What is the recommended initial management for a young woman with generalized anxiety disorder and a history of panic attacks?

Management of Young Female with Anxiety and History of Panic Attacks

Start with cognitive behavioral therapy (CBT) combined with an SSRI (sertraline 25-50 mg daily initially, titrating to 50-200 mg/day) as this combination provides superior outcomes to either treatment alone for anxiety disorders with panic attacks. 1, 2, 3

Initial Assessment and Screening

Before initiating treatment, conduct a structured evaluation:

• Use the GAD-7 scale to quantify anxiety severity: mild (0-9), moderate (10-14), or moderate-to-severe/severe (15-21) to guide treatment intensity 2, 4
• Assess for panic disorder specifically: Document frequency of panic attacks, physical symptoms (palpitations, sweating, trembling, shortness of breath), and any agoraphobic avoidance patterns 1
• Rule out medical mimics: Thyroid disorders, cardiac arrhythmias, hypoglycemia, and substance use/withdrawal can present identically to panic attacks 4
• Screen for comorbid depression: Anxiety and depression co-occur in the majority of cases and require simultaneous treatment 2, 4
• Obtain collateral information from family members when possible to assess functional impairment 4

First-Line Treatment: Combination Therapy

Pharmacotherapy: SSRI Selection

Sertraline is the preferred first-line SSRI based on the strongest evidence for panic disorder and generalized anxiety:

• Start with 25 mg daily for week 1 to minimize initial anxiety/agitation (a common early SSRI side effect), then increase to 50 mg daily after week 1 3
• Target therapeutic dose is 50-200 mg/day, with single daily dosing sufficient due to adequate half-life 3
• Expect timeline: Statistically significant improvement may begin by week 2, clinically significant improvement by week 6, and maximal benefit by week 12 or later 3
• Alternative SSRIs if sertraline not tolerated: Escitalopram 10-20 mg/day or fluoxetine 20-40 mg/day are reasonable alternatives 3
• Avoid paroxetine and fluvoxamine: These carry higher discontinuation syndrome risk and potentially increased suicidal thinking compared to other SSRIs 3, 5

Critical Monitoring for SSRIs

• Monitor for suicidal thinking and behavior, especially in the first months and after dose changes (pooled risk 1% vs 0.2% placebo, NNH=143) 3
• Common early side effects include nausea, headache, insomnia, nervousness, and initial anxiety/agitation—most resolve with continued treatment 3
• Do not escalate doses too quickly: Allow 1-2 weeks between increases to assess tolerability 3
• Do not abandon treatment before 12 weeks: Full response requires patience due to the logarithmic response curve of SSRIs 3

Psychotherapy: Cognitive Behavioral Therapy

CBT is the psychological treatment with the strongest evidence of efficacy for anxiety disorders and should be delivered concurrently with medication:

• Recommend 12-20 structured CBT sessions targeting anxiety-specific cognitive distortions and exposure techniques 2, 3, 4
• Individual CBT is preferred over group therapy for superior clinical and cost-effectiveness 3
• CBT should include: Cognitive restructuring, behavioral activation, exposure exercises, relaxation strategies, and psychoeducation about the psychophysiology of anxiety 2, 6
• The combination of sertraline plus CBT demonstrates superior outcomes to either treatment alone, with lower relapse rates 1, 3

Alternative Medication Options

If SSRIs fail after adequate trial (12 weeks at therapeutic dose):

• SNRIs (venlafaxine) can be considered as second-line agents, though they rank lower in overall tolerability 1, 3, 7
• Avoid benzodiazepines for chronic management: Despite short-term efficacy, they carry risks of tolerance, dependence, and paradoxically may worsen long-term outcomes (one study found 63% of trauma patients on benzodiazepines developed PTSD versus 23% on placebo) 3, 7

Treatment Duration and Maintenance

• Continue SSRI therapy for minimum 9-12 months after achieving remission to prevent relapse 3
• Taper gradually when discontinuing: Never stop abruptly to avoid withdrawal symptoms, particularly with shorter half-life SSRIs 3
• Monthly follow-up is essential until symptoms subside to evaluate treatment adherence, assess medication side effects, and monitor symptom relief 2, 4

Common Pitfalls to Avoid

• Don't underestimate poor follow-through: Cautiousness and avoidance are cardinal features of anxiety, leading patients to avoid treatment recommendations—proactive outreach is critical 2, 4
• Don't use benzodiazepines as first-line chronic therapy: While they provide rapid relief, long-term use leads to dependence and potentially worse outcomes 3, 7
• Don't declare treatment failure prematurely: Allow full 12 weeks at therapeutic SSRI dose before switching agents 3
• Don't forget to address sleep: The bidirectional relationship between sleep and anxiety means improved sleep facilitates anxiety treatment response 3

Adjunctive Interventions

• Structured physical activity/exercise (aerobic training such as active walking or jogging) has demonstrated efficacy and should be systematically recommended as adjunctive treatment 2, 6
• Psychoeducation about the psychophysiology of anxiety reactions and treatment rationale improves adherence 2, 6
• Self-help resources based on CBT principles, including deep breathing, relaxation, and mindfulness techniques 2, 6