Patient handout

Anxiety Disorders (GAD / panic / social anxiety / specific phobia / agoraphobia) — chronic stepwise + acute panic (APA Panic 2009; NICE NG185 2024; CANMAT 2014 Katzman PMID 25081580)

PRODUCTION

1. Your condition

This handout is for anxiety disorders (gad / panic / social anxiety / specific phobia / agoraphobia) — chronic stepwise + acute panic (apa panic 2009; nice ng185 2024; canmat 2014 katzman pmid 25081580). Your care team identified this based on: excessive worry / anxious apprehension difficult to control ≥6 months (dsm-5-tr 2022 gad criterion a; f41.1).

Other reasons your team may use this plan: recurrent unexpected panic attacks + persistent concern about additional attacks (dsm-5-tr 2022 panic disorder criterion a; f41.0); marked fear / anxiety about social situations with possible scrutiny ≥6 months (dsm-5-tr 2022 social anxiety disorder; f40.10); marked fear / avoidance of specific object or situation (dsm-5-tr 2022 specific phobia; f40.2x).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
escitalopram	5–10 mg PO daily	PO	once daily	Most effective SSRI per Cipriani Lancet 2018 NMA PMID 29477251; FDA-approved for adolescent GAD (12-17); favourable tolerability + interactions; QTc concern at higher doses
sertraline	25 mg PO daily × 1-2 wk → 50 mg → titrate; START LOW for panic disorder	PO	once daily	Cipriani 2018 — among most effective + tolerable; preferred in pregnancy + lactation; start low for panic disorder (initial activation may worsen panic — pre-counsel; Pollack 2009 NEEDS_SOURCE_REVIEW); FDA-approved for pediatric OCD
paroxetine	10 mg PO daily × 1 wk → 20 mg → titrate	PO	once daily	Effective across anxiety disorders but anticholinergic + significant discontinuation syndrome (highest withdrawal burden — Horowitz 2019 NEEDS_SOURCE_REVIEW) — AVOID in pregnancy (FDA Category D cardiac teratogenicity) + tamoxifen co-Rx (FDA 2011 CYP2D6); Stein 2009 NEEDS_SOURCE_REVIEW social anxiety FDA-label anchor
fluoxetine	10–20 mg PO daily (mornings to avoid insomnia)	PO	once daily	Long half-life buffers missed doses + reduces discontinuation syndrome; activating — may worsen panic if started high; FDA-approved for pediatric OCD; AACAP 2007 CBT + SSRI combination first-line (Walkup CAMS NEJM 2008 NEEDS_SOURCE_REVIEW)
fluvoxamine	50 mg PO QHS × 1 wk → titrate	PO	once daily QHS or BID	FDA-approved for OCD pediatric + adult; high CYP1A2 / CYP2C19 interaction burden; useful when OCD-spectrum features predominant
citalopram	10–20 mg PO daily	PO	once daily	Effective; FDA 2012 QTc warning caps dose 20 mg in elderly
venlafaxine	37.5–75 mg PO daily (XR)	PO	once daily	FDA-approved for GAD + social anxiety + panic disorder; HTN at higher doses — monitor BP; severe discontinuation syndrome — taper (CANMAT 2014 Katzman; Horowitz 2019 NEEDS_SOURCE_REVIEW)
duloxetine	30 mg PO daily × 1 wk → 60 mg	PO	once daily	FDA-approved for GAD; SNRI with neuropathic-pain + fibromyalgia indication; LFT monitoring (CANMAT 2014; APA Panic 2009)

Plan: Anxiety stepwise pharmacotherapy ladder — Step 1 SSRI/SNRI → Step 3 augmentation (APA Panic 2009; NICE NG185 2024; CANMAT 2014 Katzman PMID 25081580)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Doing well — GAD-7 <5, no SI, functioning at baseline (APA Panic 2009; CANMAT 2014)

If you have:

Worry / anxiety / panic-attack frequency at baseline (DSM-5-TR 2022)
Sleep + appetite + concentration intact (DSM-5-TR 2022)
No suicidal thoughts (C-SSRS; Posner 2011)
Engaging with usual activities and relationships (APA Panic 2009)

Do this:

Take SSRI / SNRI as prescribed every day — do not stop suddenly (APA Panic 2009; CANMAT 2014)
Continue therapy / coping practices — exposure homework, breathing exercises, sleep schedule, exercise, caffeine reduction (CANMAT 2014)
Keep follow-up appointments (APA Panic 2009)
Keep crisis line numbers (988 US) available even when feeling well (VA/DoD 2022)
Maintain consistent sleep-wake schedule; minimise alcohol and recreational drugs

YELLOW — Caution — GAD-7 rising or 5–14, return of symptoms, increased panic frequency, passive SI without plan (APA Panic 2009)

If you have:

Worry difficult to control returning; increased on-edge feeling (DSM-5-TR 2022)
Panic attacks reappearing (DSM-5-TR 2022)
Avoidance of situations expanding (specific phobia / social anxiety / agoraphobia)
Sleep / appetite / concentration declining (DSM-5-TR 2022)
Passing thoughts that life is not worth living without intent or plan (C-SSRS; Posner 2011)
Increased alcohol or substance use, or self-medicating with leftover benzodiazepines (VA/DoD 2022)
Withdrawal from supports (APA Panic 2009)

Do this:

Use coping strategies — panic-attack breathing (4-7-8 or box breathing), grounding (5-4-3-2-1 senses), exposure-hierarchy homework, call a support person (CANMAT 2014; APA Panic 2009)
Contact your provider for an early appointment — within 1 week (APA Panic 2009)
Review medication adherence with provider — consider dose increase or augmentation if at adequate dose ≥4-6 weeks (CANMAT 2014)
Avoid means of self-harm — lock or remove firearms; secure or limit medications to short supply (VA/DoD 2022)
Do NOT self-escalate benzodiazepine — call provider first to discuss (NICE NG185 2024; FDA 2016 black-box)

Call your provider if:

Symptoms not improving after 2 weeks of self-care (APA Panic 2009)
GAD-7 rises by ≥5 points (Spitzer 2006)
Any thoughts of suicide become more frequent (VA/DoD 2022)
Functioning at work / home declines (APA Panic 2009)
Considering self-escalating benzodiazepine dose (NICE NG185 2024)

RED — Medical alert — active SI with intent or plan, severe benzo withdrawal with delirium / seizure features, severe panic with chest pain in middle-aged / older adult (APA Panic 2009; VA/DoD 2022)

If you have:

Specific thoughts of how to end your life (C-SSRS; Posner 2011)
Access to means — firearms, large-quantity meds (VA/DoD 2022)
Recent self-harm or attempt (APA Panic 2009)
Severe panic with chest pain / shortness of breath / arm pain — could be cardiac, not panic; treat as cardiac until proven otherwise (APA Panic 2009; AHA / ACEP)
Severe shaking, confusion, hallucinations, sweating, racing heart after stopping or reducing benzodiazepines suddenly — possible life-threatening withdrawal
Inability to keep yourself safe (APA Panic 2009)

Do this:

Call 988 (US) / your local crisis line / emergency services NOW (VA/DoD 2022)
Go to the nearest emergency department; do not be alone (APA Panic 2009)
Hand any means (firearms, pills) to a trusted person before going (VA/DoD 2022)
Tell someone you trust what is happening (Stanley-Brown 2012)
Do not use alcohol or non-prescribed substances (APA Panic 2009)
If severe benzo withdrawal suspected — do NOT abruptly stop further; go to ED + bring medication list (NICE NG185 2024)

Call your provider if:

Any red zone trigger — emergency department immediately, do not wait (APA Panic 2009; VA/DoD 2022)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

C-SSRS positive for active SI with intent, plan, or recent preparatory behaviour in anxiety patient (especially with comorbid MDD — ~50% co-occurrence; anxiety alone modestly elevates SI; comorbid MDD substantially elevates)
Treatment-resistant anxiety = failure of ≥2 adequate trials of SSRI / SNRI from different classes at adequate dose × adequate duration (≥4-8 wk at therapeutic dose — anxiety responds slower than depression, full 8 wk often needed). Pseudo-resistance (subtherapeutic dose / inadequate duration / non-adherence / unrecognised bipolar / medical mimic — TSH, cardiac, pheo, hypoglycemia, caffeine, stimulant, substance withdrawal) must be ruled out FIRST
Patient on benzodiazepine ≥4-6 wk regular use with abrupt cessation OR rapid taper → seizure / DT-like delirium / hyperadrenergic / autonomic instability / hallucinations / hypertensive crisis. Symptoms may emerge 1-3 d after short-half-life benzo cessation (alprazolam, lorazepam) or 7-10 d after long-half-life (clonazepam, diazepam). Routes to psych.alcohol_withdrawal.core.v1 management principles (CIWA-Ar adapted; symptom-triggered or scheduled-taper benzo)
Autonomic instability + clonus + hyperreflexia + tremor + hyperthermia + AMS in patient on serotonergic agents (SSRI ± SNRI ± tramadol ± MAOI ± linezolid ± dextromethorphan ± triptans) — Hunter / Sternbach criteria(life-threatening)
GAD-7 ≥15 (severe band) with functional impairment (work / social / sleep / self-care collapse) — combination SSRI / SNRI + CBT mandatory; consider partial-hospital / IOP if functional collapse; psychiatry referral

5. Follow-up

Continue treatment ≥12 mo after remission for first episode (APA Panic 2009; CANMAT 2014 Katzman); ≥2-3 yr or indefinite if recurrent; CBT relapse-prevention reduces relapse 30-50%; lifestyle (caffeine reduction, sleep hygiene, exercise 3-5×/wk × 30 min, alcohol reduction, social engagement)

6. Sources

Guideline: APA Practice Guideline for Panic Disorder 2009 + 2020 update + NICE NG185 2024 + CANMAT 2014 Anxiety (Katzman BMC Psychiatry 2014 PMID 25081580; CANMAT 2024 update referenced — PMID NEEDS_SOURCE_REVIEW) + VA/DoD Anxiety + PTSD CPG 2022