Download 2002 CLINICAL PRACTICE GUIDELINES

OXFORD HEALTH PLANS
2002 CLINICAL PRACTICE GUIDELINES (Reviewed and approved for 2004):
DETECTION, DIAGNOSIS, AND TREATMENT OF ANXIETY DISORDERS
IN PRIMARY CARE
OVERVIEW
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Anxiety disorders are the most common psychiatric illnesses affecting both children and
adults.
An estimated 19 million adult Americans suffer from anxiety disorders and there is
significant overlap or co-morbidity with mood and substance abuse disorders.
These orders can be characterized by, relatively early ages of onset, chronicity, relapsing
or recurrent episodes of illness, and periods of disability.
Although anxiety disorders are highly treatable, only approximately one third of those
suffering from anxiety disorders receive treatment.
It is likely that the co-morbid anxiety in suicide is underestimated. Panic disorder and
agoraphobia, in particular, may be associated with increased risk of suicide.
Practitioners should be sensitive to the occurrence of anxiety disorders in their patient
population, institute screening methods to identify anxiety disorders, and implement
parameters for treatment and referral.
TYPES OF ANXIETY DISORDERS
The Anxiety Disorders include: Generalized Anxiety Disorder (GAD), Obsessive-Compulsive
Disorder (OCD), Panic Disorder (with and without a history of agoraphobia), Agoraphobia (with
and without a history of panic disorder), Acute Stress Disorder, Post-Traumatic Stress Disorder
(PTSD), Social Anxiety Disorder (Social Phobia), and Specific Phobias, Body Dysmorphic
Disorder.
WHEN TO REFER TO A MENTAL HEALTH SPECIALIST
Primary care physicians should refer a patient to a psychiatrist or experienced
Mental Health specialist under the following circumstances:
First and foremost, IF THE PATIENT PRESENTS A SUICIDE RISK.*
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The patient presents persistent
reduced capacity to function.
The patient fails to respond to an
adequate trial of anti-anxiety
medication.
There is no evidence of social
supports.
The patient requires inpatient care.
The patient has a previous history of
depression or suspicion of bipolar
disorder.
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The patient is pregnant or plans to
become pregnant.
The anxiety is resistant to treatment.
The patient has a complex medication
regimen.
The patient has certain co-morbid
conditions (i.e. substance abuse,
major depression, bipolar disorder,
dementia).
SUICIDE RISK*
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All patients suffering from an anxiety
disorder should be assessed for the risk of
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Patients are generally reassured by
questions about suicidal thoughts and by
Derived from: Mental Health: A Report of the Surgeon General Chapter 4-Anxiety, National Institute for Mental
Health-Anxiety Disorders publication No. 00-3879, American Psychiatric Association (www.psy.org) Anxiety
Disorders, under the review and supervision of the Behavioral Health Committee of Oxford Health Plans. Updated
and reviewed by Regional Quality Management, October, 2002. Reviewed and approved for 2004.
OXFORD HEALTH PLANS
suicide by subtle questioning about suicidal
education that suicidal thinking is a
thinking, impulses, and personal history of
common symptom of the anxiety, or
suicide attempts.
depression itself, and not a sign that the
patient is “crazy.”
DIAGNOSING ANXIETY DISORDERS
1.
USE THE CLINICAL INTERVIEW TO IDENTIFY SYMPTOMS OF ANXIETY:
It may be useful to employ a self-report questionnaire, which provides the patient with a
written list of symptoms related to anxiety, and asks the patient to indicate any symptoms
experienced. (See attachment)
2. BE ATTENTIVE TO COMMON PATIENT COMPLAINTS WHICH MAY INDICATE ANXIETY
DISORDERS WHEN MEDICAL WORK-UPS ARE PERSISTENTLY NEGATIVE:
 Unexplained GI symptoms, heart palpitations, rapid pounding heartbeat, tightness of
chest, hyperventilation, weakness all over, tremors, dizziness, dry mouth, sweaty,
confusion, speeded up thoughts, muscle tension/aches, fatigue.
3. SEEK OTHER CLINICAL CLUES IN THE PATIENT HISTORY WHICH PREDISPOSE FOR
ANXIETY
DISORDERS:
 Prior episodes of anxiety or depression.
 Recent stressful life events.
 Family history of depression.
 Concurrent general medical illnesses.
 Family history of eating disorders,
 Concurrent substance abuse.
substance abuse, or anxiety disorders.
 Lack of social supports.
 Personal or family history of suicide
 Use of Kava-Kava.
attempt(s).
4. THOROUGHLY EVALUATE THE PATIENT’S INITIAL COMPLAINTS WITH A MEDICAL
REVIEW OF SYSTEMS AND A PHYSICAL EXAMINATION
5. CONSIDER GENERAL MEDICAL CONDITIONS IN RELATION TO ANXIETY
DISORDERS:
 Stroke
 Fibromyalgia
 MI
 Cancer
 Dementia
 Coronary Artery Disease Medication
 Diabetes
 Side-Effects of Medications
 Drug Interactions
 Hypothyroidism
 Pseudodementia
 Parkinson's
 Alzheimer's
6. IDENTIFY AND TREAT POTENTIAL KNOWN CAUSES, IF PRESENT, OF ANXIETY
DISORDERS:
 Alcohol and Drug Abuse
 Causal Non-Mood Psychiatric Disorder
 General Medical Disorder
 Grief Reaction
7. SCREEN FOR MEDICATIONS WHICH CAN CAUSE SYMPTOMS OF ANXIETY (or
PRECIPITATE ANXIETY DISORDERS):
Derived from: Mental Health: A Report of the Surgeon General Chapter 4-Anxiety, National Institute for Mental
Health-Anxiety Disorders publication No. 00-3879, American Psychiatric Association (www.psy.org) Anxiety
Disorders, under the review and supervision of the Behavioral Health Committee of Oxford Health Plans. Updated
and reviewed by Regional Quality Management, October, 2002. Reviewed and approved for 2004.
OXFORD HEALTH PLANS
DIAGNOSTIC CRITERIA FOR ANXIETY DISORDERS
Generalized Anxiety Disorder:
1) Excessive anxiety and worry, occurring more days than not for at least 6 months, about a
number of events or activities.
2) The person finds it difficult to control the worry.
3) The anxiety and worry are associated with three (or more) of the following six symptoms (with
at least some symptoms present for more days than not for the past 6 months). Note: Only
one item is required in children.
a) Restlessness or feeling keyed up or on edge,
b) Being easily fatigued,
c) Difficulty concentrating or mind going blank,
d) Irritability,
e) Muscle tension,
f) Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep).
4) The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the
anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed
in public (as in Social Phobia), being contaminated (as in Obsessive Compulsive Disorder),
being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight
(as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder),
or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur
exclusively during Posttraumatic Stress Disorder.
5) The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
6) The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition (e.g., Hyperthyroidism) and does not
occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive
Developmental Disorder.
Obsessive-Compulsive Disorder:
1) Either obsessions or compulsions: Obsessions as defined by a, b, c, and d, and compulsions
as defined by e, and f:
a) Recurrent and persistent thoughts, impulses, or images that are experienced, at some
time during the disturbance, as intrusive and inappropriate and that cause marked anxiety
or distress,
b) The thoughts, impulses, or images are not simply excessive worries about real-life
problems,
c) The person attempts to ignore or suppress such thoughts, impulses, or images, or to
neutralize them with some other thought or action,
d) The person recognizes that the obsessional thoughts, impulses, or images are a product
of his or her own mind (not imposed from without as in thought insertion),
e) Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g.,
praying, counting, repeating words silently) that the person feels driven to perform in
response to an obsession, or according to rules that must be applied rigidly,
f) The behaviors or mental acts are aimed at preventing or reducing distress or preventing
some dreaded event or situation; however, these behaviors or mental acts either are not
connected in a realistic way with what they are designed to neutralize or prevent or are
clearly excessive.
Derived from: Mental Health: A Report of the Surgeon General Chapter 4-Anxiety, National Institute for Mental
Health-Anxiety Disorders publication No. 00-3879, American Psychiatric Association (www.psy.org) Anxiety
Disorders, under the review and supervision of the Behavioral Health Committee of Oxford Health Plans. Updated
and reviewed by Regional Quality Management, October, 2002. Reviewed and approved for 2004.
2)
3)
4)
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OXFORD HEALTH PLANS
At some point during the course of the disorder, the person has recognized that the
obsessions or compulsions are excessive or unreasonable. Note: This does not apply to
children.
The obsessions or compulsions cause marked distress, are time consuming (take more than
1 hour a day), or significantly interfere with the person’s normal routine, occupational (or
academic) functioning, or usual social activities or relationships.
If another Axis I disorder is present, the content of the obsessions or compulsions is not
restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair
pulling in the presence of Trichotillomania; concern with appearance in the presence of Body
Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder;
preoccupation with having a serious illness in the presence of Hypochondriasis;
preoccupation with sexual urges or fantasies in the presence of a Paraphilia’; or guilty
ruminations in the presence of Major Depressive Disorder).
The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition.
Panic Disorder:
1) Recurrent unexpected Panic Attacks. Criteria for Panic Attack:
a) A discrete period of intense fear or discomfort, in which four (or more) of the following
symptoms developed abruptly and reached a peak within 10 minutes:
i) Palpitations, pounding heart, or accelerated heart rate,
ii) Sweating,
iii) Trembling or shaking,
iv) Sensations of shortness of breath or smothering,
v) Feeling of choking,
vi) Chest pain or discomfort,
vii) Nausea or abdominal distress,
viii)Feeling dizzy, unsteady, lightheaded, or faint,
ix) Derealization (feelings of unreality) or depersonalization (being detached from
oneself),
x) Fear of losing control or going crazy,
xi) Fear of dying,
xii) Paresthesias (numbness or tingling sensations),
xiii)Chills or hot flushes.
2) At least one of the attacks has been followed by 1 month (or more) of one (or more) of the
following:
a) Persistent concern about having additional attacks,
b) Worry about the implications of the attack or it’s consequences (e.g., losing control, having
a heart attack, “going crazy”),
c) A significant change in behavior related to the attacks.
3) The Panic Attacks are not due to the direct physiological effects of a substance (e.g., a dug of
abuse, a medication condition (e.g., hyperthyroidism).
4) The Panic Attacks are not better accounted for by another mental disorder, such as Social
Phobia (e.g., occurring on exposure to feared social situations), Specific Phobia (e.g., on
exposure to a specific phobic situation), Obsessive-Compulsive Disorder (e.g., in response to
stimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., in response
to being away from home or close relatives.
Derived from: Mental Health: A Report of the Surgeon General Chapter 4-Anxiety, National Institute for Mental
Health-Anxiety Disorders publication No. 00-3879, American Psychiatric Association (www.psy.org) Anxiety
Disorders, under the review and supervision of the Behavioral Health Committee of Oxford Health Plans. Updated
and reviewed by Regional Quality Management, October, 2002. Reviewed and approved for 2004.
OXFORD HEALTH PLANS
Panic Disorder WITH Agoraphobia:
1) Meets the criteria for Panic Disorder.
2) The Presence of Agoraphobia (see criteria below).
Panic Disorder WITHOUT Agoraphobia:
1) Meets the criteria for Panic Disorder.
2) Absence of Agoraphobia.
Agoraphobia WITHOUT History of Panic Disorder:
1) The Presence of Agoraphobia related to fear of developing panic-like symptoms (e.g.,
dizziness or diarrhea). Criteria for Agoraphobia:
a) Anxiety about being in places or situations from which escape might be difficult (or
embarrassing) or in which help may not be available in the event of having an unexpected
or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobic fears
typically involve characteristic clusters of situations that include being outside the home
alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus,
train, or automobile.
Note: Consider the diagnosis of Specific Phobia if the avoidance is limited to one or only a few
specific situations, or Social Phobia if the avoidance is limited to social situations.
b) The situations are avoided (e.g., travel is restricted) or else are endured with marked
distress or with anxiety about having a Panic Attack or panic-like symptoms, or require the
presence of a companion.
c) The anxiety or phobic avoidance is not better accounted for by another mental disorder,
such as Social Phobia (e.g., avoidance limited to social situations because of fear of
embarrassment), Specific Phobia (e.g., avoidance limited to a single situation like
elevators), Obsessive-Compulsive Disorder (e.g., avoidance of dirt in someone with an
obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance of stimuli
associated with a severe stressor), or Separation Anxiety Disorder (e/g/, avoidance of
leaving home or relatives).
2) Criteria have never been met for Panic Disorder.
3) The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition.
4) If an associated general medical condition is present, the fear described in first criterion is
clearly in excess of that usually associated with the condition.
Acute Stress Disorder:
1) The person has been exposed to a traumatic event in which both of the following were
present:
a) The person experienced, witnessed, or was confronted with an event or events that
involved actual or threatened death or serious injury, or a threat to the physical integrity of
self or others,
b) The person’s response involved intense fear, helplessness, or horror.
2) Either while experiencing or after experiencing the distressing event, the individual has three
(or more) of the following dissociative symptoms:
a) A subjective sense of numbing, detachment, or absence of emotional responsiveness,
b) A reduction in awareness of his or her surroundings (e.g., “being in a daze”)
c) Derealization,
d) Depersonalization,
Derived from: Mental Health: A Report of the Surgeon General Chapter 4-Anxiety, National Institute for Mental
Health-Anxiety Disorders publication No. 00-3879, American Psychiatric Association (www.psy.org) Anxiety
Disorders, under the review and supervision of the Behavioral Health Committee of Oxford Health Plans. Updated
and reviewed by Regional Quality Management, October, 2002. Reviewed and approved for 2004.
3)
4)
5)
6)
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OXFORD HEALTH PLANS
e) Dissociative amnesia (i.e., inability to recall an important aspect of the trauma).
The traumatic event is persistently re-experienced in at least one of the following ways:
recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the
experience; or distress on exposure to reminders of the traumatic event.
Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings,
conversations, activities, places, people).
Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor
concentration, hyper vigilance, exaggerated startle response, motor restlessness).
The disturbance causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning or impairs the individual’s ability to pursue some
necessary task, such as obtaining necessary assistance or mobilizing personal resources by
telling family members about the traumatic experience.
The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within
4 weeks of the traumatic event.
The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition, is not better accounted for by Brief
Psychotic Disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II
disorder.
Posttraumatic Stress Disorder:
1) The person has been exposed to a traumatic event in which both of the following were
present:
a) The person experienced, witnessed, or was confronted with an event or events that
involved actual or threatened death or serious injury, or a threat to the physical integrity of
self or others,
b) The person’s response involved intense fear, helplessness, or horror.
2) The Traumatic event is persistently re-experienced in one (or more) of the following ways:
a) Recurrent and intrusive distressing recollections of the event, including images, thoughts,
or perceptions. Note: In young children, repetitive play may occur in which themes or
aspects of the trauma are expressed.
b) Recurrent distressing dreams of the event. Note: In children, there may be frightening
dreams without recognizable content.
c) Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the
experience, illusions, hallucinations, and dissociative flashback episodes, including those
that occur on awakening or when intoxicated). Note: In young children, trauma-specific
reenactment may occur.
d) Intense psychological distress at exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event.
e) Physiological reactivity on exposure to internal or external cues that symbolize or
resemble an aspect of the traumatic event.
3) Persistent avoidance of stimuli associated with the trauma and numbing of general
responsiveness (not present before the trauma), as indicated by three (or more) of the
following:
a) Efforts to avoid thoughts, feelings, or conversations associated with the trauma,
b) Efforts to avoid activities, places, or people that arouse recollections of the trauma,
c) Inability to recall an important aspect of the trauma,
d) Markedly diminished interest or participation in significant activities,
e) Feeling of detachment or estrangement from others,
Derived from: Mental Health: A Report of the Surgeon General Chapter 4-Anxiety, National Institute for Mental
Health-Anxiety Disorders publication No. 00-3879, American Psychiatric Association (www.psy.org) Anxiety
Disorders, under the review and supervision of the Behavioral Health Committee of Oxford Health Plans. Updated
and reviewed by Regional Quality Management, October, 2002. Reviewed and approved for 2004.
OXFORD HEALTH PLANS
f) Restricted range of affect (e.g., unable to have loving feelings),
g) Sense of a foreshortened future (e.g., does not expect to have a career, marriage,
children, or a normal life span).
4) Persistent symptoms of increased arousal (not present before the trauma), as indicated by
two (or more) of the following:
a) Difficulty falling or staying asleep,
b) Irritability or outbursts of anger,
c) Difficulty concentrating,
d) Hypervigilance,
e) Exaggerated startle response.
5) Duration of the disturbance (symptoms in 2, 3, and 4) is more than 1 month.
6) The disturbance causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
Specify if:
 Acute: if duration of symptoms is less than 3 months,
 Chronic: if duration of symptoms is 3 months or more.
Specify if:
 With Delayed Onset: if onset of symptoms is at least 6 months after the stressor.
Social Phobia:
1) A marked and persistent fear of one or more social or performance situations in which the
person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears
that he or she will act in a way (or show anxiety symptoms) that will be humiliating or
embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate
social relationships with familiar people and the anxiety must occur in poor settings, not just in
interactions with adults.
2) Exposure to the feared social situation almost invariably provokes anxiety, which may take
the form of a situationally bound or situationally predisposed Panic Attack. Note: In children,
the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations
with unfamiliar people.
3) The person recognizes that the fear is excessive or unreasonable. Note: In children, this
feature may be absent.
4) The feared social or performance situations are avoided or else are endured with intense
anxiety or distress.
5) The avoidance, anxious anticipation, or distress in the feared social or performance
situation(s) interferes significantly with the person’s normal routine, occupational (academic)
functioning, or social activities or relationships, or there is marked distress about having the
phobia.
6) In individuals under age 18 years, the duration is at least 6 months.
7) The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition and is not better accounted for by
another mental disorder (e.g., Panic disorder With or Without Agoraphobia, separation
Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or
Schizoid Personality Disorder).
8) If a general medical condition or another mental disorder is present, the fear in Criterion 1 is
unrelated to it, e.g., the fear is not of Stuttering, trembling, Parkinson’s disease, or exhibiting
abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.
Specify if:
Derived from: Mental Health: A Report of the Surgeon General Chapter 4-Anxiety, National Institute for Mental
Health-Anxiety Disorders publication No. 00-3879, American Psychiatric Association (www.psy.org) Anxiety
Disorders, under the review and supervision of the Behavioral Health Committee of Oxford Health Plans. Updated
and reviewed by Regional Quality Management, October, 2002. Reviewed and approved for 2004.

OXFORD HEALTH PLANS
Generalized: if the fears include most social situations (also consider the additional
diagnosis of Avoidant Personality Disorder).
Specific Phobia:
1) Marked and persistent fear that is excessive or unreasonable, cued by the presence or
anticipation of a specific object or situation (e.g., flying, heights, animals, receiving and
injection, seeing blood).
2) Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response,
which may take the form of a situationally bound or situationally predisposed Panic Attack.
Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or clinging.
3) The person recognizes that the fear is excessive or unreasonable. Note: In children, this
feature may be absent.
4) The phobic situation(s) is avoided or else is endured with intense anxiety or distress.
5) The avoidance, anxious anticipation, or distress in the feared situation(s) interferes
significantly with the person’s normal routine, occupational (or academic) functioning, or
social activities or relationships, or there is marked distress about having the phobia.
6) In individuals under age 18 years, the duration is at least 6 months.
7) The anxiety, Panic Attacks, or phobic avoidance associated with the specific object or
situation are not better accounted for by another mental disorder, such as ObsessiveCompulsive Disorder (e.g., fear of dirt in someone with an obsession about contamination),
Posttraumatic Stress Disorder (e.g., avoidance of social situations because of fear of
embarrassment), Panic disorder With Agoraphobia, or Agoraphobia Without History of Panic
Disorder.
Specify type:
 Animal Type,
 Natural Environment Type (e.g., heights, storms, water),
 Blood-Injection-Injury Type,
 Situational Type (e.g., airplanes, elevators, enclosed places),
 Other Type (e.g., phobic avoidance of situations that may lead to choking, vomiting, or
contracting an illness; in children, avoidance of loud sounds of costumed characters).
Body Dysmorphic Disorder:
1) Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s
concern is markedly excessive.
2) The preoccupation causes clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
3) The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body
shape and size in Anorexia Nervosa).
DIFFERENTIAL DIAGNOSIS FOR ANXIETY DISORDERS
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Trichotillomania
Major Depressive Episode
Hypochondriasis
Delusional Disorder
Superstitions
Repetitive checking behaviors
Brief Psychotic Disorder
Delirium
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Stereotypic Movement Disorder
Eating Disorders
Paraphilias
Pathological Gambling
Alcohol Dependence or Abuse
Caffeine
Adjustment Disorder
Pervasive Developmental Disorder
Derived from: Mental Health: A Report of the Surgeon General Chapter 4-Anxiety, National Institute for Mental
Health-Anxiety Disorders publication No. 00-3879, American Psychiatric Association (www.psy.org) Anxiety
Disorders, under the review and supervision of the Behavioral Health Committee of Oxford Health Plans. Updated
and reviewed by Regional Quality Management, October, 2002. Reviewed and approved for 2004.
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OXFORD HEALTH PLANS
Schizoid Personality Disorder
 Avoidant Personality Disorder
Performance Anxiety
 Body Dysmorphic Disorder
Tic Disorder
 Psychotic Disorder Not Otherwise
Specified
Anxiety Disorder Due to a General Medical
Condition
 Schizophrenia
Substance-Induced Anxiety Disorder
 Over the Counter Drugs/Herbal
Supplements
TREATMENT OPTIONS FOR ANXIETY DISORDERS
Anxiety Disorders are very treatable. Success will vary with the individual. Some respond to short
term/brief treatment, while others may need longer. Treatment can be complicated by the fact
that people very often have more than one anxiety disorder, or suffer from another co-morbid
condition such as depression or substance abuse. This is why the treatment needs to be tailored
to the individual. Although individualized, there are several standard approaches that have
proven to be quite effective. A therapist or psychiatrist might use one, or a combination of these
therapies.
Behavioral Therapy:
The goal is to modify and gain control over unwanted behavior. The individual will learn to cope
with difficult situations, often through controlled exposure to them. This helps to give the
individual a sense of having control over their life.
Cognitive Therapy:
The goal is to change unproductive or harmful thought patterns. The individual examines their
thoughts related to their feelings and behaviors and learns to separate realistic from unrealistic
thoughts. As with Behavioral Therapy, the individual is actively involved in their recovery and has
a sense of control over their life.
Cognitive-Behavioral Therapy (CBT):
This is a combination of Cognitive and Behavioral Therapies, often referred to as CBT. The individual learns a
combination of cognitive and behavioral skills that can be used as stated above to actively involve then in the
treatment and provide a sense of control.
Relaxation Techniques:
The goal it to help the individual develop the ability to more effectively cope with the stresses that contribute to
anxiety, as well as with some of the physical symptoms of anxiety. The techniques that are taught include breathing
re-training and exercise.
Medication:
Medication is often used in conjunction with one or more of the therapies described above. Sometimes antidepressants or anxiolytics (anti-anxiety medication) are used to alleviate severe symptoms so that other forms of
therapy can go forward. It is effective for many people suffering from anxiety disorders, and can be either a short
term or long term option, depending on the individual’s needs.
OTHER TREATMENT MODALITIES
MANAGING MEDICATION FOR ANXIETY DISORDERS
PRIOR TO INITIATING DRUG TREATMENT:
 Primary care physicians are encouraged to consult with, or refer to a psychiatrist
concerning questions of appropriate treatment for Anxiety Disorders.
 Before initiating a medication regime, it is essential to identify and refer any patients at risk
for self-harm or medically meaningful self-neglect.
 Communicate the side effects of medication prior to start of medication regime.
Derived from: Mental Health: A Report of the Surgeon General Chapter 4-Anxiety, National Institute for Mental
Health-Anxiety Disorders publication No. 00-3879, American Psychiatric Association (www.psy.org) Anxiety
Disorders, under the review and supervision of the Behavioral Health Committee of Oxford Health Plans. Updated
and reviewed by Regional Quality Management, October, 2002. Reviewed and approved for 2004.

OXFORD HEALTH PLANS
Communication with the patient should include the following:
1. Frame the anxiety disorder as a medical illness, with specific signs and symptoms.
2. Refer to a neurochemical dysregulation in the brain.
3. Emphasize that having an anxiety disorder is not indicative of a personal weakness or
fault.
STEPS IN PLACING A PATIENT ON MEDICATION
Step 1: In selecting medication, consider:
 Prior positive response
 Response in family member
 Long-term side effects
 Age
 Concurrent general medical disorder
Step 2:
Step 3:
Step 4:
Step 5:
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
Concurrent causal psychiatric disorder
Interaction with concurrent nonpsychiatric
medication
 Convenience
 Cost
 Patient preference
 History of Substance Abuse
 Consider antidepressant rather than
Benzodiazepine
Begin medication and be available by phone.
Adjust dosage (every 2 weeks) and monitor side effects (weekly/biweekly). *
Reevaluate symptoms/side effects (weekly/biweekly).
Assess symptomatic outcome at 6 weeks. For those with no meaningful symptom
response by 6 weeks, referral to a specialist is recommended.
+ Referral to a psychiatrist should be made if a previously non-suicidal patient begins to express suicidal thoughts or
behavior which have surfaced as a result of undergoing treatment.
MEDICATIONS FOR USE WITH ANXIETY DISORDERS
A.
Selective Serotonin Reuptake Inhibitors (SSRI’s): (Panic Disorder, OCD, Social Anxiety
Disorder, Generalized Anxiety Disorder). Most commonly prescribed:
Generic Name
Brand
Name
Citalopram
Fluoxetine
Sertraline
Paroxetine
Celexa
Prozac
Zoloft
Paxil
Fluvoxamine
Luvox
B.
Tablets
20, 40 mg
10, 20 mg
25, 50, 100mg
10, 20, 30,
40mg
25, 50, 100mg
Initial
Dose
Panic
Dis.
10 mg
10 mg
25 mg
10 mg
25 mg
Initial Dose
Titrate Dose
to
20-40mg/QD
10-20mg/QD
50mg/QD
10-20mg/QD
20-60 mg/QD
20-40mg/QD
100-250mg/QD
20-60mg/QD
50100mg/QD
100-250mg/QD
Benzodiazepines: (Generalized Anxiety Disorder, Social Anxiety Disorder, Panic Disorder).
Most commonly prescribed:
Lorazepam
Flurazepam
Clonazepam
Ativan
Dalmane
Klonopin
Triazolam
Halcion
.5, 1, 2 mg
15, 30mg
.5, 2 mg
2 mg in divided doses
15mg QHS
.5 mg TID
.125, .25 mg
.125 mg QD
2-6 mg in divided doses
15-30 mg QHS
8-10 mg in divided
doses
.125-.25 mg QD
Derived from: Mental Health: A Report of the Surgeon General Chapter 4-Anxiety, National Institute for Mental
Health-Anxiety Disorders publication No. 00-3879, American Psychiatric Association (www.psy.org) Anxiety
Disorders, under the review and supervision of the Behavioral Health Committee of Oxford Health Plans. Updated
and reviewed by Regional Quality Management, October, 2002. Reviewed and approved for 2004.
OXFORD HEALTH PLANS
Chlordiazepoxide
Temazepam
Oxazepam
Librium
Restoril
Serax
Diazepam
Valium
C.
10 QD
15 mg QHS
10 mg TID/QID
2, 5, 10 mg
2 mg BID-QID
20-40 mg QD
15-30 mg QHS
10-15 (mild-mod),15-30
(severe) mg TID/QID
2-4 mg BID-QID
Azaspirones: (Generalized Anxiety Disorder). Most commonly prescribed:
Buspar
Buspirone
D.
10, 25 mg
15, 30 mg
10, 15, 30 mg
10 mg
5 mg TID
30-45 mg in divided
doses
Tricyclic Antidepressants (TCA’s): (Panic Disorder, PTSD, OCD {Anafranil only}). Most
commonly prescribed:
Clomiprimine
Amitriptyline
Anafranil
Elavil
Nortriptyline
Pamelor
Desipramine
Norprami
n
Tofranil
Imipramine
10, 25, 50 mg
10, 25, 50, 75, 100,
150mg
10, 25, 50,
75mg
10, 25, 50, 75, 100,
150mg
10, 25, 50, 75, 100,
150mg
25 mg QD
25mg
QHS
10-25mg
QHS
100-200mg
QHS
25mg
QHS
100-200mg QD
150-300mg QHS
50-150mg QHS
200-300mg QHS
150-300mg QHS
or in divided
doses
E. Atypical Antidepressants: (Panic Disorder, OCD, Social Anxiety Disorder, Generalized
Anxiety Disorder). Most commonly prescribed:
Trazadone**
Desyrel
50, 100, 150,
50-100mg
200-600mg/QD
300mg
QHS
**Recommended for female patients only, due to risk of priapism in males.
Serzone
Nefazodone
100,
100mg
150-300mg BID
150mg
BID
Venlafaxine
Effexor
25, 37.5, 50, 75,
75-150mg BID
100mg
37.5mg/QD
Venlafaxine
Effexor
75mg, 150mg
75mg/QD
225mg/QD
XR
E. Monoamine Oxidase Inhibitors (MAOI’s) have been used primarily in the treatment of
certain atypical depressive subtypes or as a second line of treatment for depression, mostly in
treatment-resistant patients. Due to the risk of lethal hypertensive crisis related to
interactions with relatively common foods containing tyramine and with sympathomimetic
drugs, their use in the primary care setting, in the absence of close psychiatric consultation, is
discouraged.
CONSIDERATIONS IN TREATING ANXIETY DISORDERS IN THE ELDERLY
Anxiety is as prevalent in the old as it is in the young. How and when it appears though, is
distinctly different. There is also as high an incidence of depression with anxiety in the elderly as
in the young. Being a woman and having a less formal education both indicate risk factors for
Derived from: Mental Health: A Report of the Surgeon General Chapter 4-Anxiety, National Institute for Mental
Health-Anxiety Disorders publication No. 00-3879, American Psychiatric Association (www.psy.org) Anxiety
Disorders, under the review and supervision of the Behavioral Health Committee of Oxford Health Plans. Updated
and reviewed by Regional Quality Management, October, 2002. Reviewed and approved for 2004.
OXFORD HEALTH PLANS
anxiety in older adults.
An anxiety disorder was most likely present at a younger age for an older adult currently
experiencing one now. Chronic physical problems, cognitive impairment and significant
emotional losses and other stresses unique to the aging process can bring about the anxiety.
These later in life anxiety disorders are sometimes underestimated as:
 Older patients are less likely to report psychiatric symptoms and are more likely to
emphasize their physical complaints, and
 Some epidemiological studies have excluded Generalized Anxiety Disorder, one of the
most prevalent anxiety disorders in older adults.
Recognizing Anxiety in the Elderly:
Separating a medical condition from physical symptoms of an anxiety disorder is more
complicated in an older adult due to increased realistic concern about physical problems, and a
higher use of prescription medications. Agitation typical of dementia may also be difficult to
separate from anxiety.
Treatment:
Treatment in most cases should start with the primary care physician, as many older adults feel
more comfortable discussing these issues with a doctor with whom they already have a
relationship. Based on this trust, they may be more likely to go along with treatment or a referral
to a mental health professional.
Anti-depressants (especially SSRI’s), rather than anti-anxiety medication (like benzodiazepines)
are the preferred medication for most anxiety disorders. Cognitive Behavioral Therapy is being
increasingly to reduce anxiety in older adults.
A partnership between the older adult, the family and the doctor is very important, so that the
older adult has an advocate to ensure that issues encountered during treatment, such as drug
side effects, are dealt with in a timely fashion.
CONSIDERATIONS IN TREATING ANXIETY DISORDERS IN CHILDREN AND ADOLESCENTS
Some Anxiety Disorders are more common in childhood than others. Some are specific to age development.
Separation Anxiety Disorder and Specific Phobia are more common in children approximately 6-9 years old.
Generalized Anxiety Disorder and Social Anxiety Disorder are more common in middle childhood and adolescence.
Panic Disorder can occur in adolescence as well. Depression has a high rate of co-morbidity in children, especially
among teenagers.
Children display and react to symptoms of anxiety differently, which can lead to difficulty in diagnosis. It can also be
difficult to determine if the behavior is “just a phase” or really constitutes an anxiety disorder.
Social Anxiety Disorder:
Usually diagnosed in mid-teens, it can be found in children of preschool and grade school age. If
not treated, it can persist into adulthood. It may place the child at risk for depression and alcohol
abuse later. Childhood Social Anxiety Disorder can be displayed in a number of ways, such as
school refusal/avoidance.
The child will usually refuse to go to school on a regular basis, or have problems staying in
school. This is different than the child who is truant or avoids school because of antisocial
behavior or delinquency.
Another way this could be displayed in children is with separation anxiety. With Separation
Anxiety Disorder, a child will experience extreme anxiety when separated from parents or
caregivers, displaying an excessive desire to be in contact with them. It is not uncommon for the
child to fear for the parent or caregiver’s safety. Onset may occur before age of 18, but is most
common between the ages of 7-9.
Selective Mutism is thought to be a severe form of Social Anxiety Disorder. The child will refuse
to speak in situation where speech is expected or necessary, interfering with school or social
Derived from: Mental Health: A Report of the Surgeon General Chapter 4-Anxiety, National Institute for Mental
Health-Anxiety Disorders publication No. 00-3879, American Psychiatric Association (www.psy.org) Anxiety
Disorders, under the review and supervision of the Behavioral Health Committee of Oxford Health Plans. Updated
and reviewed by Regional Quality Management, October, 2002. Reviewed and approved for 2004.
OXFORD HEALTH PLANS
activities. Onset is usually before 5 years of age, and must persist for at least one month to be
diagnosed.
Specific Phobia:
Unlike adults, children usually recognize their fear is irrational or out of proportion to the situation,
but may not articulate their fears. They may just avoid situation or things they fear and endure
the anxious feelings.
Generalized Anxiety Disorder:
Children with GAD tend to be very hard on themselves, striving for perfection, sometimes redoing
tasks repeatedly. They may also seek constant approval or reassurance from others.
Panic Disorder:
Diagnosed in a child who suffers at least two unexpected attacks, followed by at least 1 month of
concern over having another attack or loosing control. The most common age of onset is in the
early to mid twenties. It is not common in young children, but can begin in adolescence.
Derived from: Mental Health: A Report of the Surgeon General Chapter 4-Anxiety, National Institute for Mental
Health-Anxiety Disorders publication No. 00-3879, American Psychiatric Association (www.psy.org) Anxiety
Disorders, under the review and supervision of the Behavioral Health Committee of Oxford Health Plans. Updated
and reviewed by Regional Quality Management, October, 2002. Reviewed and approved for 2004.
OXFORD HEALTH PLANS
Self-Report Questionnaire
A Do you feel afraid and uncomfortable when you are around other people?
Is it hard for you to be at work or school?
(Please check yes if the following describes what happens to you).
1 I have an intense fear that I will do or say something and embarrass myself in front of other people
2 I am always very afraid of making a mistake and being watched and judged by other people
3 Fear and embarrassment makes me avoid doing things I want to do or speaking to people
4 I worry for days or weeks before I have to meet new people
5 I blush, sweat a lot, tremble, or feel like I have to throw up before and during an event where I an
with new people
6 I usually stay away from social situations such as school events and making speeches
7 I often drink to try to make these fears go away
B Do you have sudden bursts of fear for no reason?
(Please check yes if the following describes what happens to you).
1 I have chest pains or a racing heart
2 I have a hard time breathing or a choking feeling
3 I feel dizzy or sweat a lot
4 I have stomach problems or feel like I need to throw up
5 I shake, tremble or tingle
6 I feel out of control
7 I feel unreal
C Do you worry all the time?
(Please check yes if the following describes what happens to you).
1 I never stop worrying about things big and small
2 I have headaches and other aches and pains for no reason
3 I am tense a lot and have trouble relaxing
4 I have trouble keeping my mind on one thing
5 I get crabby or grouchy
6 I have trouble falling asleep or staying asleep
7 I sweat and have hot flashes
8 I sometimes have a lump in my throat or feel like I need to throw up when I am worried
D Do you feel trapped in a pattern of unwanted and upsetting thoughts?
Do you feel you have to do the same things over and over again for no good reason?
(Please check yes if the following describes what happens to you).
1 I have upsetting thoughts or images enter my mind again and again
2 I feel like I can’t stop these thoughts or images, even though I want to.
3 I have a hard time stopping myself from doing things again and again, like: counting, checking on
things, washing my hands, re-arranging objects, doing things until it feels rith5, collecting useless
objects
4 I worry a lot about terrible things that could happen if I’m not careful. I have unwanted urges to
hurt someone but know I never would
Derived from: Mental Health: A Report of the Surgeon General Chapter 4-Anxiety, National Institute for Mental
Health-Anxiety Disorders publication No. 00-3879, American Psychiatric Association (www.psy.org) Anxiety
Disorders, under the review and supervision of the Behavioral Health Committee of Oxford Health Plans. Updated
and reviewed by Regional Quality Management, October, 2002. Reviewed and approved for 2004.
Yes
Yes
Yes
Yes
OXFORD HEALTH PLANS
Self-Report Questionnaire (Continued)
E Have you lived through a very scary and dangerous event?
(Please check yes if the following describes what happens to you).
1 I feel like the terrible event is happening all over again. This feeling often comes without warning
2 I have nightmares and scary memories of the terrifying event
3 I stay away from places that remind me of the event
4 I jump and feel very upset when something happens without warning
5 I have a hard time trusting or feeling close to other people
6 I get mad very easily
7 I feel guilty because others died and I lived
8 I have trouble sleeping, and my muscles are tense
Derived from: Mental Health: A Report of the Surgeon General Chapter 4-Anxiety, National Institute for Mental
Health-Anxiety Disorders publication No. 00-3879, American Psychiatric Association (www.psy.org) Anxiety
Disorders, under the review and supervision of the Behavioral Health Committee of Oxford Health Plans. Updated
and reviewed by Regional Quality Management, October, 2002. Reviewed and approved for 2004.
Yes