Treatment of anxiety disorders. Anxiety disorders (generalized anxiety disorder, panic disorder/agoraphobia, social anxiety disorder, and others) are the most prevalent psychiatric disorders, and are associated with a high burden of illness. Anxiety disorders are often underrecognized and undertreated in primary care. Treatment is indicated when a patient shows marked distress or suffers from complications resulting from the disorder. The treatment recommendations given in this article are based on guidelines, meta-analyses, and systematic reviews of randomized controlled studies. Anxiety disorders should be treated with psychological therapy, pharmacotherapy, or a combination of both. Cognitive behavioral therapy can be regarded as the psychotherapy with the highest level of evidence. First-line drugs are the selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Benzodiazepines are not recommended for routine use. Other treatment options include pregabalin, tricyclic antidepressants, buspirone, moclobemide, and others. After remission, medications should be continued for 6 to 12 months. When developing a treatment plan, efficacy, adverse effects, interactions, costs, and the preference of the patient should be considered.
Keywords: drug treatment, generalized anxiety disorder, panic disorder, psychotherapy, social anxiety disorder, treatment
Introduction
Anxiety disorders are the most prevalent psychiatric disorders and are associated with a high burden of illness.1–3 With a 12-month prevalence of 10.3%, specific (isolated) phobias are the most common anxiety disorders,4 although persons suffering from isolated phobias rarely seek treatment. Panic disorder with or without agoraphobia (PDA) is the next most common type with a prevalence of 6.0%, followed by social anxiety disorder (SAD, also called social phobia; 2.7%) and generalized anxiety disorder (GAD; 2.2%). Evidence is lacking on whether these disorders have become more frequent in recent decades.5,6 Women are 1.5 to two times more likely than men to receive a diagnosis of anxiety disorder.7
The age of onset for anxiety disorders differs among the disorders. Separation anxiety disorder and specific phobia start during childhood, with a median age of onset of 7 years, followed by SAD (13 years), agoraphobia without panic attacks (20 years), and panic disorder (24 years).8 GAD may start even later in life. Anxiety disorders tend to run a chronic course, with symptoms fluctuating in severity between periods of relapse and remission in GAD and PDA9 and a more chronic course in SAD. After the age of 50, a marked decrease in the prevalence of anxiety disorders has been observed in epidemiological studies.8,10–12 GAD is the only anxiety disorder that is still common in people aged 50 years or more.
The current conceptualization of the etiology of anxiety disorders includes an interaction of psychosocial factors, eg, childhood adversity, stress, or trauma, and a genetic vulnerability, which manifests in neurobiological and neuropsychological dysfunctions. The evidence for potential biomarkers for anxiety disorders in the fields of neuroimaging, genetics, neurochemistry, neurophysiology, and neurocognition has been summarized in two recent consensus papers.13,14 Despite comprehensive, high-quality neurobiological research in the field of anxiety disorders, these reviews indicate that specific biomarkers for anxiety disorders have yet to be identified. Thus, it is difficult to give recommendations for specific biomarkers (eg, genetic polymorphisms) that could help identify persons at risk for an anxiety disorder.
Obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) were formerly included in the anxiety disorders, but have now been placed in other chapters in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Therefore, OCD and PTSD are not discussed in this review.
Diagnosis
A short description of the anxiety disorders is given in Table I. Anxiety disorders are often underdiagnosed in primary care.
TABLE I. Anxiety disorders: short description according to ICD-10 and DSM-5 classification. Adapted from reference 107: World Health Organization. ICD-10 Chapter V (F) Classification of Mental and Behvioural Disorders: Clinical Descriptions and Diagnostic Guidelines. “Blue Book” Clinical Descriptions and Diagnostic Guidelines. Geneva, Switzerland: World Health Organization; 1991.
| Anxiety disorder | Description | |
| ICD-10 classification | DSM-5 classification | |
| Panic Disorder F41.0 | Panic Disorder 300.01 (F41.0) | Anxiety attacks of sudden onset, with physical manifestations of anxiety (eg, palpitations, sweating, tremor, dry mouth, dyspnea, feeling of choking; chest pain; abdominal discomfort; feeling of unreality, paresthesia, etc). Panic attacks can arise out of the blue; however, many patients start to avoid situations in which they fear that panic attacks might occur. |
| Agoraphobia F40.0 without Panic Disorder F40.00 with Panic Disorder F40.01 | Agoraphobia 300.22 (F40.00) | Fear of places where it might be difficult or embarrassing to escape if a panic attack should occur (crowds, on public transport, or in closed spaces, eg, elevators). Fear of being alone is also common. |
| Generalized anxiety disorder F41.1 | Generalized Anxiety Disorder 300.02 (F41.1) | Patients suffer from somatic anxiety symptoms (tremor, palpitations, dizziness, nausea, muscle tension, etc.) and from psychic symptoms, including concentrating, nervousness, insomnia, and constant worry, eg, that they (or a relative) might have an accident or become ill. |
| Social Phobia F40.1 | Social Anxiety Disorder (Social Phobia) 300.23 (F40.10) | Patients are afraid of situations in which they are the center of attention and may be criticized—eg, public speaking, visits to authorities, conversations with superiors on the job, or with persons of the opposite sex. They are afraid of appearing clumsy, embarrassing themselves, or being judged negatively. |
| Specific (Isolated) Phobias F40.2 | Specific Phobia 300.29 | Phobias which are restricted to singular, circumscribed situations, often related to animals (eg, cats, spiders, or insects), or other natural phenomena (eg, blood, heights, deep water). |
| Mixed Anxiety and Depressive Disorder F41.2 | – | Simultaneous presence of anxiety and depression, with neither predominating. However, neither component is sufficiently severe to justify a diagnosis of anxiety or depression in itself. If the diagnostic criteria for anxiety or depression (or both) are fulfilled, then the corresponding diagnosis should be made, rather than mixed anxiety and depressive disorder. |
| Separation Anxiety Disorder of Childhood (F93.0) | Separation Anxiety Disorder 309.21 (F93.0) | Inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached. In ICD-10, the disorder can only be diagnosed in children. |
| Selective Mutism (F94.0) | Selective Mutism 312.23 (F94.0) | Consistent failure to speak in social situations in which there is an expectation to speak (eg, school) even though the individual speaks in other situations. |
| DSM-5, Diagnostic and Statistical Manual of Mental Disorders, 5th edition; ICD-10, 10th revision of the International Statistical Classification of Diseases and Related Health Problems |
In DSM-5, the group of anxiety disorders has been expanded to include separation anxiety disorder, a diagnosis the previous DSM version reserved for children only.16,17 The change was based on the findings of epidemiological studies that revealed the unexpectedly high prevalence of the condition in adults.18 DSM-5 also introduces selective mutism—the failure of children to speak in special social situations—and a new term called illness anxiety disorder, defined by excessive preoccupation and fear of having a serious medical illness. Illness anxiety disorder was formerly called hypochondriasis in DSM-IV and Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10); in DSM-5, it is not classified under anxiety disorders but belongs to the Somatic Symptom and Related Disorders category. In the current ICD-11 Beta Draft,19 hypochondriasis is placed in the group Obsessive-Compulsive or Related Disorders. It is characterized by catastrophic misinterpretation of bodily symptoms and is manifest as obsessive and excessive health-related behaviors. The fear of having a serious medical condition persists despite thorough medical evaluation and repeated reassurance that the patient does not suffer from the feared illness.
Mixed anxiety and depression is a category listed only in ICD-10 and not in DSM-5. It is often diagnosed in primary care. Research on the treatment of this disorder is limited.20 Adjustment disorder with mixed anxiety and depressed mood (F43.22) is a condition with similar symptomatology. It occurs as a reaction to stressful life events.
The differential diagnosis of anxiety disorders includes common mental disorders, such as other anxiety disorders, major depression, and somatic symptom disorders, as well as physical illnesses such as coronary heart or lung diseases, hyperthyroidism, and others.
Anxiety disorders often co-occur with other anxiety disorders, major depression, somatic symptom disorders, personality disorders, and substance abuse disorders.21 For example, major depression was found to be highly correlated with all anxiety disorders in a large European survey (eg, with GAD, the odds ratio was 33.7; with panic disorder, it was 29.4).22 Anxiety disorders were also strongly interrelated: GAD was highly associated with agoraphobia (25.7), panic disorder (20.3), and SAD (13.5).
To determine the severity of anxiety disorders and to monitor treatment progress, commonly used rating scales can be used, including the Hamilton Anxiety Scale (HAM-A)23 for GAD, the Panic and Agoraphobia Scale (PAS)24 for panic disorder/agoraphobia, and the Liebowitz Social Anxiety Scale (LSAS)25 for SAD.
Treatment
The two main treatments for anxiety disorders are psychotherapy and medications. You may benefit most from a combination of the two. It may take some trial and error to discover which treatments work best for you. Treatment of anxiety disorders
Psychotherapy
Also known as talk therapy or psychological counseling, psychotherapy involves working with a therapist to reduce your anxiety symptoms. It can be an effective treatment for anxiety.
Cognitive behavioral therapy (CBT) is the most effective form of psychotherapy for anxiety disorders. Generally a short-term treatment, CBT focuses on teaching you specific skills to improve your symptoms and gradually return to the activities you’ve avoided because of anxiety.
CBT includes exposure therapy, in which you gradually encounter the object or situation that triggers your anxiety so you build confidence that you can manage the situation and anxiety symptoms. Treatment of anxiety disorders
Medications
Several types of medications are used to help relieve symptoms, depending on the type of anxiety disorder you have and whether you also have other mental or physical health issues. For example:
- Certain antidepressants are also used to treat anxiety disorders.
- An anti-anxiety medication called buspirone may be prescribed.
- In limited circumstances, your doctor may prescribe other types of medications, such as sedatives, also called benzodiazepines, or beta blockers. These medications are for short-term relief of anxiety symptoms and are not intended to be used long term.
Talk with your doctor about benefits, risks and possible side effects of medications. Treatment of anxiety disorders