Anxiety Disorders — Overview & Assessment

Anxiety disorders — GAD, panic disorder, OCD, PTSD, phobias, and social anxiety disorder — affect around 14% of people aged 16–85, and are prominent both as standalone conditions and alongside depression and other chronic illness.

Not every patient with anxiety symptoms needs treatment — most mild-moderate symptoms resolve without intervention. The need to treat is driven by severity and persistence of symptoms, comorbid mental/physical illness, and the degree of disability/impact on social functioning.

Key points

• Anxiety disorders form a spectrum from mild to severe, and are common.
• Comprehensive clinical assessment is the essential first step — obtain a clear diagnosis, and recognise patients often have more than one disorder at once (e.g. GAD plus panic disorder plus depression).
• Where treatment is indicated:
  • CBT is first-line for GAD, panic disorder, and panic attacks — effective at reducing anxiety symptoms in both the short and long term.
  • SSRIs and SNRIs are effective across the range of anxiety disorders and are generally suitable first-line pharmacotherapy.
  • Short-term adjunctive benzodiazepines can help reduce the symptom-worsening that sometimes occurs in the first days-to-weeks of starting an antidepressant, aiding adherence.
  • Benzodiazepine use in anxiety disorders should mostly be limited to severe or treatment-resistant cases.
  • Patients using two or more psychoactive drugs together (polydrug use) may be more vulnerable to serious harm.

RACGP evidence grading (from Prescribing drugs of dependence, Part B — benzodiazepines in anxiety disorders):

	Recommendation	Grade
1	CBT is one of the treatments of choice for GAD, panic disorder, and panic attacks, given its short- and long-term effectiveness — though patient preference should be considered.	A
2	Consider an SSRI for first-line drug treatment — effective across anxiety and related disorders in the short and long term, and generally well tolerated.	A
3	Benzodiazepines have evidence of benefit in GAD, social anxiety disorder, and panic disorder, but not OCD or PTSD.	A/B

Assessment

Focused history: let the patient describe the symptoms that concern them most; ask about substance use; identify triggers/events and symptom timing; screen for medical conditions that can present as anxiety (thyroid disease, hypoglycaemia, cardiac disorders, chronic respiratory disease, vitamin B deficiency, inner-ear conditions, acute aspartame reactions, benzodiazepine/alcohol withdrawal); ask about co-existing psychiatric disorders.

Examination: general appearance (signs of anxiety, anaemia, substance use); vital signs (pulse irregularity, fever, BP, tachypnoea); cardiovascular (arrhythmia, ischaemic heart disease, heart failure, valve disease); respiratory (local or generalised lung disease); thyroid (including signs of hyperthyroidism/thyroid eye disease); neurological (focal signs).

Investigations: FBE, UEC, LFTs, fasting glucose, TFTs; with clinical discretion — ECG (especially if chest pain is prominent), CXR, echocardiogram, CT brain, EEG, Holter monitor, urine catecholamines, drug screen.

Assess severity: DASS-21 or K10 give quantitative scores useful for monitoring progress over time.

Management

• Psychoeducation about the nature and purpose of anxiety, how it presents, and what can be done — introducing CBT and relaxation strategies.
• Psychological treatment: CBT with relaxation techniques (guided imagery, progressive muscle relaxation), mindfulness-based meditation, exposure techniques.
• Pharmacological treatment: SSRIs, with short-term benzodiazepines reserved for more serious symptoms.

Initial medication options by condition:

Condition	Medication options
Generalised anxiety disorder	SSRI, duloxetine (30–120 mg), venlafaxine CR (75–225 mg)
Panic disorder	SSRI, venlafaxine CR (75–225 mg)
Obsessive-compulsive disorder	SSRI
Agoraphobia (without panic)	None
Social anxiety disorder (generalised)	SSRI, venlafaxine CR (75–225 mg)
Social anxiety disorder (non-generalised)	Propranolol 10–40 mg orally, 30–60 minutes before the event/performance
Specific phobias	Not routinely recommended
Post-traumatic stress disorder	SSRI, mirtazapine

See also GAD, Panic Disorder, Social Anxiety Disorder, Agoraphobia, Specific Phobia, OCD, and PTSD for condition-specific detail.