Generalized anxiety disorder, agoraphobia, and panic disorder: Clinical sciences

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Introduction0:00–0:33

Generalized anxiety disorder, agoraphobia, and panic disorder are common anxiety disorders seen in all types of practice settings.
Generalized anxiety disorder is characterized by excessive anxiety and worry accompanied by physical symptoms. Agoraphobia is the fear of being in public places and is usually, but not always, associated with panic disorder.
Finally, panic disorder is a condition of recurrent, unexpected panic attacks which are characterized by an abrupt surge of discomfort or fear.
When your patient presents with a chief concern suggesting an anxiety disorder, your next step is to conduct a focused history and physical examination.

H&P0:33–0:41

Let’s start with generalized anxiety disorder, or GAD. Your patient will report excessive anxiety and worry about routine situations, such as finances, relationships, work or school performance, or health.

Generalized Anxiety Disorder0:41–1:02

They might also report symptoms like muscle tension or fatigue. Physical exam might show a constricted or tense affect.

Labs/DSM-51:02–2:11

Next, order labs to rule out physical conditions with symptoms like GAD. These include a CBC with differential to rule out anemia, TSH and free T4 levels to rule out thyroid disease, as well as a urine drug screen to rule out substance use.
If these labs show abnormalities, consider an alternative diagnosis. On the other hand, if lab results are within normal limits, suspect generalized anxiety disorder or GAD and assess the DSM-5 criteria to confirm the diagnosis.
To meet the criteria, your patient’s anxiety and worry must be present more days than not for at least 6 months and be associated with three or more of the following physical symptoms: restlessness, fatigue, poor concentration, irritability, muscle tension, or poor sleep.
In addition, the anxiety and worry will be difficult to control; cause significant distress; or impair their ability to function.
If these criteria are met, and there’s no medical condition, substance use, or other mental disorder that could cause the symptoms, diagnose generalized anxiety disorder.
Treatment includes both psychotherapy or medical management, although patients with mild cases may do well with just one or the other.

GAD treatment2:11–4:08

Interventions can include supportive psychotherapy, cognitive behavioral therapy, or CBT for short; or relaxation training.
In supportive psychotherapy, the therapist focuses on creating a strong therapeutic alliance with the patient and providing teaching about how to improve coping strategies when stressed.
Cognitive behavioral therapists teach patients to monitor for maladaptive thoughts and behaviors and replace these with less anxiety-provoking versions.
Finally, relaxation training involves psychosomatic exercises that help decrease muscle tension and promote a sense of calm.
Medical management involves first-line medications such as selective serotonin reuptake inhibitors or SSRIs, like sertraline, fluoxetine, or citalopram.
If these are ineffective, switch to second-line medications which include serotonin-norepinephrine reuptake inhibitors or SNRIs, like venlafaxine, or a tricyclic antidepressant or TCA, like amitriptyline.
If augmentation is needed, consider adding buspirone or gabapentin. Finally, benzodiazepines should be avoided in GAD, since anxiety in GAD is pervasive rather than episodic, and chronic use of benzodiazepines can lead to tolerance, physical dependence, and addiction.
Here’s a clinical pearl to keep in mind! Watch out for side effects of SSRIs.
The three most common ones are headaches, GI distress like nausea or diarrhea, and sexual side effects like low libido or anorgasmia.
And here’s a high yield fact! Antidepressants take several weeks to start working, so be sure to give enough time between medication changes before assessing the effectiveness of the medication.

Agoraphobia4:08–6:00

Alright, now let’s switch gears and discuss agoraphobia, which can occur alone or in the context of panic disorder. First, let’s focus on agoraphobia alone.
Your patient will report that they avoid public places, but that they don’t experience panic attacks. Physical examination may reveal a constricted or anxious affect.
With these findings, suspect agoraphobia. Then, assess the DSM-5 criteria for this condition.
Your patient must express feeling either fear or anxiety in two or more situations like using public transportation; being in open spaces like a parking lot; being in enclosed spaces like a theater; standing in line or being in a crowd; or being alone outside of their home.
They’ll report avoiding situations like these or endure them with extreme anxiety due to fear that they’ll be unable to escape or that there’s no help available if something terrible happens, like visibly panicking or becoming embarrassed.
The amount of anxiety they experience is also out of proportion to the actual danger these situations pose to them, and it impairs their ability to function.
If agoraphobia has been persistent for at least 6 months, and there’s no medical condition, substance use, or other mental disorder that could cause the symptoms, diagnose agoraphobia.
Here’s a clinical pearl! Patients often develop agoraphobia due to a fear of having embarrassing or debilitating symptoms in public, such as shortness of breath, incontinence, nausea, vomiting, or falls.
Keep in mind that worrying about this can be normal in patients with chronic physical illnesses, so only diagnose agoraphobia if the fear is out of proportion to the situation and if the fear causes notable impairment, like missing important family events or failing to attend doctor’s appointments.
Okay, let’s move on to treatment. The primary treatment for agoraphobia is CBT, in which the patient learns to assess the validity of their fears and develop more realistic thoughts.

Agoraphobia Treatment6:00–6:31

The therapist also guides the patient through exposure to feared situations in a safe environment, while strengthening coping skills.
Medical treatment is less helpful for this condition; however, some patients might need SSRIs and a trial of benzodiazepines.
Next, let’s discuss panic disorder. Your patient will report recurrent panic attacks, characterized by an abrupt period of intense fear, accompanied by an uncomfortable surge of autonomic symptoms, where the heart beats faster, respirations increase, and muscles tense up.

Panic Disorder6:31–8:22

Physical exam will reveal tachycardia or diaphoresis during the attack but might be unremarkable between episodes. Your next step is to order labs to rule out medical conditions that might present with similar symptoms.
Major labs include cardiac enzymes if the patient reports symptoms suggesting an acute coronary syndrome, like chest discomfort; TSH and free T4 levels to rule out hyperthyroidism; a urine drug screen to assess for substance use; and urine metanephrines if the patient has an elevated heart rate and blood pressure, to rule out pheochromocytoma.
Lastly, obtain a 12-lead ECG. If this workup reveals any abnormal results, consider an alternative diagnosis and treat any associated medical condition.
On the other hand, if the results are within normal limits, suspect panic disorder and assess the DSM-5 criteria to confirm the diagnosis.
To meet criteria, the patient must report repeated, unexpected panic attacks, characterized by four or more symptoms like palpitations, sweating, shortness of breath, dizziness, chest discomfort, or nausea; as well as feelings of detachment, losing control, or even fear of dying.
Also, they must experience at least one month of nearly constant worry about future episodes or make a maladaptive change in their behavior to avoid having attacks, or both.
If these criteria are met, and there’s no medical condition, substance use, or other mental disorder that could cause the symptoms, diagnose panic disorder.
Next, assess for agoraphobia! Agoraphobia often coexists with panic disorder and can be considered a subtype of panic disorder.

Panic Disorder w/o Agoraphobia8:22–8:44

If agoraphobia is present, diagnose panic disorder with agoraphobia. Otherwise, it should be pretty obvious, your patient has panic disorder without agoraphobia.
Either way, treatment for panic disorder is the same, whether agoraphobia is present or not. It’s just good to know what you’re dealing with.

Panic Disorder - Treatment8:44–10:18

Options include lifestyle modifications, psychotherapy, and medical management. Lifestyle modifications include counseling about limiting caffeine, nicotine, and other psychostimulants, as these can increase anxiety and many of the physical symptoms associated with panic attacks.
Engaging in regular physical activity is another important lifestyle modification. Recommend 20 to 30 minutes of aerobic exercise, such as brisk walking or jogging, as tolerated, 3 to 4 days per week.
Psychotherapy should include both psychoeducation and CBT. Psychoeducation teaches the patient about the nature of panic attacks and associated symptoms.
CBT addresses maladaptive thoughts associated with the episodes and teaches coping skills. It can also include graduated exposure to stressful situations, which can bolster resilience.
If agoraphobia is present, treatment includes exposure to feared situations in a safe environment. Medical management is often used simultaneously with psychotherapy.
This involves first-line SSRIs, while SNRIs and TCAs are second-line. Additionally, short-term augmentation with benzodiazepines is commonly used as a bridge, since patients may not experience benefit from antidepressants for up to a month.
If panic attacks are infrequent, monotherapy with benzodiazepines, as needed, is also an option. Alright, as a quick recap… Generalized anxiety disorder or GAD, agoraphobia, and panic disorder are common anxiety disorders seen in all types of practice settings.

Review10:18–10:58

Generalized anxiety disorder is characterized by excessive anxiety and worry accompanied by physical symptoms. Agoraphobia is the fear of being in public places and is usually, but not always, associated with panic disorder.
Finally, panic disorder is a condition of recurrent, unexpected panic attacks which are characterized by an abrupt surge of discomfort or fear.
Treatment options can include psychotherapy, cognitive behavioral therapy, lifestyle modifications, and medications like antidepressants,