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

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.

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

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. 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.

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.