Residency · Residency · Family Medicine
Anxiety Disorders: Recognition and Management
Introduction
Anxiety disorders are the most prevalent class of mental illness, affecting approximately 30% of adults at some point in their lives. Despite their frequency, they remain underdiagnosed in primary care. Family physicians play a central role in early recognition, appropriate workup, and initiation of evidence-based treatment.
Classification of Anxiety Disorders
Generalized Anxiety Disorder (GAD) is characterized by excessive, difficult-to-control worry about multiple domains lasting six months or more. Panic Disorder involves recurrent unexpected panic attacks with persistent concern about future attacks or maladaptive behavioral changes. Social Anxiety Disorder is marked by significant fear or anxiety about social situations involving scrutiny by others. Specific Phobias involve intense fear of a specific object or situation such as heights, animals, or blood-injection-injury. Agoraphobia is the fear and avoidance of situations where escape may be difficult.
Screening and Assessment
Validated Tools
The GAD-7 is a seven-item self-report scale with scores of 5, 10, and 15 representing mild, moderate, and severe anxiety thresholds. The GAD-2 is a brief two-item screener with high sensitivity for detecting anxiety disorders. The PHQ-4 combines the PHQ-2 and GAD-2 for combined depression and anxiety screening. The Panic Disorder Severity Scale (PDSS) is useful for monitoring panic disorder treatment response.
Clinical Interview
The clinical interview should assess onset, duration, triggers, avoidance behaviors, and functional impairment. Comorbid depression, present in approximately 60% of anxiety disorder patients, should be screened for. Substance use including caffeine and stimulant intake should be assessed. Suicidal ideation, which is elevated in anxiety disorders, requires evaluation.
Differential Diagnosis and Workup
Medical Mimics of Anxiety
Several medical conditions can mimic anxiety. Hyperthyroidism should be evaluated with a TSH. Cardiac arrhythmias warrant an ECG if palpitations are prominent. Pheochromocytoma, though rare, should be considered in episodic hypertension with anxiety. Hypoglycemia should be assessed with fasting glucose in diabetics on insulin or sulfonylureas. Medication-induced anxiety can result from stimulants, bronchodilators, corticosteroids, and thyroid hormone excess.
Recommended Initial Workup
The initial workup includes TSH, CBC, and a basic metabolic panel. An ECG should be obtained if cardiac symptoms are reported. A urine drug screen is appropriate when substance use is suspected.
Pharmacotherapy
First-Line: SSRIs and SNRIs
SSRIs (sertraline, escitalopram, paroxetine) and SNRIs (venlafaxine, duloxetine) are first-line for GAD, panic disorder, and social anxiety disorder. Treatment should start at low doses to minimize initial anxiogenic effects. Full therapeutic benefit requires four to eight weeks. Treatment should continue for a minimum of 12 months after achieving remission.
| Agent Class | Examples | Indications | Key Considerations |
|---|---|---|---|
| SSRIs (first-line) | Sertraline, escitalopram, paroxetine | GAD, panic, social anxiety | Start low; full effect 4-8 weeks |
| SNRIs (first-line) | Venlafaxine, duloxetine | GAD, social anxiety | Discontinuation syndrome with venlafaxine |
| Buspirone | — | GAD only | No abuse potential; 2-4 week onset |
| Benzodiazepines | Lorazepam, clonazepam | Short-term bridge (2-4 weeks) | Dependence risk; avoid in elderly/SUD |
| Propranolol | — | Performance anxiety only | Does not treat generalized anxiety |
Second-Line and Adjunctive Agents
Buspirone is effective for GAD with no abuse potential, though it takes two to four weeks for onset. Hydroxyzine is useful for short-term or as-needed anxiety relief. Pregabalin is evidence-based for GAD in some guidelines, though monitoring for misuse is necessary.
Benzodiazepines: Judicious Use
Benzodiazepines provide rapid symptom relief but carry risks of dependence, tolerance, cognitive impairment, and falls. They should be reserved for short-term use of two to four weeks during SSRI initiation or acute crises. They should be avoided in older adults (Beers Criteria), patients with substance use disorders, and those on concurrent opioids. If used, shorter-acting agents such as lorazepam are preferred over long-acting agents such as diazepam and clonazepam.
Beta-Blockers
Propranolol is useful for performance-specific social anxiety such as public speaking but does not treat generalized or pervasive social anxiety.
Psychotherapy
Cognitive Behavioral Therapy
CBT is the gold standard psychotherapy for all anxiety disorders. Core components include cognitive restructuring, exposure-based techniques, and behavioral activation. It is effective as monotherapy for mild to moderate anxiety or combined with medication for moderate to severe cases. Digital CBT platforms, including guided internet-based CBT, are effective alternatives when in-person therapy is unavailable.
Other Evidence-Based Approaches
Acceptance and Commitment Therapy (ACT) focuses on psychological flexibility and values-based action. Applied relaxation uses progressive muscle relaxation and diaphragmatic breathing. Mindfulness-Based Stress Reduction (MBSR) has moderate evidence for GAD.
Special Populations
In older adults, anxiety often presents with somatic complaints; benzodiazepines should be avoided, and SSRIs should be started at lower doses. For pregnant patients, CBT is first-line, with sertraline being the preferred SSRI if medication is needed. In children and adolescents, CBT is first-line, with fluoxetine or sertraline considered if pharmacotherapy is warranted.
Follow-Up and Monitoring
The GAD-7 should be repeated at each visit to monitor treatment response. Side effects, adherence, and functional improvement should be assessed. If no response is seen after eight weeks at an adequate dose, switching medication class or adding psychotherapy should be considered. When discontinuing SSRIs or SNRIs, gradual tapering over weeks to months is essential.
Clinical Pearls
Always rule out medical causes of anxiety before attributing symptoms to a primary anxiety disorder. Comorbid depression is the rule rather than the exception, and both conditions should be screened for simultaneously. Patients should be educated that SSRIs may transiently worsen anxiety in the first one to two weeks; starting at half the usual dose mitigates this effect. Benzodiazepines should be a bridge, not a destination, and an exit plan should be established from the outset. Exercise at 30 minutes of moderate aerobic activity most days has a moderate effect size comparable to some pharmacotherapies.
References
- Stein MB, Sareen J. Generalized anxiety disorder. N Engl J Med. 2015;373(21):2059-2068.
- Bandelow B, Michaelis S, Wedekind D. Treatment of anxiety disorders. Dialogues Clin Neurosci. 2017;19(2):93-107.
- Cuijpers P, Cristea IA, Karyotaki E, et al. How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update. World Psychiatry. 2016;15(3):245-258.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed., text revision. Washington, DC: APA; 2022.