What are the symptoms and treatment options for severe anxiety disorder?

From the Guidelines

Severe anxiety disorder can be effectively managed through a combination of medication, therapy, and lifestyle changes, with cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) being first-line treatment options. The symptoms of severe anxiety disorder include marked fear or anxiety about one or more social situations, fear of being negatively evaluated, and avoidance of social situations, which can cause clinically meaningful distress or impairment in social, occupational, or other important areas of functioning 1.

For treatment, CBT is highly recommended, typically involving 12-16 weekly sessions to develop coping strategies and challenge anxious thoughts, as it has been shown to be effective in managing anxiety symptoms 1. In addition to CBT, SSRIs such as fluvoxamine, paroxetine, and escitalopram are also recommended, as they have been shown to be effective in reducing anxiety symptoms 1.

Some key points to consider when treating severe anxiety disorder include:

• Using benzodiazepines like lorazepam or alprazolam for immediate relief, but only for short-term use (less than 2-4 weeks) due to addiction potential
• Starting with a low dose of SSRIs, such as sertraline (25mg daily) or escitalopram (10-20mg daily), and increasing as needed
• Encouraging regular exercise (30 minutes daily), adequate sleep (7-9 hours), limiting caffeine and alcohol, and practicing relaxation techniques like deep breathing or progressive muscle relaxation to reduce anxiety symptoms
• Consulting a healthcare provider if symptoms don't improve within 4-6 weeks of treatment to adjust the approach 1.

It's also important to note that the choice of treatment should be determined by the patient's availability and preference, taking into account the patient's age, symptoms, and other factors 1.

From the FDA Drug Label

Panic disorder (DSM-IV) is characterized by recurrent unexpected panic attacks, i.e., a discrete period of intense fear or discomfort in which 4 (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes: (1) palpitations, pounding heart, or accelerated heart rate; (2) sweating; (3) trembling or shaking; (4) sensations of shortness of breath or smothering; (5) feeling of choking; (6) chest pain or discomfort; (7) nausea or abdominal distress; (8) feeling dizzy, unsteady, lightheaded, or faint; (9) derealization (feelings of unreality) or depersonalization (being detached from oneself); (10) fear of losing control; (11) fear of dying; (12) paresthesias (numbness or tingling sensations); (13) chills or hot flushes.

Social anxiety disorder, as defined by DSM-IV, is characterized by marked and persistent fear of social or performance situations involving exposure to unfamiliar people or possible scrutiny by others and by fears of acting in a humiliating or embarrassing way

Generalized Anxiety Disorder (DSM-IV) is characterized by excessive anxiety and worry (apprehensive expectation) that is persistent for at least 6 months and which the person finds difficult to control It must be associated with at least 3 of the following 6 symptoms: Restlessness or feeling keyed up or on edge, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension, sleep disturbance

Posttraumatic Stress Disorder (PTSD) is characterized by exposure to a traumatic event that involved actual or threatened death or serious injury, or threat to the physical integrity of self or others, and a response that involves intense fear, helplessness, or horror

The symptoms of severe anxiety disorder include:

• Recurrent unexpected panic attacks with symptoms such as palpitations, sweating, trembling, shortness of breath, and fear of losing control or dying
• Social anxiety with marked and persistent fear of social or performance situations
• Generalized anxiety with excessive anxiety and worry that is persistent for at least 6 months and associated with symptoms such as restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance
• Posttraumatic stress disorder (PTSD) with exposure to a traumatic event and a response that involves intense fear, helplessness, or horror

Treatment options for severe anxiety disorder include:

• Sertraline 2
• Paroxetine 3 and 3

These medications are indicated for the treatment of various anxiety disorders, including panic disorder, social anxiety disorder, generalized anxiety disorder, and posttraumatic stress disorder.

From the Research

Symptoms of Severe Anxiety Disorder

• Symptoms of anxiety disorders include worry, social and performance fears, unexpected and/or triggered panic attacks, anticipatory anxiety, and avoidance behaviors 4
• Physical symptoms such as palpitations, shortness of breath, and dizziness are also common 4
• Generalized anxiety disorder, social anxiety disorder, and panic disorder are common anxiety disorders seen in primary care, with lifetime prevalence rates of 6.2%, 13%, and 5.2%, respectively 4

Treatment Options for Severe Anxiety Disorder

• First-line treatments include pharmacotherapy and psychotherapy 4
• Selective serotonin reuptake inhibitors (SSRIs, e.g., sertraline) and serotonin-norepinephrine reuptake inhibitors (SNRIs, e.g., venlafaxine extended release) are commonly used pharmacotherapies for generalized anxiety disorder, social anxiety disorder, and panic disorder 4
• Cognitive behavioral therapy is the psychotherapy with the most evidence of efficacy for anxiety disorders 4
• Other treatment options include benzodiazepines, alpha2delta calcium-channel blockers, reversible inhibitors of monoamine oxidase A, antiepileptics, and atypical antipsychotics, although these may be considered second- or third-line treatments 5
• Combination treatments may be beneficial, but more research is needed 5

Efficacy of Treatment Options

• Meta-analyses suggest that SSRIs and SNRIs are associated with small to medium effect sizes compared with placebo for generalized anxiety disorder, social anxiety disorder, and panic disorder 4
• Cognitive behavioral therapy has been shown to have a large effect size for generalized anxiety disorder and small to medium effect sizes for social anxiety disorder and panic disorder 4
• Studies have shown that patients with anxiety disorders who are maintained on paroxetine, sertraline, or clonazepam have a low relapse rate 5
• Both paroxetine and sertraline have been shown to be effective and well-tolerated treatments for generalized anxiety disorder 6