Introduction
Methods
1
| Meta-analysis or at least 2 randomized controlled trials (RCTs) that included a placebo condition |
2
| At least 1 RCT with placebo or active comparison condition |
3
| Uncontrolled trial with at least 10 subjects |
4
| Anecdotal reports or expert opinion |
First-line
| Level 1 or Level 2 evidence plus clinical support for efficacy and safety |
Second-line
| Level 3 evidence or higher plus clinical support for efficacy and safety |
Third-line
| Level 4 evidence or higher plus clinical support for efficacy and safety |
Not recommended
| Level 1 or Level 2 evidence for lack of efficacy |
Principles of diagnosis and management of anxiety and related disorders
Epidemiology
Prevalence and impact
Suicide risk
Initial assessment of patients with anxiety
• Screen for anxiety and related symptoms • Conduct differential diagnosis (consider severity, impairment, and comorbidity) • Identify specific anxiety or related disorder • Psychological and/or pharmacological treatment • Perform follow-up |
Screen for anxiety and related symptoms
• During the past two weeks how much have you been bothered by the following problems? ○ Feeling nervous, anxious, frightened, worried, or on edge ○ Feeling panic or being frightened ○ Avoiding situations that make you anxious |
• Do you have sudden episodes/spells/attacks of intense fear or discomfort that are unexpected or out of the blue? If you answered "YES" then continue • Have you had more than one of these attacks? • Does the worst part of these attacks usually peak within several minutes? • Have you ever had one of these attacks and spent the next month or more living in fear of having another attack or worrying about the consequences of the attack? |
SAD (Based on Mini-SPIN [28]) • Does fear of embarrassment cause you to avoid doing things or speaking to people? • Do you avoid activities in which you are the center of attention? • Is being embarrassed or looking stupid among your worst fears? |
GAD [31] • During the past 4 weeks, have you been bothered by feeling worried, tense, or anxious most of the time? • Are you frequently tense, irritable, and having trouble sleeping? |
Obsessions:
• Are you bothered by repeated and unwanted thoughts of any of the following types: ○ Thoughts of hurting someone else ○ Sexual thoughts ○ Excessive concern about contamination/germs/disease ○ Preoccupation with doubts (“what if” questions) or an inability to make decisions ○ Mental rituals (e.g., counting, praying, repeating) ○ Other unwanted intrusive thoughts • If you answered "YES" to any of the above… Do you have trouble resisting these thoughts, images, or impulses when they come into your mind?
Compulsions:
• Do you feel driven to perform certain actions or habits over and over again, or in a certain way, or until it feels just right? Such as: ○ Washing, cleaning ○ Checking (e.g., doors, locks, appliances) ○ Ordering/arranging ○ Repeating (e.g., counting, touching, praying) ○ Hoarding/collecting/saving • If you answered "YES" to any of the above… Do you have trouble resisting the urge to do these things? |
• Have you experienced or seen a life-threatening or traumatic event such as a rape, accident, someone badly hurt or killed, assault, natural or man-made disaster, war, or torture?
If you answered "YES" then continue
• Do you re-experience the event in disturbing (upsetting) ways such as dreams, intrusive memories, flashbacks, or physical reactions to situations that remind you of the event? |
Conduct differential diagnosis
• Family history of anxiety [33] |
Comorbid medical and psychiatric disorders
Baseline assessment
Basic lab tests | |
---|---|
• Complete blood count | • Fasting glucose |
• Fasting lipid profile (TC, vLDL, LDL, HDL, TG) | • Thyroid-stimulating hormone |
• Electrolytes | • Liver enzymes |
If warranted
| |
• Urine toxicology for substance use |
Identify specific anxiety or related disorder
Disorder | Key features |
---|---|
Panic disorder | • Recurrent unexpected panic attacks, in the absence of triggers • Persistent concern about additional panic attacks and/or maladaptive change in behavior related to the attacks |
Agoraphobia | • Marked, unreasonable fear or anxiety about a situation • Active avoidance of feared situation due to thoughts that escape might be difficult or help unavailable if panic-like symptoms occur |
Specific phobia | • Marked, unreasonable fear or anxiety about a specific object or situation, which is actively avoided (e.g., flying, heights, animals, receiving an injection, seeing blood) |
Social anxiety disorder (SAD) | • Marked, excessive or unrealistic fear or anxiety about social situations in which there is possible exposure to scrutiny by others • Active avoidance of feared situation |
Generalized anxiety disorder (GAD) | • Excessive, difficult to control anxiety and worry (apprehensive expectation) about multiple events or activities (e.g., school/work difficulties) • Accompanied by symptoms such as restlessness/feeling on edge or muscle tension |
Obsessive–compulsive disorder (OCD) | • Obsessions: recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and that cause marked anxiety or distress • Compulsions: repetitive behaviors (e.g., hand washing) or mental acts (e.g., counting) that the individual feels driven to perform to reduce the anxiety generated by the obsessions |
Posttraumatic stress disorder (PTSD) | • Exposure to actual or threatened death, serious injury, or sexual violation • Intrusion symptoms (e.g., distressing memories or dreams, flashbacks, intense distress) and avoidance of stimuli associated with the event • Negative alterations in cognitions and mood (e.g., negative beliefs and emotions, detachment), as well as marked alterations in arousal and reactivity (e.g., irritable behavior, hypervigilance) |
Psychological and pharmacological treatment
Overview of psychological treatment
Exposure
| • Encourage patients to face fears • Patients learn corrective information through experience • Extinction of fear occurs through repeated exposure • Successful coping enhances self-efficacy |
Safety response inhibition
| • Patients restrict their usual anxiety-reducing behaviors (e.g., escape, need for reassurance) • Decreases negative reinforcement • Coping with anxiety without using anxiety-reducing behavior enhances self-efficacy |
Cognitive strategies
| • Cognitive restructuring, behavioral experiments, and related strategies target patients’ exaggerated perception of danger (e.g., fear of negative evaluation in SAD) • Provides corrective information regarding the level of threat • Can also target self-efficacy beliefs |
Arousal management
| • Relaxation and breathing control skills can help patient control increased anxiety levels |
Surrender of safety signals
| • Patient relinquishes safety signals (e.g., presence of a companion, knowledge of the location of the nearest toilet) • Patients learn adaptive self-efficacy beliefs |
Overview of pharmacological treatment
Anxiety disorders | Panic disorder | Social anxiety disorder | Obsessive–compulsive disorder | Generalized anxiety disorder | Posttraumatic stress disorder | |
---|---|---|---|---|---|---|
ANTIDEPRESSANTS | ||||||
SSRIs
| ||||||
Escitalopram (Cipralex®) | X | X | ||||
Fluoxetine (Prozac®) | X | |||||
Fluvoxamine (Luvox®) | X | |||||
Paroxetine (Paxil®) | X | X | X | X | X | |
Paroxetine CR (Paxil® CR) | X | X | ||||
Sertraline (Zoloft®) | X | X | ||||
TCAs
| ||||||
Clomipramine | X | |||||
Other antidepressants
| ||||||
Venlafaxine XR (Effexor® XR) | X | X | X | |||
Duloxetine (Cymbalta®) | X | |||||
AZAPIRONES
| ||||||
Buspirone (BuSpar®, Buspirex®) | X | |||||
BENZODIAZEPINES*
| X |
Safety and side effects
Follow-up
Assessing response to treatment
Panic disorder and agoraphobia
Epidemiology
Comorbidity
Diagnosis
• An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and includes ≥4 of the following symptoms: (1) Palpitations, pounding heart, or accelerated heart rate (2) Sweating (3) Trembling or shaking (4) Sensations of shortness of breath or smothering (5) Feelings of choking (6) Chest pain or discomfort (7) Nausea or abdominal distress (8) Feeling dizzy, unsteady, light-headed, or faint (9) Chills or heat sensations (10) Paresthesias (numbness or tingling sensations) (11) Derealization (feelings of unreality) or depersonalization (being detached from oneself) (12) Fear of losing control or going crazy (13) Fear of dying |
• The person has experienced both of the following: ○ Recurrent unexpected panic attacks ○ ≥1 of the attacks followed by ≥1 month of 1 or both of the following: • Persistent concern or worry about additional panic attacks or their consequences • Significant maladaptive change in behavior related to the attacks |
• Marked fear or anxiety about ≥2 of the following 5 groups of situations: (1) Public transportation (e.g., traveling in automobiles, buses, trains, ships, or planes) (2) Open spaces (e.g., parking lots, market places, or bridges) (3) Being in shops, theatres, or cinemas (4) Standing in line or being in a crowd (5) Being outside of the home alone in other situations |
• The individual fears or avoids these situations due to thoughts that escape might be difficult or help might not be available in the event of panic-like symptoms |
• The agoraphobic situations almost always provoke fear or anxiety |
• The situations are actively avoided, require presence of a companion, or endured with marked fear or anxiety |
• The fear or anxiety is out of proportion to actual danger posed by agoraphobic situation |
• The fear, anxiety, or avoidance is persistent, typically lasting ≥6 months |
• The fear, anxiety, and avoidance cause clinically significant distress or functional impairment |
Psychological treatment
Combined psychological and pharmacological treatment
Long-term effects of psychological treatment
Pharmacological treatment
Agent | Level of evidence | Agent | Level of evidence |
---|---|---|---|
Antidepressants
| |||
SSRIs
|
TCAs
| ||
1 | 1 | ||
1 | 1 | ||
1 |
MAOIs and RIMAs
| ||
1 | Phenelzine [240] | 2 | |
1 | 1* | ||
Escitalopram [198] | 2 | Tranylcypromine [243] | 3 |
Paroxetine CR [225] | 2 |
Other antidepressants
| |
SNRIs
| 1 | ||
1 | 2 | ||
Duloxetine [230] | 3 | 3* | |
Milnacipran [231] | 3 | ||
Other therapies
| |||
Anxiolytics
|
Atypical antipsychotics
| ||
Benzodiazepines
| 2 | ||
1 | Olanzapine [268] | 3 | |
1 | Quetiapine [267] | 3 | |
1 | Adjunctive aripiprazole [269] | 3 | |
1 | Adjunctive olanzapine [270] | 3 | |
1 | Adjunctive risperidone [271] | 3 | |
Adjunctive alprazolam ODT [266] | 3 |
Anticonvulsants
| |
Other treatments
| 3 | ||
1 (-ve) | Levetiracetam [276] | 3 | |
Trazodone [283] | 2 (-ve) | Gabapentin [277] | 2 (-ve)† |
2 (-ve) | 2 (-ve) | ||
Adjunctive pindolol [286] | 2 | Carbamazepine [280] | 3 (-ve) |
Adjunctive divalproex [281] | 3 |
First-line | Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, paroxetine CR, sertraline, venlafaxine XR |
---|---|
Second-line
| Alprazolam, clomipramine, clonazepam, diazepam, imipramine, lorazepam, mirtazapine, reboxetine |
Third-line
| Bupropion SR, divalproex, duloxetine, gabapentin, levetiracetam, milnacipran, moclobemide, olanzapine, phenelzine, quetiapine, risperidone, tranylcypromine |
Adjunctive therapy
| Second-line: alprazolam ODT, clonazepam Third-line: aripiprazole, divalproex, olanzapine, pindolol, risperidone |
Not recommended
| Buspirone, propranolol, tiagabine, trazodone |
First-line agents
Second-line agents
Third-line agents
Adjunctive therapy
Not recommended
Maintenance pharmacological treatment
Biological and alternative therapies
Summary
Specific phobia
Epidemiology
Comorbidities
Diagnosis
• Marked fear or anxiety about a specific object or situation (e.g., flying, seeing blood) • The phobic object or situation almost always provokes immediate fear or anxiety and is actively avoided or endured with marked fear or anxiety • The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation • The fear, anxiety, or avoidance is persistent, typically ≥6 months • There is marked distress or functional impairment |
Specifier | Examples |
---|---|
Animal | Spiders, insects, dogs |
Natural environment | Heights, storms, water |
Blood-injection-injury | Needles, invasive medical procedures |
Situational | Airplanes, elevators, enclosed spaces |
Other | Choking or vomiting. In children, loud sounds or costumed characters |
Psychological treatment
Psychological treatment | Phobia |
---|---|
Exposure-based treatments | |
Virtual reality exposure | |
Computer-based self-help programs | |
Applied muscle tension (exposure combined with muscle tension exercises) | |
Cognitive therapy and exposure |
Combined psychological and pharmacological treatment
Pharmacological treatment
Summary
Social anxiety disorder
Epidemiology
Psychiatric comorbidity
Diagnosis
• Marked fear or anxiety about social situations in which the person may be exposed to scrutiny by others |
• Fear that actions or showing anxiety symptoms will cause negative evaluation (e.g., embarrassment, humiliation) or offend others |
• The social situation: ○ Almost always provokes fear or anxiety ○ Is actively avoided or endured with marked fear or anxiety |
• The fear, anxiety, or avoidance: ○ Is out of proportion to the actual threat posed by the social situation ○ Is persistent, typically ≥6 months ○ Causes significant distress or functional impairment |
• If another medical condition is present (e.g., stuttering, obesity), the disturbance is unrelated or out of proportion to it |
• Specify “performance only” if the fear is restricted to speaking or performing in public |
Psychological treatment
Combined psychological and pharmacological treatments
Long-term effects of psychological treatment
Pharmacological treatment
Agent | Level of evidence | Agent | Level of evidence |
---|---|---|---|
Antidepressants
| |||
1 |
TCAs
| ||
1 | 3 | ||
1 | Imipramine [460] | 3 (-ve) | |
1 |
MAOIs and RIMAs
| ||
1 | 1 | ||
1 | 1* | ||
1* |
Other antidepressants
| ||
2 | 1* | ||
Paroxetine CR [452] | 2 | Bupropion SR [469] | 3 |
Adjunctive paroxetine [453] | 3 | ||
SNRIs
| |||
1 | |||
Duloxetine [457] | 2 | ||
Other therapies
| |||
Anxiolytics
|
Anticonvulsants
| ||
Benzodiazepines
| 1 | ||
1 | 2 | ||
Alprazolam [386] | 2 | 2 (-ve) | |
Bromazepam [472] | 2 | Divalproex [481] | 3 |
Adjunctive clonazepam [473] | 2 (-ve) | 3 | |
Topiramate [483] | 3 | ||
Other treatments
|
Atypical antipsychotics
| ||
1 (-ve) | Olanzapine [493] | 2 | |
1 (-ve) | 2 (-ve) | ||
1* | Adjunctive aripiprazole [496] | 3 | |
Propranolol [488] | 2 (-ve) | Adjunctive risperidone [271] | 3 |
Selegiline [489] | 3 | ||
Pergolide [490] | 3 (-ve) | ||
Adjunctive buspirone [491] | 3 | ||
Adjunctive pindolol [492] | 2 (-ve) |
First-line
| Escitalopram, fluvoxamine, fluvoxamine CR, paroxetine, paroxetine CR, pregabalin, sertraline, venlafaxine XR |
Second-line
| Alprazolam, bromazepam, citalopram, clonazepam, gabapentin, phenelzine |
Third-line
| Atomoxetine, bupropion SR, clomipramine, divalproex, duloxetine, fluoxetine, mirtazapine, moclobemide, olanzapine, selegiline, tiagabine, topiramate |
Adjunctive therapy
| Third-line: aripiprazole, buspirone, paroxetine, risperidone Not recommended: clonazepam, pindolol |
Not recommended
| Atenolol*, buspirone, imipramine, levetiracetam, propranolol*, quetiapine |
First-line agents
Second-line agents
Third-line agents
Adjunctive therapy
Not recommended
Maintenance pharmacological treatment
Biological and alternative therapies
Summary
Generalized anxiety disorder
Epidemiology
Comorbidity
Diagnosis
• Excessive anxiety and worry (apprehensive expectation) about a number of events or activities (e.g., school/work performance) |
• The individual finds it difficult to control the worry |
• Excessive anxiety and worry are associated with ≥3 of the following symptoms (with at least some occurring more days than not for ≥6 months): ○ Restlessness or feeling keyed-up or on edge, being easily fatigued, difficulty concentrating, irritability, muscle tension, or sleep disturbance |
• The disturbance causes clinically significant distress or functional impairment |
Psychological treatment
Psychological and pharmacological treatment
Pharmacological treatment
Agent | Level of evidence | Agent | Level of evidence |
---|---|---|---|
Antidepressants
| |||
SSRIs
|
TCAs
| ||
1 | 1 | ||
1 |
Other antidepressants
| ||
1 | 1 | ||
Citalopram [562] | 3 | 1* | |
Fluoxetine [563] | 3 | Bupropion XL [549] | 2 |
3 | Trazodone [583] | 2 | |
SNRIs
| Mirtazapine [588] | 3 | |
1 | |||
1 | |||
Other therapies
| |||
Anxiolytics
|
Atypical antipsychotics
| ||
Benzodiazepines
| 1 | ||
1 | 1* | ||
1 | 1* | ||
1 | Adjunctive olanzapine [608] | 2 | |
1 | 3 | ||
Adjunctive quetiapine XR [610] | 3 | ||
2 (-ve) | |||
Anticonvulsants
|
Other treatments
| ||
1 | 1 | ||
Divalproex chrono [614] | 2 | 1 | |
1 (-ve) | Pexacerfont [552] | 2 (-ve) | |
Adjunctive pregabalin [617] | 2 | Propranolol [621] | 2 (-ve) |
Memantine [622] | 4 (-ve) |
First-line
| Agomelatine, duloxetine, escitalopram, paroxetine, paroxetine CR, pregabalin, sertraline, venlafaxine XR |
Second-line
| Alprazolam*, bromazepam*, bupropion XL*, buspirone, diazepam*, hydroxyzine, imipramine, lorazepam*, quetiapine XR*, vortioxetine |
Third-line
| Citalopram, divalproex chrono, fluoxetine, mirtazapine, trazodone |
Adjunctive therapy
| Second-line: pregabalin Third-line: aripiprazole, olanzapine, quetiapine, quetiapine XR, risperidone Not recommended: ziprasidone |
Not recommended
| Beta blockers (propranolol), pexacerfont, tiagabine |
First-line agents
Second-line agents
Third-line agents
Adjunctive therapy
Not recommended
Maintenance pharmacological treatment
Biological and alternative therapies
Summary
Obsessive-compulsive disorder
Epidemiology
Comorbidity
Diagnosis
• Presence of either obsessions, compulsions, or both ○ Obsessions are defined by the following: • Recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and that cause marked anxiety or distress • The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with other thoughts or actions ○ Compulsions are defined by the following: • Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rigid rules • Compulsions are aimed preventing or reducing anxiety or preventing some dreaded situation or event; however, they are not connected in a realistic way with what they are designed to neutralize or are clearly excessive |
• The obsessions or compulsions are time-consuming (e.g., take >1 h/day) or cause clinically significant distress or functional impairment |
• Specify patient’s degree of insight as to reality of OCD beliefs: ○ Good or fair insight (i.e., definitely or probably not true) ○ Poor insight (i.e., probably true) ○ Absent insight (i.e., completely convinced beliefs are true) |
• Specify if "tic-related" OCD |
Psychological treatment
Combined psychological and pharmacological treatment
Pharmacological treatment
Agent | Level of evidence | Agent | Level of evidence |
---|---|---|---|
Antidepressants
| |||
SSRIs
|
MAOIs
| ||
1 | 2* | ||
1 | Tranylcypromine [739] | 4 | |
1 |
TCAs
| ||
1 | 1 | ||
1 | 2 | ||
2 | 2 (-ve) | ||
IV citalopram [729] | 3 | 2 (-ve) | |
Adjunctive citalopram [730] | 3 |
Other antidepressants
| |
SNRIs
| Mirtazapine [748] | 2 | |
2 | Bupropion [749] | 3 (-ve) | |
4 | Adjunctive mirtazapine [727] | 3 | |
Other therapies
| |||
Antipsychotics
|
Anxiolytics
| ||
1 |
Benzodiazepines
| ||
1* | Clonazepam [771] | 2 (-ve) | |
1* | Adjunctive clonazepam [772] | 2 (-ve) | |
1* |
Other treatments
| ||
2 | Clonidine [773] | 2 (-ve) | |
Adjunctive amisulpride [770] | 3 | 1* | |
Adjunctive ziprasidone [767] | 4 | Adjunctive celecoxib [777] | 2 |
Anticonvulsants
| Adjunctive granisetron [778] | 2 | |
1* | 2 | ||
2 | 2 | ||
3 | 2 | ||
3 (-ve) | 2 | ||
Opioids
| 3 | ||
4 | 1 (-ve) | ||
Naltrexone [807] | 3 (-ve) | 2 (-ve) | |
Adjunctive morphine [808] | 2 | Adjunctive minocycline [794] | 4 (-ve) |
First-line
| Escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline |
Second-line
| Citalopram, clomipramine, mirtazapine, venlafaxine XR |
Third-line
| IV citalopram, IV clomipramine, duloxetine, phenelzine, tramadol, tranylcypromine |
Adjunctive therapy
| First-line: aripiprazole, risperidone Second-line: memantine, quetiapine, topiramate Third-line: amisulpride, celecoxib, citalopram, granisetron, haloperidol, IV ketamine, mirtazapine, N-acetylcysteine, olanzapine, ondansetron, pindolol, pregabalin, riluzole, ziprasidone Not recommended: buspirone, clonazepam, lithium, morphine |
Not recommended
| Clonazepam, clonidine, desipramine |
First-line agents
Second-line agents
Third-line agents
Adjunctive therapy
Not recommended
Maintenance pharmacological treatment
Biological and alternative therapies
Summary
Posttraumatic stress disorder
Epidemiology
Comorbidity
Diagnosis
• The person has been exposed to actual or threatened death, serious injury, or sexual violation in ≥1 of the following ways: ○ Directly experienced or witnessed the traumatic event, learned that trauma occurred to close family member or friend (actual or threatened death must have been violent or accidental), experienced repeated exposure to aversive details of trauma |
• Presence of ≥1 of the following intrusion symptoms associated with the trauma: ○ Recurrent, involuntary, and intrusive distressing memories, distressing dreams, dissociative reactions (e.g., flashbacks), psychological or physiological distress at reminders of trauma |
• Persistent avoidance of stimuli associated with the trauma, including ≥1 of the following: ○ Avoidance of distressing memories or feelings and external reminders (e.g., people, places) of the trauma |
• Negative alterations in cognitions and mood associated with the trauma, including ≥2 of the following: ○ Inability to recall important aspect of the trauma, diminished interest or participation in activities, feeling of detachment or estrangement from others, persistent negative beliefs, distorted blame, and negative emotional state |
• Marked alterations in arousal and reactivity associated with the trauma, including ≥2 of the following: ○ Irritable or aggressive behavior, reckless or self-destructive behavior, hypervigilance, exaggerated startle response, problems with concentration, sleep disturbance |
• Duration of disturbance >1 month |
• Symptoms cause clinically significant distress or impaired functioning |
• Specify whether with dissociative symptoms (depersonalization or derealization) or with delayed expression (full criteria not met until at least 6 months after the event) |
Prevention and early intervention
Psychological treatment
Combined psychological and pharmacological treatment
Long-term effects of psychological treatment
Pharmacological treatment
Agent | Level of evidence | Agent | Level of evidence |
---|---|---|---|
Antidepressants
| |||
SSRIs
|
TCAs
| ||
1* | 1 | ||
1 | Amitriptyline [994] | 2 | |
1* | 2* | ||
2 |
MAOIs and RIMAs
| ||
Escitalopram [985] | 3 | 1* | |
2 (-ve) | 3 | ||
SNRIs
|
Other antidepressants
| ||
1 | 2 | ||
3 | Reboxetine [984] | 2 | |
Bupropion SR 1003 | 3 | ||
3 | |||
Adjunctive bupropion SR 1005 | 2 (-ve) | ||
Other therapies
| |||
Anxiolytics
|
Anticonvulsants
| ||
Benzodiazepines
| 1* | ||
Alprazolam 1006 | 2 (-ve) | Lamotrigine 1011 | 2 |
3 (-ve) | 3 | ||
Atypical antipsychotics
| 1 (-ve) | ||
Risperidone 1030 | 2 | Tiagabine 1018 | 2 (-ve) |
3 | 4 | ||
3 | Adjunctive levetiracetam 1021 | 4 | |
2 (-ve) | Adjunctive pregabalin 1022 | 4 | |
1* | 4 | ||
Adjunctive olanzapine 1045 | 2 | 2 (-ve) | |
3 |
Other treatments
| ||
3 | 4 | ||
Trazodone 1053 | 4 | ||
Memantine 1054 | 4 | ||
Adjunctive eszopiclone 1055 | 2 | ||
Adjunctive clonidine 1056 | 3 | ||
1 (-ve) | |||
Adjunctive zolpidem 1059 | 2 (-ve) |
First-line
| Fluoxetine, paroxetine, sertraline, venlafaxine XR |
Second-line
| Fluvoxamine, mirtazapine, phenelzine |
Third-line
| Amitriptyline, aripiprazole, bupropion SR, buspirone, carbamazepine, desipramine, duloxetine, escitalopram, imipramine, lamotrigine, memantine, moclobemide, quetiapine, reboxetine, risperidone, tianeptine, topiramate, trazodone |
Adjunctive therapy
| Second-line: eszopiclone, olanzapine, risperidone Third-line: aripiprazole, clonidine, gabapentin, levetiracetam, pregabalin, quetiapine, reboxetine, tiagabine Not recommended: bupropion SR, guanfacine, topiramate, zolpidem |
Not recommended
| Alprazolam, citalopram, clonazepam, desipramine, divalproex, olanzapine, tiagabine |
First-line agents
Second-line agents
Third-line agents
Adjunctive therapies
Treatments for specific PTSD-associated symptoms
Not recommended
Maintenance pharmacological treatment
Biological and alternative therapies
Summary
Special populations
Women during pregnancy and the postpartum period
Epidemiology
Treatment issues
Summary
Children and adolescents
Epidemiology
Anxiety and related disorder | Estimated prevalence (%) | |
---|---|---|
12-month | Lifetime | |
Any anxiety disorder | 24.9 | 31.9 |
Separation anxiety disorder | 1.6 | 7.6 |
Specific phobia | 15.8 | 19.3 |
Social anxiety disorder | 8.2 | 9.1 |
Posttraumatic stress disorder | 3.9 | 5.0 |
Panic disorder | 1.9 | 2.3 |
Generalized anxiety disorder | 1.1 | 2.2 |
Diagnostic issues
Anxiety or related disorder | DSM-5 diagnoses specific to children |
---|---|
Separation anxiety disorder | • Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached, as evidenced by ≥3 of the following: ○ Distress when separation occurs, worry about loss or separation, reluctance to leave home, be alone, or go to sleep because of fear of separation, nightmares involving separation, or complaints of physical symptoms (e.g., headaches, upset stomach) when separation occurs • Duration of at least 4 weeks • Onset before 18 years of age • The disturbance causes clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning |
Selective mutism | • Consistent failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations |
Anxiety or related disorder
|
Changes to adult DSM-5 diagnostic criteria specific to children
|
Specific phobia | • The fear or anxiety may be expressed by crying, tantrums, freezing, or clinging • Other specifiers: loud sounds or costumed characters |
SAD (social phobia) | • The anxiety must occur in peer settings, not just during interactions with adults • The fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failure to speak in social situations |
OCD, panic disorder | • No pediatric specific criteria |
PTSD | • Qualifiers in children ○ Intrusion symptoms: repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed; there may be frightening dreams without recognizable content; trauma-specific re-enactment may occur in play • Specific subtype for children ≤6 years of age |
GAD | • Less stringent criteria for symptoms than in adults |
Prevention strategies
Treatment issues
Psychological treatment
Pharmacological treatment
Disorder | Antidepressants | Benzodiazepines and other treatments |
---|---|---|
OCD |
Antipsychotics
| |
Adjunctive aripiprazole (Level 3) 1293 | ||
Other
| ||
Fluvoxamine (Level 2) 1271 | Riluzole (Level 4) 1294 | |
Paroxetine (Level 2) 1272 | ||
Sertraline (Level 2) 1273 | ||
Panic disorder |
Anxiolytics
| |
Alprazolam (Level 4) 1289 | ||
SAD |
Anxiolytics
| |
Fluvoxamine (Level 2) 1278 | Alprazolam (Level 2, -ve) 1290 | |
Paroxetine (Level 2) 1279 | ||
Venlafaxine XR (Level 2) 1282 | ||
Escitalopram (Level 3) 1280 | ||
Sertraline (Level 3) 1281 | ||
Mirtazapine (Level 3) 1283 | ||
Separation anxiety disorder | Fluoxetine (Level 2) 1277 |
Anxiolytics
|
Fluvoxamine (Level 2) 1278 | Clonazepam (Level 2, -ve) 1292 | |
GAD | Fluoxetine (Level 2) 1277 |
Anxiolytics
|
Fluvoxamine (Level 2) 1278 | Alprazolam (Level 2, -ve) 1290 | |
Sertraline (Level 2) 1284 | ||
School-refusal | Citalopram (Level 4) 1285 |
Anxiolytics
|
Adjunctive imipramine (Level 2) 1259 | Alprazolam (Level 2, -ve) 1291 | |
PTSD | Sertraline (Level 2, -ve) 1286 | |
Adjunctive sertraline (Level 2, -ve) [946] |