Assessment and Management of Anxiety Attacks

Immediate Assessment

The American Academy of Child and Adolescent Psychiatry recommends assessing immediately for risk of harm to self or others, psychosis, or severe agitation—these require emergency psychiatric referral and one-to-one observation 2, 1
Facilitate a safe environment and initiate harm-reduction interventions if safety concerns are identified, as suggested by the Journal of Clinical Oncology 3, 2
Administer the GAD-7 (7-item self-report scale) to quantify anxiety severity with scores ranging 0-21, according to Praxis Medical Insights 1, 4
GAD-7 scoring interpretation: 0-4: Mild symptoms, 5-9: Moderate symptoms, 10-14: Moderate-severe symptoms requiring intervention, 15-21: Severe symptoms, as defined by Praxis Medical Insights 4, 1

Identify specific anxiety symptoms: panic attacks, trembling, sweating, tachypnea, tachycardia, palpitations, and sweaty palms, as recommended by the Journal of Clinical Oncology 2
Assess severity of symptoms, possible stressors, risk factors, times of vulnerability, and functional impairment in social, occupational, or other life domains, according to the Journal of Clinical Oncology and Praxis Medical Insights 2, 5

Order thyroid function tests (TSH, free T4) to rule out hyperthyroidism, which commonly mimics anxiety symptoms, as suggested by Praxis Medical Insights 1, 5
Consider cardiac conditions (arrhythmias, coronary artery disease), endocrine disorders, respiratory conditions, neurological disorders, and substance-related causes, according to Praxis Medical Insights 5

50-60% of patients with anxiety disorders have comorbid depression—screen using standardized tools, as recommended by the Journal of Clinical Oncology 3
Assess for other anxiety disorders, obsessive-compulsive disorder, and substance use disorders, according to Praxis Medical Insights 5

For moderate-severe to severe symptoms (GAD-7: 10-21), initiate combination treatment with SSRI plus CBT, which is superior to either treatment alone, as suggested by Praxis Medical Insights 1, 4
Start sertraline 50 mg daily (preferred SSRI) in the morning or evening, according to Praxis Medical Insights 1

CBT is first-line psychotherapy with large effect sizes (Hedges g = 1.01) for anxiety disorders, as recommended by Praxis Medical Insights 1
Core CBT elements include education about anxiety, behavioral goal setting, self-monitoring, relaxation techniques, cognitive restructuring, and graduated exposure, according to the Journal of the American Academy of Child and Adolescent Psychiatry 6

Sertraline is the preferred first-line SSRI for anxiety disorders, as suggested by Praxis Medical Insights 1
Continue pharmacotherapy for 12 months after achieving remission before considering tapering to prevent relapse, according to Praxis Medical Insights 5

Reassess symptoms every 4-6 weeks using GAD-7 to monitor treatment response, as recommended by Praxis Medical Insights 4
Immediate referral required for: suicidal ideation/self-harm, harm to others, psychosis, severe agitation, according to Praxis Medical Insights 1, 5

Do not attribute all anxiety symptoms to psychiatric causes without ruling out hyperthyroidism and cardiac conditions first, as suggested by Praxis Medical Insights 1, 5
Do not use benzodiazepines as first-line long-term treatment due to dependence risk and cognitive impairment, according to the Journal of Clinical Oncology 2
Do not treat with monotherapy (SSRI or CBT alone) when GAD-7 ≥10—combination therapy is superior, as recommended by Praxis Medical Insights 1
Do not discontinue SSRIs before 12 months of remission—premature discontinuation increases relapse risk, according to Praxis Medical Insights 5