What is the recommended approach for an anxiety workup and treatment?

Comprehensive Approach to Anxiety Disorder Workup and Treatment

The recommended approach for anxiety workup should include standardized screening tools, comprehensive diagnostic evaluation, and a treatment plan prioritizing cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) as first-line interventions to reduce morbidity, mortality, and improve quality of life. 1

Diagnostic Assessment

Screening and Evaluation

• Use validated screening instruments:
  • Generalized Anxiety Disorder-7 (GAD-7) (sensitivity 57.6-93.9%, specificity 61-97%) 2
  • Hospital Anxiety and Depression Scale (HADS) 3
  • Penn State Worry Questionnaire (PSWQ) for generalized anxiety 3

Diagnostic Interview Components

• Identify specific anxiety symptoms:
  • Excessive worry or distress
  • Symptom frequency, severity, onset, and duration
  • Degree of functional impairment
  • Physical manifestations (palpitations, shortness of breath, dizziness) 3, 2
• Differentiate between anxiety disorders using DSM-5 criteria:
  • Separation anxiety disorder
  • Selective mutism
  • Specific phobia
  • Social anxiety disorder
  • Panic disorder
  • Agoraphobia
  • Generalized anxiety disorder 3, 4

Assessment of Comorbidities

• Evaluate for common comorbidities:
  • Depression (occurs in up to 72.7% of anxiety patients) 3
  • Substance use disorders
  • Personality disorders 4
• Rule out medical conditions that mimic anxiety:
  • Thyroid disorders
  • Cardiac conditions
  • Respiratory disorders
  • Substance intoxication or withdrawal 4

Treatment Algorithm

First-Line Treatments

1. Psychotherapy

   • CBT is the first-line psychological treatment with strongest evidence across anxiety disorders 1
   • Typical CBT protocol:
     • 14 individual sessions over 4 months
     • Components: education about anxiety, behavioral goal setting, cognitive restructuring, relaxation techniques, and graduated exposure 1

2. Pharmacotherapy

   • SSRIs are first-line medication treatment 1, 2
     • Sertraline: Start at 25-50mg daily, may increase by 50mg increments at intervals not less than 1 week, up to 200mg daily 5
     • Escitalopram and Paroxetine are also effective first-line options 1
   • SNRIs (e.g., venlafaxine extended-release) are also first-line options 2
   • Medication management principles:
     • Start at lower doses and titrate gradually
     • Monitor for side effects and treatment response at 4 and 8 weeks
     • Target complete remission of symptoms, not just improvement 1

Alternative and Adjunctive Treatments

• Mindfulness-Based Interventions (MBIs) 1
• Relaxation techniques (deep breathing, progressive muscle relaxation) 1
• Regular exercise and physical activity programs 1
• Yoga (particularly beneficial for certain populations) 1

Special Populations

Children and Adolescents

• CBT is the first-line treatment 1
• SSRIs may be offered for social anxiety, generalized anxiety, separation anxiety, or panic disorder 1
• For children with OCD, start sertraline at 25mg daily (ages 6-12) or 50mg daily (ages 13-17) 5

Comorbid Conditions

• When anxiety co-occurs with depression:
  • Combined CBT and SSRI treatment may be more effective than either alone 4
  • SSRIs and SNRIs can effectively treat both conditions 2

Treatment Monitoring and Maintenance

Outcome Measurement

• Assess treatment success by:
  • Reduction in anxiety symptoms
  • Improved interpersonal functioning
  • Enhanced quality of life
  • Decreased avoidance behaviors
  • Return to normal daily activities 1

Maintenance Treatment

• For chronic anxiety disorders (social anxiety, OCD, panic disorder):
  • Continue effective medication for several months beyond initial response
  • Periodically reassess the need for maintenance treatment 5
  • For social anxiety disorder, maintenance treatment may be needed for up to 24 weeks following 20 weeks of initial treatment 5

Common Pitfalls to Avoid

• Failing to use standardized screening tools, leading to missed diagnoses 3
• Overlooking medical conditions that can mimic anxiety symptoms 4
• Inadequate treatment duration (premature discontinuation) 5
• Focusing only on the principal anxiety disorder while missing comorbid conditions 3
• Using insufficient medication doses or inadequate duration of CBT 1, 5

By following this structured approach to anxiety workup and treatment, clinicians can improve diagnosis accuracy and optimize treatment outcomes, ultimately reducing morbidity and mortality while enhancing patients' quality of life.