Chapter 90: Generalized Anxiety Disorder, Panic Disorder, and Social Anxiety Disorder

KEY CONCEPTS

• Anxiety disorders are among the most common psychiatric disorders and are underdiagnosed and undertreated.

• The long-term goal in treatment of generalized anxiety disorder (GAD) is remission with minimal or no anxiety symptoms and no functional impairment.

• Antidepressants are the agents of choice for the management of GAD.

• In GAD, antidepressants have a lag time of 2 to 4 weeks or longer before antianxiety effects occur.

• When monitoring the effectiveness of antidepressants in panic disorder, it is important to allow an adequate amount of time (8-12 weeks) to achieve full therapeutic response.

• The optimal duration of panic therapy is unknown; 12 to 24 months of pharmacotherapy is recommended before gradual medication discontinuation over 4 to 6 months is attempted.

• Social anxiety disorder (SAD) is a chronic long-term illness requiring extended therapy. After improvement, a 6- to 12-month or longer medication maintenance period is recommended before considering treatment discontinuation.

• The selective serotonin reuptake inhibitors or venlafaxine are considered first-line pharmacotherapy for SAD.

• An adequate trial of antidepressants in SAD lasts at least 8 weeks, and maximal benefit may not be seen until 12 weeks.

• In SAD, the three principal domains in which improvement should be observed are symptoms, functionality, and well-being.

Patient Care Process for Anxiety Disorders

Collect

• Patient characteristics (eg, age, sex, pregnancy)

• Patient medical history (personal and family)

• Patient psychiatric history (personal and family)

• Social history (eg, caffeine, nicotine, ethanol, or other substance use including route of administration)

• Current medications including over-the-counter (OTC), herbal products, dietary supplements, and prior psychiatric medication use

• Mental status examination

• Objective data

  • Blood pressure (BP), heart rate (HR), respiratory rate (RR), height, and weight

  • Labs including thyroid stimulating hormone (TSH)

  • Urinalysis including urine medications testing

  • Generalized Anxiety Disorder 7-Item Scale, Hamilton Anxiety Disorder Rating Scale (HAM-A), Sheehan Disability Scale, and Patient Health Questionnaire-9 (PHQ-9)

Assess

• Presence of generalized anxiety disorder, panic disorder, or social anxiety disorder

• Presence of comorbid depression or substance use disorder

• Ability/willingness to begin nonpharmacologic treatments, including availability in geographic region

• Ability/willingness to begin pharmacologic treatment

• Ability/willingness to afford nonpharmacologic and/or pharmacologic treatment(s)

• Support of family members/caregivers for treatment

Plan*

• Pharmacotherapy regimen including specific medication(s), dose, route, frequency, and duration (see Fig. 90-1, and Tables 90-4, 90-5, 90-8, and 90-9)

• Monitoring parameters including efficacy (eg, rating scales, quality of life)

• Patient education (eg, disease, life style changes, medication adherence, when to expect medication to begin working, possible adverse reactions, expected duration of therapy, when to contact healthcare professional)

• Self-monitoring for resolution of anxiety symptoms

Implement*

• Provide patient education regarding all aspects of treatment plan

• Use motivational interviewing and coaching strategies to maximize adherence

• Schedule follow-up

Follow-up: Monitor and Evaluate

• Resolution of anxiety symptoms

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