What is the assessment and treatment approach for a patient presenting with an anxiety attack?

Assessment and Management of Anxiety Attacks

For a patient presenting with an anxiety attack, immediately assess for safety risks (suicidal ideation, harm to others, severe agitation) requiring emergency psychiatric referral, then use the GAD-7 screening tool to stratify severity and guide treatment with SSRIs (sertraline preferred) combined with Cognitive Behavioral Therapy for moderate-severe symptoms (GAD-7 ≥10). 1

Immediate Assessment

Safety Evaluation

• Assess immediately for risk of harm to self or others, psychosis, or severe agitation—these require emergency psychiatric referral and one-to-one observation. 2, 1
• Facilitate a safe environment and initiate harm-reduction interventions if safety concerns are identified. 2

Severity Stratification Using GAD-7

• Administer the GAD-7 (7-item self-report scale) to quantify anxiety severity with scores ranging 0-21. 1, 3
• GAD-7 scoring interpretation:
  • 0-4: Mild symptoms 3
  • 5-9: Moderate symptoms 3
  • 10-14: Moderate-severe symptoms requiring intervention 1, 3
  • 15-21: Severe symptoms 3

Clinical Assessment Components

• Identify specific anxiety symptoms: panic attacks, trembling, sweating, tachypnea, tachycardia, palpitations, and sweaty palms. 2
• Assess severity of symptoms, possible stressors, risk factors, times of vulnerability, and functional impairment in social, occupational, or other life domains. 2, 4
• Explore underlying medical causes that can mimic anxiety. 2

Rule Out Medical Causes

• Order thyroid function tests (TSH, free T4) to rule out hyperthyroidism, which commonly mimics anxiety symptoms. 1, 4
• Consider cardiac conditions (arrhythmias, coronary artery disease), endocrine disorders, respiratory conditions, neurological disorders, and substance-related causes. 4
• Treat any identified medical causes (unrelieved pain, fatigue) and delirium (infection, electrolyte imbalance) first before attributing symptoms to primary anxiety disorder. 2

Screen for Comorbidities

• 50-60% of patients with anxiety disorders have comorbid depression—screen using standardized tools. 2
• Assess for other anxiety disorders, obsessive-compulsive disorder, and substance use disorders. 4

Treatment Algorithm Based on Severity

Mild Symptoms (GAD-7: 0-4)

• Provide psychoeducation about anxiety and its management. 3
• Offer nonfacilitated or guided self-help based on Cognitive Behavioral Therapy principles. 3
• Ensure effective coping skills and access to social support. 3
• Reassess symptoms every 4-6 weeks using GAD-7. 3

Moderate Symptoms (GAD-7: 5-9)

• Initiate low-intensity CBT-based interventions including self-help or computerized programs. 3
• Consider group psychosocial interventions. 3
• Consider pharmacotherapy if symptoms persist or functional impairment is significant. 3
• Reassess every 4-6 weeks. 3

Moderate-Severe to Severe Symptoms (GAD-7: 10-21)

• Initiate combination treatment with SSRI plus CBT, which is superior to either treatment alone. 1, 3
• Start sertraline 50 mg daily (preferred SSRI) in the morning or evening. 1, 5
• Patients not responding to 50 mg/day may benefit from dose increases up to 200 mg/day. 5
• Refer to licensed mental health professionals for structured CBT delivery. 3

Cognitive Behavioral Therapy Components

CBT is first-line psychotherapy with large effect sizes (Hedges g = 1.01) for anxiety disorders. 1

Core CBT Elements

• Education about anxiety and its physiological manifestations. 2
• Behavioral goal setting with contingent rewards. 2
• Self-monitoring for connections between worries, thoughts, and behaviors. 2
• Relaxation techniques: deep breathing, progressive muscle relaxation, guided imagery. 2
• Cognitive restructuring challenging catastrophizing, over-generalization, negative prediction, and all-or-nothing thinking. 2
• Graduated exposure (cornerstone of treatment): create fear hierarchy and master in stepwise manner. 2
• Problem-solving and social skills training relevant to anxiety-provoking situations. 2

Family and Environmental Interventions

• Address anxiogenic parenting patterns including overprotection, overcontrol, high criticism, and modeling of anxious thoughts. 3
• Strengthen family problem-solving and communication skills. 2
• Implement school-directed interventions when applicable (504 plans, individualized education plans). 2

Pharmacotherapy Details

SSRI Prescribing

• Sertraline is the preferred first-line SSRI for anxiety disorders. 1
• Initiate at 50 mg once daily (morning or evening). 5
• Dose adjustments should not occur at intervals less than 1 week due to 24-hour elimination half-life. 5
• Maximum dose: 200 mg/day. 5
• Continue pharmacotherapy for 12 months after achieving remission before considering tapering to prevent relapse. 4

SSRI Considerations

• Inform patients about adverse effect profiles and potential drug interactions. 2
• Warn patients of potential harm or adverse effects. 2
• Caution with benzodiazepines: use should be time-limited due to abuse/dependence risk and cognitive impairment. 2

MAOI Interactions

• At least 14 days must elapse between discontinuation of an MAOI and initiation of sertraline, and vice versa. 5
• Do not start sertraline in patients receiving linezolid or intravenous methylene blue due to serotonin syndrome risk. 5

Follow-Up and Monitoring

Reassessment Schedule

• Reassess symptoms every 4-6 weeks using GAD-7 to monitor treatment response. 3
• Additional screening at: changes in disease status, life circumstances, family crisis, personal transitions, or when symptoms not responding to current interventions. 3

Criteria for Psychiatric Referral

• Immediate referral required for: suicidal ideation/self-harm, harm to others, psychosis, severe agitation. 1, 4
• Routine referral indicated for: moderate-severe symptoms (GAD-7 ≥10), symptoms not responding to initial treatment, severe functional impairment. 1, 4

Patient and Family Education

• Provide education about anxiety, its management, and what specific symptoms warrant immediate contact with physician or nurse. 2
• Discuss symptom worsening that requires urgent evaluation. 2
• Explain treatment rationale and potential benefits in shared decision-making process. 2

Common Pitfalls to Avoid

• Do not attribute all anxiety symptoms to psychiatric causes without ruling out hyperthyroidism and cardiac conditions first. 1, 4
• Do not use benzodiazepines as first-line long-term treatment due to dependence risk and cognitive impairment. 2
• Do not treat with monotherapy (SSRI or CBT alone) when GAD-7 ≥10—combination therapy is superior. 1
• Do not discontinue SSRIs before 12 months of remission—premature discontinuation increases relapse risk. 4
• When comorbid depression and anxiety exist, treat depression first as usual practice. 2