Generalised anxiety disorder and panic attacks: diagnosis and treatment

By Cristiano Antonino On Mar 5, 2023

Generalised Anxiety Disorder (GAD) and Panic Disorder (PD) are among the most common mental disorders and can have a negative impact on a person’s quality of life and interrupt important activities of daily living

Generalised anxiety

Individuals with generalised anxiety (GAD) usually have excessive anxiety about normal everyday situations.

In this case, anxiety is intrusive, causes discomfort or functional impairment and often involves multiple domains (e.g. finances, work, health).

It is often associated with physical symptoms such as sleep disturbances, restlessness, muscle tension, gastrointestinal symptoms and chronic headaches.

Factors associated with this disorder are female gender, low level of education, poor health and the presence of numerous stress factors.

The panic attack

Panic disorder (PD), on the other hand, which in most cases arises after an obvious and prolonged anxiogenic state, presents panic attacks that may be episodic or unexpected, and occur without a clear trigger.

They are defined by the rapid onset of intense fear (usually a 10-minute peak).

The symptomatic manifestations of a panic attack, described in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), include:

palpitations,
accelerated heartbeat,
sweating,
trembling,
choking sensation,
pain or discomfort in the chest,
nausea.

Another requirement of such a disorder is that the subject worries about further panic attacks or changes their behaviour maladaptively to avoid them.

How to diagnose anxiety disorders

Scientific studies suggest that a lack of diagnosis or misdiagnosis is high, with symptoms often attributed to physical causes.

When assessing a patient for a suspected anxiety disorder, it is important to exclude medical conditions with similar presentations (e.g. endocrine conditions such as hyperthyroidism, pheochromocytoma or hyperparathyroidism; cardiopulmonary conditions such as arrhythmia or obstructive lung disease; neurological conditions such as temporal lobe epilepsy or transient ischaemic attacks).

Other psychiatric disorders (e.g. other anxiety disorders, major depressive disorder, bipolar disorder), use of substances such as caffeine, albuterol, levothyroxine or decongestants; or substance withdrawal may also present similar symptoms and should be ruled out.

Studies suggest that generalised anxiety and panic disorder in most cases occur concurrently with at least one other psychiatric disorder, such as mood, anxiety or substance use disorders.

When anxiety disorders occur with other conditions, historical, physical and laboratory findings can be helpful in distinguishing each diagnosis and developing appropriate treatment plans.

How generalised anxiety and panic attack are treated

With regard to the treatment of generalised anxiety disorder and panic attack disorder, drug therapy coupled with psychotherapy is a reasonable initial treatment option.

Medications should be titrated up slowly to reduce the initial trigger.

Drug therapy

Due to the typical delay in onset of action, drugs should not be considered ineffective until they have been used for at least four weeks.

Once symptoms have improved, medication should be used for 12 months before reduction to reduce relapse.

Some patients will require longer treatment.

Of the most commonly used drug therapies, benzodiazepines are effective in reducing anxiety, but there is a dose-response relationship associated with tolerance, sedation, confusion and increased mortality.

When used in combination with antidepressants, they may accelerate recovery from anxiety-related symptoms but do not improve long-term outcomes.

Psychotherapy

While, psychotherapy includes many different approaches such as cognitive behavioural therapy (CBT) and applied relaxation.

CBT is very useful in the treatment of Anxiety Disorders

The cognitive part leads to a change in thinking that supports fears, while the behavioural part often involves training subjects to relax deeply and helps to desensitise subjects to anxiety triggers.

To be effective, therapy must be directed at the subject’s specific anxieties and adapted to their needs.

This intervention promotes focused attention on the present, recognition of one’s emotional state and meditation for further stress reduction.

Compassionate listening and education are an important basis in the treatment of anxiety disorders.

The establishment of a therapeutic alliance between patient and physician is important to alleviate the fear of intervention and progress towards treatment.

Other remedies for anxiety disorders

Common lifestyle recommendations that can reduce anxiety include identifying and removing possible triggers (e.g. caffeine, stimulants, nicotine, dietary triggers, stress) and improving the quality/quantity of sleep and physical activity.

Caffeine can trigger PD and other types of anxiety.

Those with PD may be more sensitive to caffeine than the general population due to genetic polymorphisms in adenosine receptors.

Many studies show an association between disordered sleep and anxiety, but the causality is unclear.

In addition to decreasing depression and anxiety, physical activity is associated with improved physical health, life satisfaction, cognitive functioning and psychological well-being.

Physical activity is a cost-effective approach in the treatment of GAD and PD.

Exercise at 60% to 90% of maximum heart rate for 20 minutes three times a week has been shown to reduce anxiety; yoga is also effective.

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