Anxiety Disorders: GAD and Panic Disorder

Anxiety is a normal response to stress, but in anxiety disorders it becomes excessive, persistent and disabling. Anxiety disorders are among the most common mental health conditions. They often occur together with depression, and frequently present with physical symptoms such as palpitations, chest tightness or dizziness.

Main types

• Generalised anxiety disorder (GAD): excessive, hard-to-control worry about many everyday things, present on most days for at least 6 months (DSM-5). It comes with symptoms such as:
  • restlessness
  • fatigue
  • poor concentration
  • irritability
  • muscle tension
  • sleep disturbance
• Panic disorder: recurrent, unexpected panic attacks, which are sudden surges of intense fear peaking within minutes, with palpitations, sweating, trembling, breathlessness, chest pain, dizziness and fear of dying. The person then worries about further attacks.
• Social anxiety disorder: intense fear of social situations and of being judged.
• Specific phobias: fear of particular objects or situations.
• Related conditions: obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD), now classified separately.

Assessment

• History of symptoms, triggers, duration and impact on daily life.
• Screening tools: for example GAD-7.
• Exclude physical causes and mimics:
  • hyperthyroidism
  • arrhythmias
  • hypoglycaemia
  • asthma
  • caffeine excess
  • stimulant use
  • alcohol or benzodiazepine withdrawal
  • rarely, phaeochromocytoma
• Investigations are guided by the clinical picture, for example an ECG for palpitations or chest pain, and thyroid function.
• Screen for coexisting conditions: depression, substance misuse and suicide risk.

Management

A stepped-care approach, as in NICE guidance:

1. Education and active monitoring. Explain that the symptoms are real and are caused by anxiety, not a hidden physical disease.
2. Low-intensity psychological interventions: guided self-help, psychoeducation groups.
3. High-intensity interventions: cognitive behavioural therapy (CBT) or applied relaxation, and/or medication.
4. Specialist care for complex or treatment-resistant cases.

Medication

• SSRIs (for example sertraline) are first-line for GAD and panic disorder. SNRIs are an alternative.
• Start low and warn that anxiety can briefly worsen early in treatment. Benefit takes several weeks.
• Benzodiazepines should not be used routinely or long-term, because of dependence, tolerance and withdrawal. At most, they are for short-term use in a crisis.
• Pregabalin is an option for GAD in some guidelines. Note its misuse potential.
• Beta-blockers can reduce physical symptoms in performance anxiety, but are not a treatment for GAD.

Self-help

• Regular exercise.
• Good sleep habits.
• Reducing caffeine and alcohol.
• Breathing and relaxation techniques.
• Mindfulness.
• Social support.

Managing a panic attack

• Reassure the patient.
• Exclude dangerous physical causes where indicated.
• Encourage slow breathing.
• Explain the cycle of physical sensations and fear.
• Long-term, CBT is highly effective.

Exam pearls

• Exclude hyperthyroidism and cardiac arrhythmias in a "panicky" patient with palpitations.
• CBT is the psychological treatment with the strongest evidence.
• Avoid long-term benzodiazepines.

If anxiety is accompanied by thoughts of self-harm or suicide, seek urgent help from a doctor or local emergency services.

See also Depression and the psychiatry chapter of our Medicine Companion.

Test yourself

5 exam-style single-best-answer questions. Choose your answer, then tap “Show answer”.

1. Duration of worry required for GAD (DSM-5):

   1. 1 month
   2. 2 weeks
   3. At least 6 months
   4. 1 year
   5. 3 days
   Show answer

   Answer: C. At least 6 months
   Excessive worry on most days for at least 6 months.

2. Psychological therapy with the strongest evidence for anxiety disorders:

   1. Art therapy
   2. Psychoanalysis
   3. Cognitive behavioural therapy
   4. None
   5. Hypnosis
   Show answer

   Answer: C. Cognitive behavioural therapy
   CBT has the strongest evidence for GAD and panic disorder.

3. First-line medicine for GAD and panic disorder:

   1. Opioid
   2. Antipsychotic
   3. An SSRI such as sertraline
   4. Long-term diazepam
   5. Propranolol alone
   Show answer

   Answer: C. An SSRI such as sertraline
   SSRIs are first-line; benzodiazepines are not for long-term use.

4. Palpitations, weight loss and tremor in an 'anxious' patient. Which test?

   1. Vitamin D
   2. Lipid profile
   3. Thyroid function
   4. Urine culture
   5. Amylase
   Show answer

   Answer: C. Thyroid function
   Hyperthyroidism mimics anxiety.

5. Main problem with long-term benzodiazepines:

   1. Hair growth
   2. Anaemia
   3. Hypertension
   4. Weight loss
   5. Dependence, tolerance and withdrawal
   Show answer

   Answer: E. Dependence, tolerance and withdrawal
   Benzodiazepines cause dependence and should only be used short-term in a crisis.

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Disclaimer

For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues.