One-liner#

Evaluate and manage anxiety disorders in primary care using validated screening tools and first-line treatments (SSRIs, SNRIs, psychotherapy), while distinguishing from medical causes and knowing when to refer.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Panic attack with chest pain, dyspnea, or syncope in patient with cardiac risk factors → rule out ACS, PE, arrhythmia
• Severe agitation with inability to be redirected → may need acute psychiatric intervention
• Active suicidal ideation with plan/intent → ED for psychiatric evaluation
• Symptoms of serotonin syndrome (if on serotonergic medications): fever, rigidity, hyperreflexia, altered mental status

Urgent (not ED, but expedited):

• Panic attacks so frequent patient cannot function
• Severe agoraphobia (housebound)
• Anxiety with active substance withdrawal

Key history#

GAD-7 (administer at every visit):

• Score 0-4: minimal
• Score 5-9: mild
• Score 10-14: moderate
• Score 15-21: severe

Core symptoms of generalized anxiety:

• Excessive worry about multiple domains (work, health, family, finances)
• Difficulty controlling worry
• Duration ≥6 months
• Associated symptoms: restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance

Panic attack symptoms:

• Sudden onset, peaks within minutes
• Palpitations, sweating, trembling
• Shortness of breath, chest pain
• Nausea, dizziness, paresthesias
• Fear of losing control or dying
• Derealization/depersonalization

Pattern recognition questions:

• “What triggers your anxiety?” (situational vs generalized)
• “Do you have sudden episodes of intense fear?” (panic)
• “Do you avoid certain situations?” (phobias, agoraphobia)
• “Are you worried about being judged by others?” (social anxiety)
• “Do you have intrusive thoughts you can’t control?” (OCD—refer to psychiatry)
• “Have you experienced a traumatic event?” (PTSD—often needs specialty care)

Functional impact:

• Work/school performance
• Relationships and social activities
• Avoidance behaviors
• Sleep quality

Rule out medical causes:

• Hyperthyroidism
• Cardiac arrhythmias
• Pheochromocytoma (rare but classic)
• Hypoglycemia
• Medication/substance-induced (caffeine, stimulants, decongestants, steroids, thyroid hormone)
• Substance withdrawal (alcohol, benzodiazepines, opioids)

Substance use screen:

• Caffeine intake (often overlooked)
• Alcohol (can cause/worsen anxiety; withdrawal mimics panic)
• Cannabis (can trigger panic)
• Stimulants (cocaine, amphetamines, ADHD medications)

Comorbidities:

• Depression (60%+ comorbid)
• Other anxiety disorders
• Substance use disorders
• Chronic pain

Focused exam#

Vital signs:

• Tachycardia (anxiety vs hyperthyroidism vs arrhythmia)
• Elevated BP (anxiety vs pheochromocytoma)
• Tremor

Physical exam (to rule out medical causes):

• Thyroid: goiter, nodules
• Cardiac: irregular rhythm, murmurs
• Neurologic: tremor, hyperreflexia (hyperthyroidism)

Mental status exam:

• Appearance: restless, fidgeting, tense
• Behavior: hypervigilant, easily startled
• Speech: rapid, pressured
• Mood: “anxious,” “nervous,” “on edge”
• Affect: anxious, tense
• Thought content: worry, catastrophizing, fear
• No psychotic symptoms (if present, consider other diagnoses)

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

First-line (for new anxiety presentation):

Consider based on presentation:

When NOT to order extensive workup:

• Classic GAD or panic disorder presentation
• No red flags for medical cause
• Young, healthy patient with clear psychosocial stressors
• Do NOT order brain imaging for anxiety without focal neurologic findings

Initial management#

Mild anxiety (GAD-7 5-9):

• Psychotherapy (CBT) may be sufficient
• Lifestyle: limit caffeine, regular exercise, sleep hygiene
• Close follow-up

Moderate to severe anxiety (GAD-7 ≥10):

• Medication recommended
• SSRI or SNRI first-line
• Combine with psychotherapy for best outcomes

Key principles:

• SSRIs/SNRIs take 4-6 weeks for full effect
• Start low (anxious patients sensitive to activation)
• Warn about initial worsening before improvement
• Avoid benzodiazepines as first-line (dependence, cognitive effects, falls in elderly)

Management by diagnosis#

Generalized anxiety disorder#

Education:

• GAD is a medical condition, not a character flaw
• Treatment is effective for most people
• Medications take 4-6 weeks to work fully
• Therapy (CBT) is as effective as medication and has lasting benefits

Treatment:

Benzodiazepines—use with caution:

When to use benzodiazepines:

• Bridge therapy while waiting for SSRI to work (limit to 2-4 weeks)
• Infrequent, predictable situational anxiety (e.g., flying 2x/year)
• NOT for daily, long-term use in primary care

When NOT to use benzodiazepines:

• History of substance use disorder
• Elderly (falls, cognitive impairment—Beers criteria)
• Concurrent opioid use
• As monotherapy for GAD or panic disorder

Alternative for patients who cannot take SSRIs or benzos:

Pregnancy/breastfeeding:

• Untreated anxiety carries risks; weigh benefits vs risks
• SSRIs: sertraline preferred (most safety data)
• Benzodiazepines: avoid if possible; if used, lowest dose, shortest duration
• Buspirone: limited data but appears safe
• Hydroxyzine: avoid in first trimester (limited data)
• Refer to psychiatry or MFM for complex cases

Elderly considerations:

• Start SSRIs at half dose
• Escitalopram max 10 mg if >65
• AVOID benzodiazepines (Beers criteria—falls, cognitive impairment, paradoxical agitation)
• Buspirone or hydroxyzine may be safer alternatives
• Monitor for hyponatremia with SSRIs

Follow-up: 2-4 weeks after starting medication; then monthly until stable.

Panic disorder#

Education:

• Panic attacks are not dangerous (feel terrible but won’t kill you)
• The fear of panic attacks often drives avoidance and worsens the condition
• Treatment is very effective
• Goal: reduce frequency/severity of attacks AND reduce avoidance

Treatment:

• SSRI/SNRI first-line (same medications as GAD)
• Start at LOWER doses than for depression (anxious patients sensitive)
• CBT with interoceptive exposure highly effective

For acute panic attacks (patient education):

• Breathing techniques: slow, diaphragmatic breathing
• Grounding techniques: 5-4-3-2-1 senses exercise
• Remind self: “This is a panic attack. It will pass. I am not dying.”
• PRN benzodiazepine only if attacks infrequent and no substance use history

Follow-up: 2 weeks initially; then monthly until stable.

Social anxiety disorder#

Education:

• Very common; often starts in adolescence
• Not just “shyness”—causes significant impairment
• Treatment helps most people

Treatment:

• SSRI/SNRI first-line
• CBT with exposure therapy highly effective
• Beta-blockers for performance-only anxiety (not generalized social anxiety)

Follow-up: Monthly until stable.

Specific phobias#

Education:

• Exposure therapy is the treatment of choice
• Medications are not first-line
• Avoidance maintains the phobia

Treatment:

• Refer for CBT with exposure therapy
• PRN benzodiazepine reasonable for rare, unavoidable exposures (e.g., MRI, dental procedure, flying 1-2x/year)

Follow-up: As needed; therapy-driven.

Anxiety with comorbid depression#

Education:

• Very common combination (60%+)
• Both need treatment
• SSRIs treat both

Treatment:

• SSRI first-line (treats both conditions)
• Start low (anxious patients sensitive)
• Prioritize safety assessment (depression + anxiety increases suicide risk)

Follow-up: 2 weeks initially; close monitoring.

Follow-up#

Initial treatment:

• 2-4 weeks after starting medication (tolerability, early response)
• Monthly until stable

Maintenance:

• Every 3 months once stable
• GAD-7 at every visit
• Assess for side effects, adherence

Duration of treatment:

• Minimum 12 months after remission
• Many patients benefit from long-term maintenance
• Taper slowly if discontinuing (over weeks to months)

Return precautions:

• Worsening anxiety or panic attacks
• New or worsening depression
• Suicidal thoughts
• Side effects that are intolerable
• Symptoms not improving after 6-8 weeks

When to refer to psychiatry:

• Failed 2+ adequate medication trials
• Comorbid bipolar disorder or psychosis
• Severe OCD or PTSD
• Complex diagnostic picture
• Patient preference

Patient instructions#

• Anxiety disorders are real medical conditions. Treatment works for most people.
• The medication takes 4-6 weeks to work fully. You may feel a bit more anxious at first—this usually passes.
• Take your medication every day, even when you feel better. Don’t stop suddenly.
• Limit caffeine (coffee, energy drinks, soda)—it can make anxiety worse.
• Regular exercise, good sleep, and relaxation techniques all help.
• Therapy (especially CBT) is very effective and teaches skills that last.
• Call us if your anxiety gets much worse, you have thoughts of hurting yourself, or the medication causes problems you can’t tolerate.

Smartphrase snippets#

.ANXIETYGAD GAD-7 score [X] consistent with [mild/moderate/severe] generalized anxiety disorder. Safety assessment negative. TSH normal. Starting [sertraline 25 mg / escitalopram 5 mg] daily. Discussed that medication takes 4-6 weeks for full effect and may cause initial activation. Therapy referral offered. Caffeine reduction discussed. Follow-up in 2-4 weeks. Return precautions reviewed.

.ANXIETYPANIC Panic disorder with [frequency] panic attacks. No cardiac red flags; [ECG normal if done]. Safety assessment negative. Starting [sertraline 12.5 mg] daily with slow titration. Discussed nature of panic attacks (not dangerous, will pass). Breathing techniques reviewed. Therapy referral for CBT with interoceptive exposure. Follow-up in 2 weeks.

.ANXIETYFOLLOWUP Anxiety follow-up. GAD-7 today: [X] (previous: [Y]). [Improved / stable / worsened]. Current medication: [drug, dose]. [Tolerating well / side effects: X]. Plan: [continue current regimen / increase dose / add therapy / switch medication / refer to psychiatry]. Follow-up in [timeframe].

Related pages#

• Generalized Anxiety Disorder (problem) — comprehensive ongoing management of GAD
• Panic Disorder (problem) — comprehensive ongoing management of panic disorder
• Depression — often comorbid; similar treatment
• Insomnia — anxiety commonly disrupts sleep
• Palpitations — anxiety as cause of palpitations
• Chest pain — panic attacks in differential
• Substance use — anxiety and substance use often co-occur