Treatment of anxiety disorder

There are two approaches to the management of anxiety:

• pharmacological
  • review of the evidence revealed that treatments likely to be beneficial in treatment of panic disorder include (1):
    • selective serotonin reuptake inhibitors
    • tricyclic antidepressants e.g. imipramine
• psychological e.g. cognitive behavioural therapy
  
  

Treatment also involves:

• education about the condition
• distraction strategies
• breathing exercises

NICE recommends the following approach: (2)

Step 1: all known and suspected presentations of GAD
Identification, assessment, education, monitoring.

Step 2: diagnosed GAD that has not improved after education and active monitoring in primary care
Low-intensity psychological support, non-facilitated or guided self-help, psycho-educational groups.

Step 3: GAD with an inadequate response to step 2 interventions or marked functional impairment
Cognitive behavioural therapy (CBT)/applied relaxation or drug treatment.

Step 4: complex treatment-refractory GAD and very marked functional impairment, such as self-neglect or a high risk of self-harm
Specialist drug and/or psychological treatment, multi-agency teams, crisis intervention, outpatient or inpatient care.

There are frequently comorbid conditions - eg, depression, substance abuse - which may need treating too. NICE recommends that the most severe condition be treated first. If treating a child or adolescent, be much more reluctant and cautious about prescribing.

Notes:

• if benzodiazepines are used in the management of panic disorder then there is a trade off between benefits and harms

Reference:

1. Clinical Evidence. BMJ (March 2006)

2. Overview | Generalised anxiety disorder and panic disorder in adults: management | Guidance | NICE (https://www.nice.org.uk/guidance/cg113)