What is the management for anxiety disorder presenting with palpitations and shivering?

Management of Anxiety Disorder Presenting with Palpitations and Shivering

Start an SSRI immediately—either sertraline 50 mg daily or escitalopram 10 mg daily—and refer for cognitive behavioral therapy (CBT) while ruling out medical causes of the physical symptoms. 1

Immediate Assessment and Medical Clearance

Before initiating psychiatric treatment, you must exclude medical and substance-induced causes of anxiety with palpitations and shivering:

• Check thyroid function (TSH, free T4) to rule out hyperthyroidism, which commonly presents with anxiety, palpitations, and tremor 1
• Obtain ECG to exclude cardiac arrhythmias, especially if the patient will receive SSRIs (citalopram can prolong QT interval at doses >40 mg/day) 2
• Screen for substance use: stimulants (cocaine, methamphetamine, caffeine excess), alcohol withdrawal, or recent discontinuation of benzodiazepines 2, 1
• Assess for panic disorder criteria: if symptoms occur in discrete episodes with 4+ symptoms (palpitations, sweating, trembling, shortness of breath, chest pain, nausea, dizziness, fear of dying) peaking within 10 minutes, this is panic disorder 3, 4
• Evaluate suicide risk and psychosis, which require immediate psychiatric referral 2, 1

First-Line Pharmacological Treatment

Initiate an SSRI as first-line medication 2, 1, 4:

Preferred SSRIs:

• Sertraline: Start 25-50 mg daily, increase by 25-50 mg every 1-2 weeks to target dose of 50-200 mg/day 1, 5

  • Sertraline demonstrated significant improvement in panic attack frequency (P=.01) and quality of life (P=.003) in panic disorder trials 5
  • Lower risk of drug-drug interactions compared to other SSRIs 2

• Escitalopram: Start 5-10 mg daily, increase by 5-10 mg every 1-2 weeks to 10-20 mg/day 1

  • Least effect on CYP450 enzymes, minimizing drug interactions 2
  • Maximum 10 mg/day in patients >60 years due to QT prolongation risk 2

Key Prescribing Principles:

• Start with a subtherapeutic "test" dose because SSRIs can initially worsen anxiety or agitation 2
• Increase slowly at 1-2 week intervals for shorter half-life SSRIs (sertraline, escitalopram) 2
• Continue for 9-12 months after symptom remission to prevent relapse 1
• Never stop abruptly—taper gradually to avoid discontinuation syndrome (dizziness, paresthesias, anxiety, agitation) 2, 1

First-Line Psychological Treatment

Refer for individual cognitive behavioral therapy (CBT), which has large effect sizes for anxiety disorders (Hedges g = 1.01 for generalized anxiety disorder) 1, 4:

CBT Components:

• Psychoeducation about anxiety physiology and the connection between thoughts, physical symptoms, and behaviors 2
• Cognitive restructuring to challenge catastrophizing and negative predictions about palpitations/shivering 2
• Relaxation techniques: diaphragmatic breathing, progressive muscle relaxation to directly address autonomic symptoms 2, 1
• Graduated exposure if specific triggers are identified 2
• Relapse prevention strategies 1

Combination Treatment vs. Monotherapy

Offer combination treatment (SSRI + CBT) preferentially over either alone for patients with moderate to severe symptoms 2:

• Combination sertraline + CBT showed superior outcomes compared to either treatment alone for primary anxiety, global function, treatment response, and remission (all moderate strength of evidence) 2
• This recommendation is particularly strong for social anxiety, generalized anxiety, separation anxiety, and panic disorder 2

Acute Symptom Management

For Palpitations and Shivering:

• Relaxation techniques (diaphragmatic breathing, progressive muscle relaxation) provide immediate non-pharmacological relief 1
• Reassurance that palpitations and shivering are anxiety manifestations, not cardiac or infectious emergencies (once medical causes excluded) 2
• Avoid benzodiazepines for routine use—they carry dependence risk and are not recommended as first-line treatment 1, 6, 4

When Benzodiazepines May Be Considered:

Only for very short-term use (days, not weeks) in severe crisis situations 1:

• Alprazolam 0.25-0.5 mg three times daily for anxiety, or 0.5 mg three times daily for panic disorder, with dose titration every 3-4 days if needed 3
• Maximum duration: 2-4 weeks only to avoid dependence 3
• Taper slowly when discontinuing (decrease by no more than 0.5 mg every 3 days) 3

If First SSRI Fails After 8-12 Weeks

Follow this algorithm 1:

1. Confirm adherence and therapeutic dosing for adequate duration
2. Switch to a different SSRI (e.g., sertraline to escitalopram or vice versa)
3. If second SSRI fails: Switch to SNRI (venlafaxine 75-225 mg/day)
4. Add or intensify CBT if not already implemented
5. Consider pregabalin/gabapentin as second-line agents, particularly if comorbid pain 1

Critical Pitfalls to Avoid

• Do not prescribe tricyclic antidepressants due to cardiac toxicity risk, especially problematic in patients with palpitations 1
• Do not use benzodiazepines as maintenance therapy—they are associated with dependence, cognitive impairment, and increased fall risk 1, 6
• Do not escalate SSRI doses too quickly—allow 1-2 weeks between increments to assess tolerability 1
• Do not ignore paroxetine's higher risk of suicidal thinking compared to other SSRIs and severe discontinuation syndrome 2
• Do not combine SSRIs with MAOIs due to serotonin syndrome risk 2
• Do not rely solely on medication—psychological treatment is equally important 1, 4

Ongoing Monitoring

• Use standardized scales (GAD-7, HAM-A) monthly to track response 2, 1
• Assess adherence and side effects at each visit 1
• Monitor for suicidal ideation, especially in first weeks of SSRI treatment 2
• Reassess need for continued treatment every 3-6 months 1