Recognizing Anxiety Disorders in Everyday Family Medicine Practice
Introduction
Specific anxiety disorders are among the most common mental disorders worldwide (1). Three main categories of specific anxiety disorders are distinguished: phobic anxiety disorders, panic disorder, and generalized anxiety disorder (GAD). In the International Classification of Diseases (ICD-10), anxiety disorders are included in the section Neurotic, Stress-Related, and Somatoform Disorders.
The most common anxiety disorders are phobic anxiety disorders (F40). Specific phobias are the most prevalent subtype, with a 12-month prevalence of approximately 10.3%. However, many affected individuals never seek medical help. Panic disorder is the second most common anxiety disorder, with a 12-month prevalence of approximately 6.0%. Generalized anxiety disorder is the third most common, with a 12-month prevalence ranging from 2.2% to 3.6% (2).
Women are affected by anxiety disorders approximately 1.5–2 times more frequently than men. Anxiety disorders may develop at different stages of life. Specific phobias commonly begin in childhood, on average around the age of 7 years. Social anxiety disorder usually begins during adolescence, while panic disorder most commonly develops around the age of 24 years (3).
The onset of GAD may occur later in life. Among specific anxiety disorders, GAD is unique because its prevalence remains high even among individuals older than 50 years. Anxiety disorders frequently coexist. For example, GAD often occurs together with agoraphobia, panic disorder, and social anxiety disorder.
Only a small proportion of individuals with anxiety disorders seek professional help. According to data from a European study, approximately 20.6% of patients seek treatment. Of these patients, 23% receive no treatment, 19.6% receive psychotherapy alone, 30.8% receive only pharmacological treatment, and 26.5% receive combined psychotherapy and pharmacotherapy (4).
Most Common Anxiety Disorders
Phobic Anxiety Disorders
Patients with phobic anxiety disorders experience anxiety symptoms in specific situations or in response to particular external stimuli, despite the absence of objective danger. These situations trigger fear, tension, and attempts to avoid them.
Agoraphobia (F40.0) involves fear and anxiety related to situations associated with leaving home or being in public spaces. Social phobia (F40.1) manifests as fear of being the center of attention in small groups and is associated with low self-esteem and fear of criticism.
Specific (isolated) phobias (F40.2) are linked to clearly defined situations or objects, such as fear of blood, thunder, heights, darkness, or snakes.
Panic Disorder
Panic disorder (F41.0) is characterized by recurrent, sudden, unexpected, and intense episodes of anxiety known as panic attacks. These episodes are not linked to specific situations or objects and therefore cannot be predicted.
Panic attacks may lead to avoidance behaviors, eventually contributing to the development of agoraphobia. Between panic attacks, patients frequently experience anticipatory anxiety.
Typical panic attack symptoms include rapid heartbeat, shortness of breath, dizziness, numbness in the body or limbs, and blurred vision. Individuals often experience intense fear of death, insanity, or losing self-control.
Generalized Anxiety Disorder
The main feature of generalized anxiety disorder (F41.1) is persistent anxiety related to various aspects of everyday life, often referred to as free-floating anxiety.
In GAD, anxiety is chronic, excessive, disproportionate to actual circumstances, pervasive across multiple life domains such as health, finances, and future prospects, difficult to control, and accompanied by nonspecific somatic and psychological symptoms.
Somatic symptoms may include tension-type headaches, muscle pain, back pain, rapid fatigue, sweating, tachycardia, and gastrointestinal discomfort. Psychological symptoms commonly include insomnia, irritability, and impaired concentration.
Patients often live with a constant sense of vague fear, apprehension, and impending doom, such as persistent worries that something bad will happen or that a loved one may become ill.
The course of GAD is usually chronic and may last for many years or even decades. GAD occurs more frequently in women than in men (5). Two onset periods are commonly distinguished: early adulthood and later adulthood, with the latter often associated with chronic somatic illnesses (6). Most patients with GAD are between 45 and 55 years old (7).
Although diagnostic criteria require symptoms to persist for at least 6 months, many patients wait years before seeking medical help. GAD is characterized by a fluctuating course, with periods of improvement and exacerbation, while spontaneous remission is relatively rare.
Because GAD often manifests through chronic nonspecific somatic complaints, patients usually seek help first from general practitioners rather than psychiatrists. GAD is considered the most common anxiety disorder encountered in primary care. Studies indicate that patients with GAD account for approximately 7–8% of all consultations in general practice (8).
Somatic complaints frequently dominate the clinical picture, leading to underrecognition of anxiety disorders. In children, GAD often initially presents with abdominal pain and digestive disturbances (9).
Up to 60% of GAD cases are accompanied by depression (10). In these situations, symptoms such as anhedonia, hopelessness, and characteristic circadian mood fluctuations, including worsening mood during the first half of the day, may also occur.
A common clinical pattern involves chronic fluctuating anxiety with alternating periods of improvement and worsening, while stressful life events may trigger depressive episodes.
The development of GAD is influenced by hereditary factors (11). One characteristic psychological feature of patients with GAD is intolerance of uncertainty, meaning a tendency to react negatively to situations with unclear or unpredictable outcomes (12). Cognitive behavioral therapy interventions for GAD are therefore often focused on improving tolerance of uncertainty.
Diagnosis
According to the scope of practice for family physicians, general practitioners (GPs) can independently diagnose and treat anxiety disorders. Therefore, in patients presenting with headaches of unclear origin, muscle pain, back pain, digestive complaints, or insomnia, it is useful to assess whether sufficient criteria for diagnosing a specific anxiety disorder are present.
In Lithuania, the ICD-10-AM classification system is used and should be followed when diagnosing specific anxiety disorders.
When diagnosing phobic anxiety disorders, including agoraphobia, social phobia, and specific phobias, all three of the following criteria must be present:
• anxiety symptoms must be primary and not secondary to other symptoms such as delusions or intrusive thoughts;
• anxiety must be triggered by a specific situation, for example crowds, public places, leaving home, or traveling alone in agoraphobia, and social situations in social phobia;
• avoidance of phobic situations must occur.
According to ICD-10-AM diagnostic criteria, panic disorder can only be diagnosed when specific phobias are absent. Panic attacks occurring in phobia-related situations are considered manifestations of phobic anxiety disorder severity rather than a separate diagnosis.
To diagnose panic disorder, several severe anxiety attacks must have occurred over approximately one month:
• in situations that are objectively not dangerous;
• attacks must not occur exclusively in known or predictable situations;
• between panic attacks, the patient should experience minimal anxiety symptoms.
The ICD-10-AM classification states that GAD symptoms usually persist for several consecutive months and typically include:
• a sense of impending doom, including anxiety about future failures and difficulty concentrating;
• muscle tension, including tension headaches, inability to remain still, tremors, and inability to relax;
• autonomic hyperactivity, including dizziness, sweating, tachycardia, increased breathing, epigastric discomfort, weakness, and dry mouth.
In the DSM-5 classification, GAD symptoms must persist for at least 6 months, significantly impair daily functioning, and include at least 3 of the following 6 symptoms. In children, only one symptom is required for diagnosis:
• restlessness;
• rapid fatigue;
• difficulty concentrating;
• emotional irritability;
• muscle tension;
• sleep disturbances.
To more accurately evaluate treatment indications in suspected GAD, the use of a structured questionnaire is recommended (Table 1) (13).
Table 1. GAD questionnaire| Have you experienced the following symptoms during the past 2 weeks? | Never | A few days | More than half the time | Almost every day |
| Anxiety, nervousness, feeling overwhelmed | 0 | 1 | 2 | 3 |
| Inability to control worrying | 0 | 1 | 2 | 3 |
| Excessive worry about different situations | 0 | 1 | 2 | 3 |
| Inability to relax | 0 | 1 | 2 | 3 |
| Inability to remain calm in one place | 0 | 1 | 2 | 3 |
| Becoming irritable or easily annoyed | 0 | 1 | 2 | 3 |
| Fearing that something terrible may happen soon | 0 | 1 | 2 | 3 |
• 5–9 points – mild anxiety; monitoring is recommended.
• 10–14 points – moderate clinically significant anxiety; further assessment is recommended and treatment may be considered if necessary.
• 15–21 points – severe clinically significant anxiety; treatment is likely necessary.
When GAD is suspected, it is important to ask patients whether they use alcohol or sedatives to relieve anxiety symptoms. It is also recommended to assess symptoms of depression and suicide risk.
If alcohol abuse is present, complete abstinence is strongly recommended because GAD symptoms overlap with alcohol withdrawal symptoms, making accurate diagnosis and treatment evaluation more difficult (14). GAD symptoms and indications for antidepressant treatment can only be reliably assessed after 1–4 weeks of complete sobriety.
Treatment
Specific anxiety disorders should be treated when diagnostic criteria regarding symptom duration and severity are met, meaning symptoms persist for a prolonged period, cause distress, and significantly impair daily functioning or occupational activities.
Another indication for treatment is the presence of complications associated with anxiety disorders, including depression, suicidal thoughts, alcohol abuse, or sedative misuse.
In milder cases, psychoeducation regarding lifestyle modification, relaxation techniques, stress management, and the relationship between anxiety disorders and somatic sensations may be sufficient.
The first-line psychotherapeutic treatment for specific anxiety disorders is cognitive behavioral therapy. First-line pharmacological treatment consists of antidepressants, while benzodiazepines are considered second-line treatment.
Although treatment recommendations may initially appear straightforward, clinicians frequently encounter practical questions regarding treatment selection and management. Several of these issues are discussed below.
Can Family Doctors Treat Anxiety Disorders and What Medications Can They Prescribe?
According to the established scope of practice, family doctors are allowed to treat panic and anxiety disorders, geriatric mental disorders such as Alzheimer’s disease and geriatric dementia, depressive syndromes, somatoform disorders, and may initiate treatment for chronic mental illnesses while continuing treatment following specialist consultation.
The relevant diagnostic codes include F40–43, F45, F32, F33, and R45.
Which Guidelines Should Family Doctors Follow?
When treating short-term moderate anxiety, anxiety accompanied by depressive symptoms, panic disorder with or without agoraphobia, family doctors should follow methodologies approved by the Ministry of Health of the Republic of Lithuania. If such methodologies are unavailable, physicians should follow institutional guidelines or recommendations approved by Lithuanian or international professional associations and adopted within the healthcare institution.
When prescribing reimbursable treatment, physicians must follow the Ministry of Health order On the Approval of the Procedure for Outpatient Treatment of Depressive and Mood (Affective) Disorders with Reimbursable Medicines (September 6, 2012, No. V-841).
Specific anxiety disorders are generally recommended to be initially treated with psychotherapy. Pharmacological treatment should be considered if psychotherapy alone is insufficient. However, combined psychotherapeutic and pharmacological treatment is often necessary.
It was previously believed that the effects of psychotherapy in anxiety disorders persist longer than those of pharmacological treatment. However, naturalistic studies have shown that relapse may occur following both medication and psychotherapy.
When selecting treatment methods, patient preferences should always be taken into consideration. Individual treatment approaches are discussed in greater detail below.
Psychotherapy
Among psychotherapeutic approaches, the strongest evidence for the treatment of specific anxiety disorders has been accumulated for cognitive behavioral therapy (CBT) interventions (15).
CBT principles are based on the assumption that patients with generalized anxiety disorder tend to overestimate potential risks, have difficulty tolerating uncertainty, and underestimate their ability to cope with difficulties. Through cognitive restructuring and behavioral exposure techniques, CBT aims to modify dysfunctional beliefs, reduce avoidance behavior, and teach relaxation strategies.
In panic disorder, particular emphasis is placed on educating patients about the mechanisms underlying panic attacks in order to reduce avoidance behavior. Gradual exposure techniques are also commonly applied.
In social anxiety disorder, treatment focuses on changing dysfunctional core beliefs related to social evaluation and self-perception.
Because specific anxiety disorders frequently disrupt sleep, patients are also encouraged to learn sleep hygiene principles.
One of the main barriers to broader implementation of CBT remains limited accessibility to this treatment method.
Pharmacological Treatment
Antidepressants
Antidepressants are considered first-line pharmacological treatment for specific anxiety disorders (23). Successful treatment with antidepressants not only helps reduce anxiety symptoms but may also lower the risk of developing depression.
Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are recommended as first-choice medications. Treatment response is achieved in approximately 30–50% of cases (16). No single medication has demonstrated clear superiority over others (17).
The same doses used for depression treatment are generally prescribed for anxiety disorders, and therapeutic response can usually be expected after approximately 4–6 weeks of treatment (18).
Patients should be informed that adverse effects and temporary worsening of anxiety symptoms may occur during the first two weeks of treatment (19). Patients with panic disorder are particularly sensitive to the initial activating effects of antidepressants. To reduce this risk, treatment may be initiated at half the dose commonly used for depression and gradually increased depending on tolerability. Benzodiazepines (BZDs) may also be temporarily prescribed during the initial treatment phase.
Some antidepressants, including paroxetine, fluvoxamine, and fluoxetine, strongly inhibit cytochrome P450 enzymes, which is clinically relevant in patients using multiple medications.
After remission is achieved, treatment should generally be continued for at least one year using the same therapeutic dose (20). Premature discontinuation is associated with increased relapse risk.
Abrupt discontinuation of antidepressants may worsen anxiety symptoms. Patients should therefore be informed about possible discontinuation effects. Antidepressants should be tapered gradually over at least two weeks, although clinical practice often requires a slower reduction schedule.
Withdrawal symptoms associated with antidepressants are usually milder than those caused by benzodiazepines. Among SSRIs, the most pronounced withdrawal symptoms are associated with paroxetine because of its shorter half-life.
The effectiveness of tricyclic antidepressants is considered comparable to that of newer SSRIs and SNRIs. However, newer-generation medications are substantially safer and better tolerated, therefore tricyclic antidepressants are generally reserved for patients who do not respond to other treatments.
Benzodiazepines
Although antidepressants are considered first-line treatment for anxiety disorders, benzodiazepines are frequently used at the beginning of treatment because of their rapid therapeutic effect.
After initiating benzodiazepine treatment, patients often experience rapid calming and reassurance that their symptoms can be effectively controlled. This stabilization may facilitate the initiation of psychotherapy, relaxation techniques, and other treatment approaches.
Because of their rapid onset of action, benzodiazepines remain first-line emergency treatment during panic attacks or episodes of severe acute anxiety.
Indications for benzodiazepine use include short-term treatment of moderate to severe anxiety disorders and anxiety associated with depression. They may also be prescribed for short-term treatment of panic disorder with or without agoraphobia.
Benzodiazepines have a broad spectrum of anxiolytic activity and are effective in treating multiple anxiety disorders, including both GAD and panic disorder. Therefore, medication choice is usually guided by symptom severity rather than by a specific diagnosis.
Unlike antidepressants, benzodiazepines do not initially intensify anxiety symptoms. They also reduce somatic anxiety symptoms more rapidly than antidepressants (21).
Research suggests that 55–94% of patients with anxiety disorders receive benzodiazepine treatment at some stage (22). In Lithuania, the four most commonly prescribed benzodiazepines for anxiety disorders are diazepam, bromazepam, lorazepam, and alprazolam.
Longer-acting benzodiazepines, such as diazepam and extended-release alprazolam, provide more stable symptom control, less anxiety between doses, reduced risk of misuse and dependence, and fewer withdrawal symptoms.
Alprazolam has several advantages, including rapid onset of action, which is particularly relevant in panic disorder, and less daytime sedation compared with some other benzodiazepines.
Benzodiazepines should generally be avoided in patients with substance use disorders (24). They should also be used cautiously in older adults because of their negative effects on cognition and increased risk of falls. In elderly patients, the potential harms of benzodiazepines may outweigh their expected benefits (25).
Another group requiring cautious benzodiazepine prescribing includes patients with personality disorders, particularly emotionally unstable personality disorder, and individuals with organic mental disorders. In these populations, benzodiazepines may trigger paradoxical disinhibition and accelerate the development of dependence (26).
Importantly, benzodiazepines do not treat depression itself. They are most useful during the early phase of antidepressant treatment to reduce anxiety and medication-related side effects.
Because of dependence risk, benzodiazepines are recommended for the shortest duration possible. NICE guidelines recommend limiting benzodiazepine use in GAD treatment to no longer than 2–4 weeks (17), although some sources mention durations of 3–6 months in selected cases (25).
Before prescribing benzodiazepines, clinicians should determine the planned treatment duration. If anxiety is situational and linked to temporary stressors likely to resolve quickly, such as adjustment disorders, a short course of benzodiazepine monotherapy lasting several weeks may be appropriate. Later, these medications may be prescribed for occasional as-needed use.
Benzodiazepines may also be prescribed during the initial phase of antidepressant treatment until the therapeutic effect becomes evident.
In chronic anxiety disorders, benzodiazepines effectively suppress symptoms, but symptoms often recur after discontinuation. Therefore, antidepressants are preferred for long-term treatment.
If prolonged benzodiazepine use remains necessary because of inadequate response to antidepressant monotherapy, treatment may continue for approximately six months after symptom resolution, followed by gradual discontinuation (25).
If anxiety symptoms recur, benzodiazepines may be restarted, antidepressants prescribed, or combination therapy considered. In such situations, longer-acting benzodiazepines are generally preferred because they provide more stable effects and reduce rebound anxiety between doses.
Common Clinical Questions About Benzodiazepines
How Long Can a Family Doctor Prescribe Benzodiazepines for Anxiety Treatment?
Formally, benzodiazepine treatment duration depends on treatment and diagnostic algorithms approved within the healthcare institution. According to alprazolam prescribing information, panic disorder treatment may continue for up to 8 months, although prescribing duration should follow institutional treatment protocols.
When Should Drug Dependence Be Suspected?
Signs of dependence include:
• development of tolerance requiring increasing doses;
• withdrawal symptoms after dose reduction or discontinuation;
• intense craving for the medication;
• continued use despite clear harmful consequences.
In dependence, worsening condition is often caused not by recurrence of the primary disorder but by dose reduction or discontinuation. Therefore, early recognition of emerging benzodiazepine dependence is clinically important.
What Should Be Recommended to Patients Who Have Used Benzodiazepines for Many Years?
Some patients use benzodiazepines for many years without increasing the dose and are unable or unwilling to discontinue treatment. In such situations, clinicians must individually evaluate the balance between benefits and risks.
Some authors suggest maintaining stable doses without escalation rather than forcing discontinuation. However, because benzodiazepines may cause dizziness, falls, muscle relaxation, urinary retention, constipation, and cognitive impairment in elderly patients, safer alternatives such as antidepressants or atypical antipsychotics should also be considered.
How Often Can Benzodiazepine Treatment Be Renewed?
Because no universally applicable recommendations exist, clinicians are advised to follow treatment methodologies and prescribing algorithms approved within their healthcare institution to ensure clarity and patient safety.
Other Medications
In addition to antidepressants and benzodiazepines, specific anxiety disorders may also be treated with medications from other pharmacological groups, including pregabalin and quetiapine, which may be effective in patients with generalized anxiety disorder.
Pregabalin may improve sleep quality and has a faster onset of action than antidepressants. Because it is not metabolized in the liver, it has a lower risk of pharmacokinetic interactions with other medications. NICE guidelines recommend pregabalin as a second-line treatment option for GAD (17).
When prescribing quetiapine, clinicians should consider its potential adverse effects on metabolic parameters and regularly monitor body weight.
Beta-blockers may help reduce somatic anxiety symptoms such as tachycardia and tremor.
When Should a Patient Be Referred to a Specialist?
If anxiety symptoms cannot be adequately controlled, if there is uncertainty regarding the diagnosis, or if long-term treatment exceeding 6 months is planned, the family doctor should refer the patient for psychiatric consultation.
Referral to a psychiatrist is also recommended when comorbid conditions are suspected, including:
• depression;
• alcohol or sedative dependence;
• suicide risk;
• ineffective treatment response;
• adverse drug reactions requiring treatment modification.
Treatment Resistance
If adequate therapeutic effect is not achieved during treatment of specific anxiety disorders, it is important to reassess whether the correct diagnosis has been established, whether comorbidities such as addiction disorders or personality disorders are present, and whether the medication dose and treatment duration are sufficient.
Treatment effectiveness may also be reduced by concomitant medication use and unfavorable psychosocial factors.
Medication changes are generally recommended only if no improvement is observed after 4–6 weeks of treatment.
If treatment remains ineffective, switching to an antidepressant from a different pharmacological class is recommended. In cases of partial improvement, increasing the dose of the same antidepressant may be appropriate.
Older patients often respond more slowly to treatment. In this population, clinicians should carefully consider potential drug interactions, anticholinergic adverse effects, orthostatic hypotension, increased fall risk, and paradoxical reactions to benzodiazepines.
The effectiveness of CBT in elderly patients is also generally lower compared with younger individuals.
Summary
Patients with specific anxiety disorders most commonly seek help from family doctors because these disorders frequently manifest through nonspecific somatic complaints.
Specific anxiety disorders, especially generalized anxiety disorder, are often chronic conditions that can significantly impair functioning and, if left untreated, may contribute to the development of addiction or depressive disorders.
Therefore, accurate diagnosis and timely effective treatment are essential.
The primary first-line treatment approaches for specific anxiety disorders are psychotherapy, particularly cognitive behavioral therapy, and antidepressants.
Benzodiazepines are recommended only for short-term use and in the absence of contraindications such as substance use disorders. These medications should be prescribed especially cautiously in elderly patients.
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