Anxiety disorders diagnosis and treatment algorithm

Anxiety Disorders Diagnosis and Treatment Algorithm
For the Primary Care Physician

The following diagnosis and treatment guide is a joint creation of the North Carolina
Psychiatric Association and the North Carolina Academy of Family Physicians. The work was
supported in part by a grant from the office of the North Carolina Attorney General.
Background of this grant is available from the office of the NCPA at 919-859-3370.
This guide is intended to be unique in that it emphasizes collaboration between primary care
physicians and psychiatrists and other mental health professionals. It is our belief that while
most anxiety disorders can be treated in the primary care office, the presentation of such
disorders can be sufficiently severe and complicated that consultation and referral to specialist
care is sometimes needed. Co-morbidity and treatment failure are relative indications for
The following is not an all inclusive “cookbook” and not all treatment choices are listed. It is
assumed that the primary care physician using this guide will have general familiarity with
anxiety disorders and principles of medication treatment of these disorders. This guide is best
thought of as a tool for continued learning, with places for the primary care physician to
record helpful consultation and referral resources and to make “Physician Notes to Self” as a
mechanism for continued learning. Treatment guidelines for Post Traumatic Stress Disorder
and Specific Phobia are not included but will follow in an addendum.
Referral Resources

___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Symptoms of anxiety; worry; fear; avoidance; repetitive, intrusive,
inappropriate thoughts or actions; or unexplained general medical complaint
Anxiety Disorder Due to a General Medical Condition (293.84 and specify substance or condition) Alcohol-Induced Anxiety Disorder (293.84 and specify substance Substance-Induced (including medication) Anxiety Disorder (293.84 and specify substance or condition) Panic Disorder With (300.21) or Without (300.01) Agoraphobia Panic Attacks occurring within the context of other Anxiety Disorders (e.g., Social Phobia, Specific Phobia, Posttraumatic Stress Disorder, Obsessive-Compulsive Disorder) Social Phobia (avoidance of social situations in which the person Specific Phobia (avoidance of a specific object or situation) Panic Disorder With Agoraphobia (avoidance of situations in which escape may be difficult in the event of having a Panic Agoraphobia Without History of Panic Disorder (avoidance of a situation in which escape may be difficult in the event of developing panic-like symptoms) (300.22) Consider Separation Anxiety Disorder (309.21) Consider Obsessive-Compulsive Disorder (300.3) (obsessions) and/or ritualistic behaviors or recurrent mental Posttraumatic Stress Disorder (if symptoms persist at least 4 Acute Stress Disorder (if symptoms persist for less than 4 weeks) (308.3) Consider Generalized Anxiety Disorder (300.02) events or situations and have Adjustment Disorder with Anxiety (309.24) or Adjustments Disorder with Mixed Anxiety and Depressed Mood (309.28) Consider Anxiety Disorder Not Otherwise Specified (300.00) Treatment Guidelines
Generalized Anxiety Disorder
subjective anxiety/tension, excessive worry, and a variety of physiologic complaints(GI, musculoskeletal, neurological) Start with SSRIs in doses higher than for depression.
Escitalopram(Lexapro) 10-25 mg. Once DailySertraline(Zoloft) 50-150 mg. Once DailyParoxetineCR (PaxilCR) 25-37.5 Once Daily SNRIs in usual dosesVenlafaxineXR(EffexorXR) 75-225 mg Daily Buspirone(Buspar)5-15 mg TID Alone or adjunct to above.
Note: often 6-8 weeks before evident response.
Benzodiazepines may be used alone or in combination for ongoingtreatement or in management of periods of exacerbationClonazapam(Klonopin) 1-2mg up to TID Referral to outside or co-located professional for cognitive behavioralpsychotherapy may be effective as adjunct or in lieu of medication.
PHYSICIAN NOTES TO SELF______________________________________________________________________________________________________________________________________________________________________________________ Panic Disorder
paroxysmal panic attacks, anticipatory anxiety, phobic avoidance If symptoms are acute, severe and disabling, begin with benzodiazepinesAlprazolam(Xanax) 0.25 to 1 mg TID or QIDClonazapam(Klonopin) 0.5 to 1 mg BID SSRIs in doses higher than for depression Escitalopram(Lexapro) 10-25 mg Once DailySertraline(Zoloft) 50-200 mg Once Daily A variety of psychoeducational and supportive psychotheraputic approaches havebeen found to be helpful in identifying factors that trigger or reinforce symptoms.
Targeted therapies for insight or for marital or other interpersonal dynamics can behelpful adjunctive therapies.
PHYSICIAN NOTES TO SELF_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Social Anxiety Disorder or Social Phobia
persistent anxiety in social and performance settings, excessive shyness.
SSRIs in doses higher than that for treatment of depressionParoxetineCR(Paxil CR) 25-37.5 mg Once DailyEscitalopram(Lexapro) 20-25 mg Once DailySertraline(Zoloft) 50-200 mg Once Daily Benzodiazepines: See doses above for Panic Disorder.
Cognitive Behavioral Therapy may assist in helping the patient examine and modifypersistent thought patterns that contribute to symptoms.
Theraputic approaches that address self esteem have been found helpful PHYSICIAN NOTES TO SELF ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Obsessive Compulsive Disorder
reduction of intrusive, unwanted thoughts and repetitive actions/behaviors thatcause distress or impairment SSRIs in doses greater than those for depression.
See medications/doses above for Panic Disorder Clomipramine(Anafranil) titrate from starting dose of 25 mg dailyup to final dose of 150-250mg Once Daily. Increase as tolerated.
Sedation may require H.S. dosing.
Benzodiazepines may be necessary for severe presentation, or asadjunctive therapy.
See medications/doses as above for Panic Disorder OCD can present as a severe and disabling condition. Low doses ofthe atypical antipsychotics have been helpful in such cases.
Risperidone(Risperdal) 0.25-1 mg Once or Twice Daily Traditional behavioral or Cognitive Behavioral Therapy have been found to beuseful adjunctive therapies PHYSICIAN NOTES TO SELF __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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