How can I differentiate between generalized anxiety disorder and panic disorder in a primary care setting?

Differentiating between generalized anxiety disorder (GAD) and panic disorder (PD) in a primary care setting involves understanding their distinct symptom presentations and diagnostic approaches ¹.

• Generalized Anxiety Disorder (GAD): GAD is characterized by persistent, excessive, and difficult-to-control worry about a variety of events or activities, rather than specific situations ¹. For a diagnosis of GAD, symptoms must typically be present for at least six months ². Patients with GAD may frequently attend primary care, presenting with chronic physical health problems or seeking reassurance about various somatic symptoms, particularly older individuals or those from minority ethnic groups ¹. The 2-item Generalized Anxiety Disorder scale (GAD-2) or GAD-7 can be used as screening and monitoring tools to assess feelings of anxiety and the ability to control worry ¹,².
• Panic Disorder (PD): In contrast, panic disorder is defined by recurrent, unexpected panic attacks, which are sudden episodes of intense fear or discomfort that peak within minutes ¹. It is important to note that a single panic attack does not necessarily constitute panic disorder; the diagnosis requires recurrent attacks and persistent concern about having more attacks or their consequences ¹. Patients experiencing panic attacks may present to Accident & Emergency (A&E) services, often with symptoms mimicking acute physical problems like chest pain ¹. In such cases, panic disorder is more likely if coronary artery disease is absent, or if the person is female or relatively young ¹. Unlike GAD, there is insufficient evidence to recommend a well-validated, self-reporting screening instrument specifically for panic disorder, so diagnosis relies heavily on strong consultation skills to elicit necessary information, including personal history and any self-medication ¹.

Both conditions are common in primary care and can co-exist with other conditions, particularly depression ¹. When comorbidities are present, the primary disorder – the one that is more severe and whose treatment is more likely to improve overall functioning – should be addressed first ². Drawing up a timeline of symptom development can help clarify the sequencing and priorities of co-occurring problems ¹. Primary care clinicians should be alert to the common clinical situation of comorbidity, especially panic disorder with depression and substance misuse ¹. (Valente, 1996) and (Roy-Byrne and Wagner, 2004) highlight the importance of primary care in the diagnosis and management of both conditions.