anxiety
ANXIETY

Anxiety disorders are disorders wherein the patient experiences uncontrollable fear or anxiety with behavioral disturbances that affects normal functioning.

Generalized anxiety disorder is having excessive anxiety and worry occurring for at least 6 months about several events or activities. The person finds it difficult to control the worry.
Panic disorder is when the person experienced recurrent unexpected panic attacks.
Social anxiety disorder is marked and persistent fear of social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others.

Follow Up

Generalized Anxiety Disorder and Social Anxiety Disorder

  • Provide frequent follow-up during 1st 3 months (acute phase) of therapy
    • Monitor for adverse drug effects
      • Weekly monitoring for risk of suicidal ideation and self-harm in patients with social anxiety disorder who were given a selective serotonin reuptake inhibitor or serotonin and norepinephrine reuptake inhibitor
    • Monitor for response to therapy
  • Re-assess therapy every month thereafter
  • The benefits of cognitive-behavioral therapy are maintained over 1-5 years of follow-up

Panic Disorder

  • Provide frequent follow-up during 1st 3 months (acute phase) of therapy
  • For patients receiving pharmacological therapy, monitor for adverse effects and response to therapy
  • Re-assess therapy at 8- to 12-weeks intervals

Therapy Change

Generalized Anxiety Disorder

  • If results are unsatisfactory after 4-8 weeks of treatment, consider:
    • Expert referral
    • Dose increase
    • Adding drug from another therapeutic class
    • Change in therapeutic class
    • Adding psychotherapy

Panic Disorder

  • 12 week-treatment period is needed to assess efficacy
  • If results are unsatisfactory consider:
    • Different treatment
    • Adding psychotherapy/medication
    • Expert referral
    • Re-evaluating diagnosis

Social Anxiety Disorder

  • Treatment period of 12 weeks is needed to evaluate effectiveness
  • If results are unsatisfactory consider:
    • Switching to a different drug from the same class of 1st-line agents or changing to a 2nd-line agent
    • Switching to psychotherapy
    • Expert referral
    • Re-evaluating diagnosis

Long-Term Treatment

Generalized Anxiety Disorder

  • Patients who respond to a 12-week trial of treatment should continue to be monitored for 6 more months
    • Symptom remission and return to full functioning is the goal of therapy
    • Manage late-onset drug adverse effects
  • If the medication is effective, continue treatment for at least 1 year; likelihood of relapse is high
  • Once full function has returned, attempt to withdraw treatment
    • Careful medication taper may be attempted
    • If after 2 careful attempts to discontinue medications patient still experiences anxiety symptoms, consider longer-term maintenance

Panic Disorder

Patients receiving pharmacological therapy:

  • Continue to monitor patient
    • Symptom remission and return to full functioning is the goal of therapy
    • Manage late-onset drug adverse effects
  • General recommendation: Continue medication for >1 year to maintain symptom reduction and reduce the risk of recurrence
    • Attempt discontinuation after this time and maintain close follow-up
  • Relapse is common
    • Re-institution of medication seems to help

Patients receiving psychotherapy:

  • Frequency of visits may generally be decreased
    • Discontinue after several months
  • Adding psychosocial treatment, particularly cognitive-behavioral therapy, to pharmacological therapy may enhance long-term outcomes by reducing the likelihood of relapse when pharmacotherapy is stopped
    • Some studies show remission of several years is possible with cognitive-behavioral therapy; however, effectiveness of resuming cognitive-behavioral therapy for patients whose relapse has not been studied

Social Anxiety Disorder

  • Once medication has taken effect, in vivo exposure exercises may be initiated
  • Continue to monitor patient
    • Symptom remission and return to full functioning is the goal of therapy
    • Manage late-onset drug adverse effects
  • Continue therapy for 6-12 months
    • Attempt tapering and discontinuation after this time and maintain close follow-up
      • Should symptoms recur after drug has been stopped or dose has been lowered, consider a dose increase, drug reintroduction, or individual cognitive-behavioral therapy
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