---
title: Anxiety Disorder Management
description: A comprehensive clinical reference on the diagnosis and treatment of anxiety disorders.
keywords: [anxiety, GAD, panic disorder, SSRI, benzodiazepine]
category: clinical
---

## Diagnostic Criteria

Anxiety disorders are a group of mental health conditions characterized by excessive and persistent fear, worry, and anxiety that can significantly impair daily functioning. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) outlines the following key diagnostic criteria for the most common anxiety disorders:

**Generalized Anxiety Disorder (GAD):**
- Excessive anxiety and worry about a variety of events or activities, occurring more days than not, for at least 6 months
- Difficulty controlling the worry
- The anxiety and worry are associated with at least three of the following symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, or sleep disturbance
- The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

**Panic Disorder:**
- Recurrent and unexpected panic attacks, defined as a sudden surge of intense fear or discomfort that reaches a peak within minutes
- At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
  - Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, "going crazy")
  - Significant maladaptive change in behavior related to the attacks (e.g., avoidance of exercise or unfamiliar situations)
- The panic attacks are not better explained by the direct physiological effects of a substance (e.g., caffeine) or another medical condition

## Treatment Approach

The management of anxiety disorders typically involves a combination of pharmacotherapy and psychotherapy, with the specific treatment plan tailored to the individual patient's needs and preferences.

### Pharmacotherapy

**Selective Serotonin Reuptake Inhibitors (SSRIs):**
- First-line pharmacological treatment for most anxiety disorders
- Examples: sertraline (50-200 mg/day), paroxetine (20-60 mg/day), fluoxetine (20-80 mg/day), escitalopram (10-20 mg/day)
- Start at a low dose and titrate gradually to minimize side effects
- May take 4-6 weeks for full therapeutic effect

**Benzodiazepines:**
- Can provide rapid relief of acute anxiety symptoms
- Examples: lorazepam (0.5-2 mg every 4-6 hours as needed), clonazepam (0.5-2 mg twice daily)
- Use should be limited to short-term or as-needed basis due to risk of dependence and withdrawal
- Contraindicated in patients with a history of substance abuse

**Other Medications:**
- Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine (75-225 mg/day) or duloxetine (30-120 mg/day), may be used as alternatives or adjuncts to SSRIs
- Buspirone (15-30 mg three times daily) is a non-benzodiazepine anxiolytic that can be used for chronic anxiety
- Tricyclic antidepressants (TCAs), such as imipramine (75-300 mg/day) or clomipramine (75-250 mg/day), are less commonly used due to more adverse effects

### Psychotherapy

**Cognitive-Behavioral Therapy (CBT):**
- Considered the most effective psychotherapeutic approach for anxiety disorders
- Focuses on identifying and modifying maladaptive thought patterns and behaviors that contribute to anxiety
- Includes techniques such as exposure therapy, cognitive restructuring, and relaxation training

**Other Psychotherapies:**
- Mindfulness-based therapies, such as mindfulness-based stress reduction (MBSR), can also be beneficial
- Supportive therapy, interpersonal therapy, and psychodynamic therapy may be used, especially in combination with pharmacotherapy

## Monitoring and Evaluation

Regular monitoring and evaluation are essential to assess the effectiveness of the chosen treatment plan and to identify any adverse effects or complications.

### Baseline Assessments
- Comprehensive psychiatric and medical history
- Physical examination, including vital signs and body mass index (BMI)
- Laboratory tests: complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone (TSH)
- Screening for comorbid conditions, such as depression, substance abuse, or medical illnesses

### Ongoing Monitoring
- Assess symptom severity and functional impairment using validated rating scales, such as the Generalized Anxiety Disorder-7 (GAD-7) or Panic Disorder Severity Scale (PDSS)
- Monitor for medication side effects, including weight changes, sexual dysfunction, and gastrointestinal disturbances
- Evaluate treatment response and adjust medication dosages or therapy as needed

### Treatment Evaluation
- Assess for clinical improvement, defined as a reduction in symptom severity and improved functioning
- Consider a trial of medication discontinuation or dose reduction after 12-24 months of sustained remission
- Monitor for relapse or withdrawal symptoms if discontinuing or tapering medications

## Comorbidities and Complications

Anxiety disorders frequently co-occur with other mental health conditions, such as depression, substance use disorders, and medical conditions, which can complicate management.

**Comorbid Depression:**
- Assess for the presence of depressive symptoms and consider the use of antidepressants that have been shown to be effective for both anxiety and depression, such as SSRIs or SNRIs.

**Substance Use Disorders:**
- Carefully evaluate the patient's history of substance use and avoid prescribing benzodiazepines or other potentially addictive medications in this population.
- Refer to addiction treatment services as needed.

**Medical Comorbidities:**
- Consider the potential impact of underlying medical conditions, such as thyroid disorders, chronic pain, or cardiovascular disease, on the presentation and management of anxiety.
- Coordinate care with the patient's primary care provider or relevant medical specialists.

## Special Populations

Certain patient populations may require additional considerations or modifications to the standard treatment approach.

**Older Adults:**
- Start medications at lower doses and titrate gradually to minimize the risk of adverse effects, such as sedation, falls, and cognitive impairment.
- Consider the patient's comorbidities, polypharmacy, and potential drug interactions.

**Pregnant or Breastfeeding Patients:**
- Carefully weigh the risks and benefits of pharmacotherapy, as some medications may have potential teratogenic or developmental effects.
- Prefer psychotherapy as the first-line approach, if feasible.
- If medication is necessary, choose the safest option with the lowest effective dose.

**Children and Adolescents:**
- Utilize age-appropriate psychotherapy, such as cognitive-behavioral therapy (CBT) or family therapy.
- Pharmacotherapy should be initiated at lower doses and titrated cautiously, with close monitoring for adverse effects.
- Involve the patient's family or caregivers in the treatment plan.

## Conclusion

Anxiety disorders are a common and debilitating group of mental health conditions that require a comprehensive, multifaceted approach to management. By combining evidence-based pharmacotherapy and psychotherapy, tailored to the individual patient's needs, clinicians can effectively manage anxiety disorders and improve the quality of life for those affected.