Generalised anxiety disorder and panic disorder

Anxiety is a common disorder that can present in multiple ways. NICE define the central feature as an 'excessive worry about a number of different events associated with heightened tension.'

Always look for a potential physical cause when considering a psychiatric diagnosis. In anxiety disorders, important alternative causes include hyperthyroidism, cardiac disease and medication-induced anxiety (NICE). Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants and caffeine

Management of generalised anxiety disorder (GAD)

NICE suggest a step-wise approach:

• step 1: education about GAD + active monitoring
• step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
• step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
• step 4: highly specialist input e.g. Multi agency teams

Drug treatment

• NICE suggest sertraline should be considered the first-line SSRI
• if sertraline is ineffective, offer an alternative SSRI or a serotonin-noradrenaline reuptake inhibitor (SNRI)
  • examples of SNRIs include duloxetine and venlafaxine
• If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin
• interestingly for patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm. Weekly follow-up is recommended for the first month

Management of panic disorder

Again a stepwise approach:

• step 1: recognition and diagnosis
• step 2: treatment in primary care - see below
• step 3: review and consideration of alternative treatments
• step 4: review and referral to specialist mental health services