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Am Fam Physician. 2022;106(2):157-164

Patient information: See related handout on anxiety and panic disorders, written by the authors of this article.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Generalized anxiety disorder (GAD) and panic disorder (PD) are common mental health conditions in adults that are often seen in primary care. Although there is insufficient evidence to support universal screening for PD and GAD, evaluation should be considered in patients who express recurrent, pervasive worry or present with somatic symptoms not attributed to underlying medical conditions. The GAD-7 and Patient Health Questionnaire for PD are validated screening tools that can aid in diagnosis and assessment. Anxiety disorders often present with substance use disorders, which should be treated concurrently. Effective therapies for PD and GAD include cognitive behavior therapy and anti-depressants, including selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Benzodiazepines are not recommended for first-line therapy or long-term use because of adverse reactions, risk of dependence, and higher mortality. No consistent evidence currently supports a specific prevention strategy for PD or GAD, but exercise may be beneficial.

Anxiety disorders are some of the most common mental health conditions seen in primary care, with generalized anxiety disorder (GAD) and panic disorder (PD) being the most common anxiety disorders in adults.1 Patients with anxiety disorders are more likely than those unaffected to also have other chronic medical problems and are twice as likely to present with somatic symptoms.2 Integrating mental health services with primary care decreases treatment costs and increases access to care.3 This article summarizes the diagnosis and management of GAD and PD in the general adult population.

Clinical recommendation Evidence rating Comments
There is insufficient evidence supporting universal screening for GAD in the general adult population.1012 C Systematic review, NICE guidelines, and USPSTF recommendation evaluating accuracy of tools but not on improving patient outcomes when used for screening
SSRIs and SNRIs are recommended as first-line medications for treating GAD and PD.12,37,38,45 A Systematic review data and NICE guideline
Antidepressants should be continued for at least six to 12 months after achieving treatment response to decrease the rate of relapse.12,34,35 B Systematic review of double-blind RCTs, review article, and guideline
Benzodiazepines are not more effective than anti-depressants for anxiety disorders and should not be used as first-line therapy.12,37 B Systematic review data and NICE guidelines
Psychotherapy can be as effective as medication for GAD and PD; for PD, evidence of benefit is strongest for cognitive behavior therapy.12,26,52,53 A Systematic review data and NICE guideline
Physical activity reduces symptoms of anxiety.6063 B Systematic review of low- to moderate-quality RCTs and low-quality RCTs

Typical Presentation and Diagnostic Criteria

GENERALIZED ANXIETY DISORDER

GAD is defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) as excessive worry that occurs on most days for at least six months and causes significant distress or impairment (Table 1).4 Clinically, GAD most commonly presents as excessive worry about minor issues, often manifesting with somatic symptoms and pathologic behavioral changes.5 Most studies suggest a peak onset of GAD during late adolescence or early adulthood, but it can also present later in life.6

  1. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

  2. The individual finds it difficult to control the worry.

  3. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):

    Note: Only one item is required in children.

    Restlessness or feeling keyed up or on edge.

    Being easily fatigued.

    Difficulty concentrating or mind going blank.

    Irritability.

    Muscle tension.

    Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

  4. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  5. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).

  6. The disturbance is not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

PANIC DISORDER

PD is defined by the DSM-5 as recurrent panic attacks that include characteristic symptoms and lack an obvious trigger (Table 2).4 PD includes at least one month of persistent concern for panic attack recurrence and may include mal-adaptive behavioral changes. Although other symptoms such as headache, tinnitus, and uncontrollable crying are common, they do not help define panic attacks. The most common symptom of a panic attack is heart palpitations.7 Panic attacks that are nocturnal or lack fear require a more extensive workup; however, these features are not uncommon in PD.4

  1. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time four (or more) of the following symptoms occur:

    Note: The abrupt surge can occur from a calm state or an anxious state.

    Palpitations, pounding heart, or accelerated heart rate.

    Sweating.

    Trembling or shaking.

    Sensations of shortness of breath or smothering.

    Feelings of choking.

    Chest pain or discomfort.

    Nausea or abdominal distress.

    Feeling dizzy, unsteady, light-headed, or faint.

    Chills or heat sensations.

    Paresthesias (numbness or tingling sensations).

    Derealization (feelings of unreality) or depersonalization (being detached from oneself).

    Fear of losing control or “going crazy.”

    Fear of dying.

    Note: Culture-specific symptoms (e.g., tinnitus, neck soreness, headache, uncontrollable screaming or crying) do not count as one of the four required symptoms.

  2. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:

    Persistent concern or worry about additional panic attacks or their consequences (e.g., losing control, having a heart attack, “going crazy”).

    A significant maladaptive change in behavior related to the attacks (e.g., behaviors designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations).

  3. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism, cardiopulmonary disorders).

  4. The disturbance is not better explained by another mental disorder (e.g., the panic attacks do not occur only in response to feared social situations, as in social anxiety disorder; in response to circumscribed phobic objects or situations, as in specific phobia; in response to obsessions, as in obsessive-compulsive disorder; in response to reminders of traumatic events, as in posttraumatic stress disorder; or in response to separation from attachment figures, as in separation anxiety disorder).

Diagnosis, Comorbidity, and Screening

The symptoms of GAD and PD can suggest medical diagnoses, including hyperthyroidism, arrhythmias, asthma, chronic obstructive pulmonary disease, certain medication use or withdrawal (e.g., albuterol, levothyroxine, decongestants, antidepressants, antianxiety medications), and substance use or withdrawal (e.g., caffeine, alcohol, cocaine, amphetamines, cannabinoids).4

GAD and PD commonly occur with other psychiatric conditions, including major depressive episodes, manic-hypomanic episodes, dysthymia, and substance use disorder.4,8 GAD and PD are also associated with suicidal ideation and suicide attempts.4,8 Because patients with more severe symptoms more often seek treatment, evaluating for suicidality is important.9

There is insufficient evidence to support universal screening for GAD or PD in adults at this time; however, the U.S. Preventive Services Task Force is updating guidelines regarding screening for anxiety, suicidality, and depression.10,11 Evaluation for GAD should be considered for patients who express anxiety, pervasive worry, or recurrent somatic symptoms not related to an underlying physical condition.12 The GAD-2 and GAD-7 are two-item and seven-item validated screening tools for GAD 11 (Table 313,14). The Patient Health Questionnaire for PD is the most accurate screening tool for PD in patients expressing sudden episodes of anxiety or fear 15,16 (Table 417,18). The Women's Preventive Services Initiative recommends screening for anxiety disorders in women and adolescent girls older than 13 years; however, the systematic review did not find studies that directly evaluated the overall effectiveness or harms of screening for anxiety in this population.19

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