嘅地方、社交場合？」 | Situational = phobia/social anxiety; no trigger = GAD/panic [1] | Social anxiety disorder, specific phobia, agoraphobia |
| Somatic symptoms | Palpitations, sweating, tremor, SOB, chest tightness, dizziness, numbness? | 「有冇心跳快、出汗、手震、氣喘、胸口翳悶、頭暈、手腳痺？」 | Somatic Sx common in anxiety AND in medical mimics [1][2] | Panic attack; but also hyperthyroidism, phaeochromocytoma, cardiac arrhythmia |
| Worry content | What do you worry about? Many things or one thing? | 「你主要擔心啲咩嘢？係好多唔同嘅嘢定集中一樣？」 | Multiple excessive worries = GAD; illness worry = health anxiety [1] | GAD, health anxiety/hypochondriasis |
| Depression screen | Low mood? Loss of interest? | 「有冇情緒低落？有冇對以前鍾意嘅嘢失去興趣？」 | Anxiety and depression frequently co-exist [1][3] | Mixed anxiety-depression, MDD with anxious features |
| Suicide risk | Any thoughts of self-harm or not wanting to live? | 「有冇諗過傷害自己或者唔想生存落去？」 | Must-ask – safety issue, marks deducted if omitted | Urgent psychiatric referral if active suicidal ideation |
| Substance use | Coffee, alcohol, drugs, supplements? | 「你平時飲幾多咖啡？有冇飲酒或者食其他藥物？」 | Caffeine, stimulants, alcohol withdrawal all cause anxiety [4] | Substance-induced anxiety; withdrawal state |
| Medications | Taking any medications? Including OTC, TCM? | 「有冇食緊任何藥？包括中藥、保健品？」 | Salbutamol, thyroxine, steroids, discontinuation of benzodiazepines can cause anxiety [2] | Drug-induced anxiety |
| Thyroid symptoms | Weight change, heat intolerance, tremor? | 「有冇體重變化？特別怕熱？手震？」 | Hyperthyroidism is a key medical masquerade [5] | Thyrotoxicosis |
| Cardiac symptoms | Chest pain, fainting? | 「有冇胸口痛、暈低過？」 | Rule out cardiac cause (arrhythmia, MVP) [2] | Arrhythmia, mitral valve prolapse |
| OCD symptoms | Repetitive thoughts or actions you can't control? | 「有冇重複嘅諗法或者行為，例如不停洗手，停唔到？」 | OCD is a DDx and now a separate category from anxiety disorders [6] | OCD |
| Trauma history | Any traumatic event recently? | 「最近有冇經歷過好大衝擊嘅事件？」 | PTSD/acute stress disorder [6] | PTSD, acute stress disorder |
| PMH | Any chronic diseases? | 「你之前有冇其他病？」 | Chronic disease → secondary anxiety | Anxiety secondary to medical condition |
| FHx | Family history of anxiety, depression, thyroid? | 「屋企人有冇情緒病或者甲狀腺問題？」 | Genetic loading for anxiety and thyroid disease | GAD, panic disorder, thyroid disease |
| Social / Occupation | Job? Stress? Relationships? Support? | 「你做咩工作？最近壓力大唔大？屋企人關係點？」 | Psychosocial stressors are commonly the main driver [1] | Adjustment disorder; workplace bullying |
| Functional impact | Affecting work/study/daily life? | 「有冇影響到你返工、讀書或者日常生活？」 | Required for diagnosis (impairment criterion) and CRF | Severity grading |
| Sleep | Difficulty falling asleep or staying asleep? | 「瞓得好唔好？係瞓唔著定成日醒？」 | Insomnia common in anxiety AND depression | GAD, depression, substance use |
Case Report Form Answer Builder
CC: Feeling anxious / nervousness for [duration]
HPI high-yield points to capture:
- Duration and onset (acute vs chronic, ≥6 months suggests GAD)
- Pattern: constant worry vs episodic attacks
- Triggers or precipitants (stressor, social situations, none)
- Associated somatic symptoms: palpitations, SOB, tremor, sweating, insomnia, GI upset
- Associated mood symptoms: low mood, anhedonia (screen depression)
- Functional impairment: work, relationships, ADL
- Suicide risk assessment: deny/endorse
- Substance use: caffeine, alcohol, drugs
- Relevant negatives: no weight loss/heat intolerance (excludes thyroid), no chest pain/syncope (excludes cardiac)
| Likely RFC Examples | How to Phrase |
|---|---|
| Anxiety symptoms worsening and affecting work performance | "Patient presents because anxiety symptoms have escalated over the past 2 months, now significantly impairing work function." |
| Worried symptoms mean serious physical illness (health anxiety) | "Patient seeks reassurance that symptoms are not due to heart disease." |
| Stressful life event (e.g. job loss, breakup) triggering anxiety | "Patient presents after relationship breakdown triggered escalating anxiety, seeking help." |
| Requested by family/spouse to seek help | "Patient's partner concerned about worsening irritability and avoidance." |
Key: The RFC should capture why today, why now – not just "feeling anxious." Ask: 「點解今日決定嚟睇醫生？」
| Component | Likely Content | Exact Wording for CRF |
|---|---|---|
| Idea | "I think I'm too stressed" / "I'm worried my heart is not right" | "Patient thinks symptoms are stress-related" OR "Patient worries about heart disease." |
| Concern | Fear of losing job; fear of serious illness; fear of "going crazy" | "Patient is concerned that anxiety will cause job loss" OR "Patient fears she is developing a mental illness." |
| Expectation | Wants medication / wants referral / wants reassurance / wants sick leave | "Patient hopes for medication to help sleep" OR "Patient wants to know if anything is physically wrong." |
Generalised Anxiety Disorder (GAD) [1]
Minimum supporting evidence:
- Excessive, difficult-to-control worry about multiple topics
- Duration ≥6 months
- ≥3 of: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
- Significant functional impairment
- Not better explained by another mental disorder, substance, or medical condition
GC Lecture High Yield
The GAD-7 is the standard screening tool for GAD in primary care. [1] Its 7 items (feeling nervous/on edge, unable to stop worrying, worrying too much, trouble relaxing, restlessness, easily annoyed, feeling afraid) directly map to DSM-5 criteria. Scoring: 0–4 minimal, 5–9 mild, 10–14 moderate, 15–21 severe. A score ≥10 has good sensitivity and specificity for GAD. [1]
| DDx | Key Discriminator |
|---|---|
| 1. Panic Disorder | Recurrent unexpected discrete panic attacks (peak ~10 min) with ≥4 somatic symptoms + persistent concern about further attacks; worry between attacks is about attacks themselves, not generalised [1] |
| 2. Adjustment Disorder with Anxious Mood | Clear identifiable stressor within 3 months, symptoms disproportionate but < 6 months, resolve when stressor removed [6] |
| 3. Hyperthyroidism | Weight loss, heat intolerance, tremor, tachycardia, goitre on exam; confirmed by suppressed TSH + elevated fT4 [5] |
| Domain | Problem |
|---|---|
| Biological | Somatic symptoms of anxiety (insomnia, palpitations, muscle tension) impairing daily functioning; need to exclude thyroid disease |
| Psychological | Persistent excessive worry with possible comorbid depressed mood; impact on self-esteem and coping |
| Social/Functional | Impaired work performance / risk of job loss; strained interpersonal relationships; social withdrawal/avoidance |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit It | Why It Supports This Diagnosis |
|---|---|---|---|
| GAD (most likely) | No reliable specific physical sign in brief FM station – best exam clues: restless/fidgeting during interview, tachycardia, sweaty palms, muscle tension in trapezius | Observe patient demeanour; take resting pulse; palpate trapezius for tension; note sweaty palms on handshake | These are autonomic arousal signs consistent with anxiety; however, diagnosis is clinical based on history. Write: "Patient appears anxious with restlessness, tachycardia (HR xx), and sweaty palms." |
| Panic Disorder | Hyperventilation during attack → carpopedal spasm, tachycardia | Observe during episode; Trousseau sign if hypocalcaemic alkalosis from hyperventilation | Hyperventilation with somatic symptoms during discrete attack supports panic |
| Adjustment Disorder | No specific physical sign | N/A – diagnosis is entirely history-based | State explicitly: "No specific physical sign; diagnosis based on temporal relationship with stressor" |
| Hyperthyroidism | Fine hand tremor + resting tachycardia ± goitre [5] | Place paper on outstretched hands to accentuate tremor; palpate thyroid from behind; count radial pulse | Tremor + tachycardia + goitre = highly suggestive of thyrotoxicosis |
| Phaeochromocytoma | Hypertension (may be paroxysmal) | Measure BP – look for significantly elevated BP with tachycardia during "spell" | Paroxysmal hypertension + headache + sweating + palpitations = classic triad |
| Hypoglycaemia | Sweating, tremor, tachycardia | Check capillary blood glucose; observe for diaphoresis | BG < 3.9 mmol/L with adrenergic symptoms [7] |
Exam Discriminators and Traps
Top Traps That Lose Marks
- Forgetting to ask about suicidal ideation. This is a must-ask in ANY psychiatric presentation. Marks are deducted if omitted. Use direct Cantonese: 「有冇諗過唔想生存落去或者傷害自己？」
- Not screening for depression. Anxiety and depression frequently coexist – the GC lecture emphasises this [1][3]. Always ask about low mood and anhedonia.
- Diagnosing GAD when duration is < 6 months. If onset is recent and linked to a clear stressor, consider adjustment disorder instead.
- Missing medical masquerades – especially hyperthyroidism and hypoglycaemia (in diabetics on medications). Always ask about thyroid symptoms and DM medications [5][7].
- Ignoring substance use. Caffeine excess, alcohol withdrawal, and stimulant use are commonly missed causes.
- Not eliciting ICE properly. Students often skip "Concern" – this is where the hidden agenda lives.
- Confusing GAD with panic disorder. GAD = persistent worry; panic = discrete episodic attacks with peak in 10 min.
- Not assessing functional impact. Without documented impairment, you cannot justify the diagnosis or the biopsychosocial formulation.
| Red Flag | Action |
|---|---|
| Active suicidal ideation with plan/intent | Urgent psychiatric referral / A&E |
| Psychotic features (hallucinations, delusions) | Urgent psychiatric referral |
| Severe self-neglect or inability to care for self | Urgent psychiatric referral |
| Suspected thyroid storm (fever, confusion, tachycardia, agitation) | A&E |
| Suspected phaeochromocytoma (hypertensive crisis) | A&E |
「如果你有任何時候覺得頂唔順、想傷害自己，記住可以打撒瑪利亞防止自殺會熱線 2389 2222，或者即刻去急症室。我哋下次覆診再跟進。」
High Yield Summary
What to ASK: Duration & pattern (constant vs episodic), triggers, somatic symptoms (palpitations/tremor/sweating/SOB), depression screen (mood + anhedonia), suicide risk, substance use (caffeine/alcohol/drugs), thyroid symptoms, functional impact, ICE, psychosocial stressors.
What to WRITE on CRF: CC with duration → HPI capturing pattern + somatic + mood symptoms + negatives → RFC as "why today" → ICE with specific patient words → Most likely dx: GAD (if ≥6 mo, multiple worries, functional impairment) → DDx: panic disorder, adjustment disorder, hyperthyroidism → Biopsychosocial: somatic symptoms / excessive worry + low mood / work impairment + social withdrawal → Physical sign: restlessness, tachycardia, sweaty palms (for GAD); fine tremor + goitre (for thyroid DDx).
What NOT to MISS: Suicide screening, depression comorbidity, thyroid masquerade, substance use, functional impact, and the hidden agenda behind "why today."
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 167. I feel very nervous Anxiety disorders.pdf [2] Senior notes: Maksim Medicine Notes.pdf (Cardiology – Palpitation DDx) [3] Lecture slides: GC 017. Common mental health problems in primary care.pdf (GAD-7 screening tool) [4] Lecture slides: GC 166. I cannot help myself, taking these pills just feels good Substance abuse and addiction.pdf [5] Senior notes: Ryan Ho Endocrine.pdf (Assessment of Thyroid Status) [6] Lecture slides: GC 171. Stress-related disorders and obsessive-compulsive disorder.pdf [7] Senior notes: Block A - Polyuria and polydipsia_ glucose metabolism; diabetes mellitus; diabetic ketoacidosis.pdf (Hypoglycaemia)
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