Approach to Assessment and Management of Anxiety Disorders
Definition and Classification
- Anxiety disorders are characterized by excessive, uncontrollable worry about multiple life domains, accompanied by physical symptoms, panic attacks, avoidance behaviors, and social fears that cause significant functional impairment 1
- Generalized Anxiety Disorder (GAD) is a chronic, pervasive worry about multiple topics beyond cancer or medical concerns, with physical symptoms 2, 1
- The American College of Cardiology recommends considering anxiety disorders in patients with cardiac conditions, as anxiety can exacerbate cardiac symptoms 1
Severity Stratification and Assessment
- The GAD-7 score is used to stratify anxiety severity, with scores ranging from 0-21, and a score of 10 or higher indicating moderate-severe anxiety requiring intervention 2
- The American Psychiatric Association recommends using standardized screening tools, such as the GAD-7, to assess anxiety severity 1
- A score of 10-14 on the GAD-7 indicates moderate-severe anxiety, while a score of 15-21 indicates severe anxiety 2
Differential Diagnosis and Medical Conditions
- Thyroid disorders, such as hyperthyroidism, can mimic anxiety symptoms and should be ruled out through laboratory testing 1, 3
- Cardiac conditions, such as arrhythmias and coronary artery disease, can also contribute to anxiety symptoms 1
- The American Heart Association recommends considering anxiety disorders in patients with cardiac conditions, as anxiety can exacerbate cardiac symptoms 1
Treatment and Management
- The American Psychological Association recommends Cognitive Behavioral Therapy (CBT) as the first-line psychotherapy for anxiety disorders, with a large effect size (Hedges g = 1.01) for GAD 2
- Selective Serotonin Reuptake Inhibitors (SSRIs) are recommended as the first-line pharmacotherapy for anxiety disorders, with sertraline being a preferred SSRI 3
- The National Institute of Mental Health recommends combining SSRI with CBT for moderate-severe anxiety, as this combination is superior to either alone 3
Referral and Consultation
- Immediate psychiatric referral is required for patients with suicidal ideation, harm to others, psychosis, or severe agitation 4, 1
- Referral to psychology/psychiatry is recommended for patients with moderate-severe symptoms, symptoms not responding to initial treatment, or functional impairment 2
- The American Academy of Pediatrics recommends referring children and adolescents with anxiety disorders to a pediatric psychologist or psychiatrist for diagnosis and treatment 5