Anxiety & Trauma Disorders

Approach to the anxious patient

Focus and duration make the diagnosis. Anxiety disorders are separated by what the fear is about (everything, the next attack, escape, a specific object, scrutiny) and how long it has lasted; most require ≥6 months. Trauma and stressor disorders are separated almost entirely by timing.

Exclude mimics first. Hyperthyroidism, arrhythmia or ischemia (get an ECG for chest pain or palpitations), hypoglycemia, pheochromocytoma, caffeine and stimulants, and alcohol or benzodiazepine withdrawal can all present as anxiety.

Treatment pattern. An SSRI or SNRI plus CBT is first-line for nearly every anxiety and trauma disorder, with exposure-based therapy at the core for phobias, OCD, and PTSD. Benzodiazepines are, at most, a short-term bridge.

Screening. The USPSTF recommends screening for anxiety (for example with the GAD-7) in adults 64 or younger, including pregnant and postpartum patients (2023), and in children and adolescents 8 to 18 (2022).

GAD, panic, and phobias

Generalized anxiety disorder (GAD) is excessive, hard-to-control worry about multiple domains, more days than not for ≥6 months, plus ≥3 of restlessness, fatigue, poor concentration, irritability, muscle tension, and sleep disturbance.

Panic disorder is recurrent UNEXPECTED panic attacks plus ≥1 month of persistent worry about further attacks or a maladaptive change in behavior. An attack is an abrupt autonomic surge (palpitations, dyspnea, chest pain, sweating, derealization, fear of dying) that peaks within minutes.

A panic attack is a specifier, not a disorder, and can occur in many conditions; panic disorder requires unexpected attacks plus the month of anticipatory worry.

Agoraphobia is fear or avoidance of ≥2 situations (public transport, open spaces, enclosed spaces, crowds or lines, being outside the home alone) because escape might be difficult or help unavailable if panic strikes, for ≥6 months. It can occur with or without panic disorder.

Specific phobia is out-of-proportion fear of an object or situation (heights, animals, blood-injection-injury) with immediate anxiety and avoidance for ≥6 months. Blood-injection-injury phobia is unique: a vasovagal (diphasic) response, with a brief rise and then a fall in heart rate and blood pressure, causes fainting, so patients are taught applied muscle tension.

Social anxiety disorder is fear of social or performance situations where one may be scrutinized or embarrassed, for ≥6 months. The performance-only type (public speaking, recitals) is treated with propranolol or a benzodiazepine taken before the event.

Separation anxiety disorder is excessive, developmentally inappropriate fear of separation from attachment figures (school refusal, refusing to sleep away, nightmares, physical complaints before separation) lasting at least 4 weeks in children and adolescents (typically 6 months in adults). It is the most common anxiety disorder in young children; CBT with parent involvement is first-line, adding an SSRI if severe.

Obsessive-compulsive disorder

OCD combines intrusive, unwanted obsessions that raise anxiety with compulsions (repetitive behaviors or mental acts such as checking, washing, or counting) performed to neutralize it, consuming more than 1 hour a day or causing marked distress. Most patients recognize the behavior as excessive: the symptoms are ego-dystonic.

Treatment. First-line is a high-dose SSRI plus exposure and response prevention (ERP), which breaks the loop by exposing the patient to the trigger while blocking the ritual. OCD often needs higher SSRI doses and longer trials than depression. Clomipramine (a TCA) is second-line.

DSM-5 moved OCD out of the anxiety disorders into its own category with body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder. Contrast obsessive-compulsive personality disorder: perfectionism and rigidity that feel right to the patient (ego-syntonic), without true obsessions or compulsions.

Trauma- and stressor-related disorders

PTSD follows exposure to actual or threatened death, serious injury, or sexual violence, with symptoms lasting more than 1 month across 4 clusters: intrusion (flashbacks, nightmares), avoidance of reminders, negative alterations in cognition and mood (numbing, guilt, detachment), and hyperarousal (hypervigilance, startle, insomnia).

PTSD treatment. First-line is trauma-focused CBT (such as prolonged exposure or cognitive processing therapy) and an SSRI or venlafaxine; sertraline and paroxetine are FDA-approved, and fluoxetine is also used. Prazosin, an α1 antagonist, is sometimes used for trauma-related nightmares, but evidence is mixed after a large negative VA trial and it is not first-line. Benzodiazepines are AVOIDED.

Acute stress disorder is the same PTSD-like picture (intrusion, negative mood, dissociation, avoidance, arousal) lasting from 3 days up to 1 month after trauma; if symptoms persist beyond 1 month, the diagnosis becomes PTSD. Treat with trauma-focused CBT and avoid benzodiazepines.

Adjustment disorder is emotional or behavioral distress out of proportion to an identifiable stressor (job loss, breakup, illness) that does not meet criteria for another disorder such as MDD or PTSD. Treat with psychotherapy.

Pharmacotherapy principles

SSRIs and SNRIs are first-line for essentially every anxiety and trauma disorder, paired with CBT or exposure. Full effect takes 4–6 weeks, so counsel patients about the delay and about transient early activation (jitteriness, a brief rise in anxiety); starting at a low dose helps, especially in panic disorder.

Adjuncts. Buspirone, a 5-HT1A partial agonist, augments GAD treatment; it is nonsedating with no abuse potential but takes weeks to work and is useless as needed. Beta-blockers such as propranolol blunt the tremor and tachycardia of performance anxiety.

A patient with an active alcohol use disorder is a poor candidate for benzodiazepines because of cross-tolerance, dependence, and additive respiratory depression.