Generalized Anxiety Disorder and Panic Disorder: Screening, Diagnosis and Treatment

SUMMARY

Generalized anxiety disorder (GAD) and panic disorder (PD) are two of the most common mental disorders in the United States, with a yearly prevalence of around 3% in the adult population. Generalized anxiety disorder is characterized by excessive and constant worry that interferes with daily functioning, while the hallmark of panic disorder is recurrent and unexpected panic attacks. These diseases are often unrecognized at first and may take years before a diagnosis is made. The American Academy of Family Physicians has released a guideline on screening and management to improve care of these patients.

SIGNS AND SYMPTOMS

Clinical Presentation

Generalized anxiety disorder
- Excessive anxiety about ordinary situations
- Anxiety is intrusive and impairs functioning
- Encompasses multiple domains of life (e.g., health, relationships, finances, work)
- Physical symptoms including: Changes in sleep | Muscle tensions | Chronic headaches | Fatigue | GI complaints | Restlessness
- Median age of onset is 30 years old
- Associated with: Female sex | Unmarried | Lower education level | Poor health
Panic disorder
- Unexpected and intermittent panic attacks
- Occur without a clear trigger
- Rapid onset of intense fear, peaking within about 10 minutes
- Worries about repeat attacks cause patient to develop maladaptive behavior
- Physical symptoms include: Palpitations | Chest pain | Sweating | Derealization | Trembling | Choking sensation | Paresthesias

Differential Diagnosis

Medical conditions: Pheochromocytoma | Hyperthyroidism | Arrhythmia | Obstructive lung disease | Epilepsy
Psychological conditions: Major depressive disorder | Mania | Bipolar disorder | Other anxiety conditions (e.g., social anxiety, separation anxiety, phobias)
Medications and substances: Caffeine | Albuterol | Methamphetamines | Cocaine | Decongestants | Levothyroxine | Substance withdrawal (e.g., opiates, SSRIs)

SCREENING

Generalized Anxiety Disorder

The USPSTF recommends screening for anxiety in all adults, age ≤ 64 years, including pregnant and postpartum persons
If the screening test is positive for anxiety, a confirmatory diagnostic assessment and follow-up are needed
All adults who have never been screened should undergo screening at least once
No standardized screening intervals are recommended, providers should use best judgement on repeating screening based on patients risk factors, history and co-morbid conditions
Generalized anxiety disorder screening tools are available (find links in ‘Learn More – Primary Sources’ below)
- General Anxiety Disorder (GAD)-7
- PROMIS Emotional Distress Anxiety Short Form
- Geriatric Anxiety Scale (GAS) Short Form

Panic Disorder

No standard screening tools or screening intervals are recommended

DIAGNOSIS

Generalized anxiety disorder

Diagnosis is made clinically via the following DSM-V criteria
Excessive anxiety and worry occurring most days over the course of 6 months
- Must encompass multiple domains (e.g., school, work, health)
Difficulty controlling the worry
Associated with ≥ 3 of the following symptoms, on most days over the course of 6 months
- Restlessness | Feeling on edge
- Easily fatigued
- Difficulty concentrating | Mind going blank
- Irritability
- Muscle tension
- Sleep disturbances
The above physical and psychological symptoms cause clinically significant distress or
impairment in functioning
The symptoms are not due to other medical condition or substance
The symptoms are not due to other mental health condition

Panic disorder

Diagnosis is made clinically via the following DSM-V criteria
Patient is having recurrent, unexpected panic attacks
≥ 4 of the following symptoms occur during the attacks
- Palpitations | Pounding heart | Sweating | Trembling/shaking | Sensations of shortness of breath | Feelings of choking | Chest pain | GI complaints | Feeling dizzy or lightheaded | Chills or heat | Paresthesia | Derealization | Depersonalization | Fear of losing control | Fear of dying
At least one of the attacks has been followed by ≥ 1 month of one or both of the following
- Persistent concern or worry about additional panic attacks or their consequences
- Maladaptive behaviors develop in response to panic attacks
The symptoms are not due to other medical condition or substance
The symptoms are not due to other mental health condition

TREATMENT

Medication or psychotherapy are reasonable initial treatment options
Decision on which avenue to try first depends on patient’s preferences and accessibility
Consider starting both medication and psychotherapy when symptoms are severe
Benzodiazepines reduce anxiety but use limited by side effects, tolerance and potential for abuse
- Recommended only in short courses as an adjunct during a crisis

Psychotherapy

Psychotherapy is as effective as pharmacotherapy for both GAD and PD
Should be performed weekly for at least 8 weeks before assessing effect
Rebound symptoms may occur less often following psychotherapy compared to pharmacotherapy
Cognitive behavior therapy (CBT)
- Therapy must be directed at patient’s specific anxieties to be effective
Mindfulness-based stress reduction
- Promotes focus on the present and uses meditation techniques

Pharmacotherapy

Medications should be titrated slowly until high-end dosage is reached
Medications should not be considered ineffective until patient has completed 4 weeks of therapy at the high-end dosing
Following improvement of symptoms, pharmacotherapy should be continued for at least 12 months before attempting to taper off
GAD
- 1^st line: SSRIs | SNRIs | Buspirone (Buspar)
- 2^nd line: TCAs | Pregabalin (Lyrica) | Quetiapine (Seroquel) | Hydroxyzine
PD
- 1^st line: SSRIs | Venlafaxine extended release (Effexor XR)
- 2^nd line: TCAs (as effective in PD as SSRIs but use limited by side effects) | Hydroxyzine

Alternative and Complementary Therapies

AAFP stresses that compassionate listening and a strong therapeutic alliance are critical in the treatment of anxiety related disorders
Identify and remove or treat any possible triggers
- Tobacco use | Caffeine |Life stressors | Disordered sleep
Exercise is an important adjunctive therapy shown to reduce anxiety
- AAFP recommends exercising at 60% to 90% of maximal heart rate for 20
  minutes 3x/week
- Yoga has been shown to be an effective therapy for anxiety

The following may be helpful for some patients: Music therapy | Aromatherapy | Acupuncture | Massage
Insufficient evidence to recommend most botanicals and supplements for the treatment of anxiety
- The exception is Kava extract, though use is limited by hepatotoxicity

FOLLOW UP

Severity measure tools to track disease burden and progress over time (find links in ‘Learn More – Primary Sources’ below)
- The Severity Measure for Generalized Anxiety Disorder
- The Severity Measure for Panic Disorder–Adult
Consider psychiatric referral if
- Disease worsens despite therapy
- Significant co-morbid psychiatric conditions
- Atypical presentations

KEY POINTS

GAD and PD are relatively common mental health conditions that are often missed in the outpatient setting
USPSTF recommends screening all adults (age ≤ 64 years) for GAD
Treatment for GAD and PD include pharmacotherapy (SSRIs, SNRIs, antiepileptics), psychotherapy (e.g., CBT, relaxation techniques) and exercise as an important adjunct