Anxiety spectrum disorders

Generalised anxiety disorder (GAD)

Panic disorder

Post-traumatic stress disorder (PTSD)

Obsessive-compulsive disorder

Social phobia

Clinical presentation

- irrational worries
- motor tension
- hypervigilance
- somatic symptoms (eg hyperventilation, tachycardia and sweating)
- present all/most of time

- sudden unpredictable episodes of severe anxiety
- shortness of breath
- fear of suffocation/dying
- urgent desire to flee
- short-lived episodes of sudden unpredictable severe anxiety

- history of a traumatic life event (as perceived by the sufferer)
- emotional numbness or detachment
- intrusive flashbacks or vivid dreams
- disabling fear of re-exposure, causing avoidance of perceived similar situations

- obsessional thinking (eg constantly thinking that the door has been left unlocked)
- compulsive behaviour (eg constantly going back to check)

- extreme fear of social situations (eg eating in public places or public speaking)
- fear of humiliation or embarrassment
- avoidant behaviour (eg never eating in restaurants)
- anxious anticipation (eg feeling sick on entering a restaurant)

Emergency management

Benzodiazepines (normally for short-term use only: max 2 to 4 weeks, very rarely long-term).

Benzodiazepines (have a rapid effect, although panic symptoms return quickly if the drug is withdrawn).

Not usually appropriate.

Not usually appropriate.

Benzodiazepines (have a rapid effect and may be useful on a ‘when required’ basis).

Non-drug treatments

See: ‘The Matrix – 2015 A guide to delivering evidence-based Psychological Therapies in Scotland’ (https://www.nes.scot.nhs.uk)

These are equally as effective as drug treatment.

Best evidence is for guided self-help or group psychoeducation (eg Stresspac/www.llttf.com) for mild cases.

CBT* for moderate or severe cases.

Best evidence is for guided self-help (bibliotherapy or via internet (eg www.llttf.com) in mild cases).

For moderate panic disorder consider individual CBT* which can be augmented with bibliotherapy, internet/computer packages and/or group CBT*.

In more severe cases, individual CBT* (up to 20 sessions) supplemented with written material. 

Best evidence is for brief trauma-focussed CBT* if presentation is mild (although this should not be offered to asymptomatic patients as a preventative measure).

Beyond mild presentations, trauma-focussed CBT or Eye Movement Desensitisation and Reprocessing (EMDR) are both well supported.

Best evidence is for CBT*, which should incorporate Exposure and Response Prevention (Ex/RP). This holds across all levels of severity.

Combined drug and psychological therapy may be the most effective option.

Best evidence is for guided self-help for mild cases (bibliotherapy or via internet).

For moderate and severe cases, consider either behavioural therapy (incorporating exposure) or CBT* (incorporating exposure and cognitive restructuring).

If presentation is severe enough to meet criteria for avoidant personality disorder, consider CBT (20 sessions).

Drug treatment

Treatment of anxiety may prevent the subsequent development of depression. See section 4.1 and Guidance for the treatment of GAD.

First choice: sertraline or alternative SSRI** (although may initially exacerbate symptoms. A lower starting dose of 25mg sertraline is often required).

Second-line antidepressant: venlafaxine or mirtazapine

Referral for specialist advice   (options include alternative antidepressants, pregabalin***, duloxetine*** or antipsychotic).

NICE do not recommend benzodiazepines.

SSRIs** (therapeutic effect can be delayed and patients can experience an initial exacerbation of panic symptoms).

Referral for specialist advice.

SSRIs**

Referral for specialist advice.  (Prazosin for nightmares (should   not be sole treatment for PTSD).

SSRIs**

Clomipramine.

Referral for specialist advice.

SSRIs**

Referral for specialist advice.