Treatment Guidelines for Generalized Anxiety Disorder and Panic Disorder in Adults

 

Britain’s National Institute for Clinical Excellence (NICE) has a reputation for research-based clinical guidance that is untainted by big pharmaceutical money. The NICE guidelines are considered so well-researched that they are adopted by Britain’s National Health Service.

The guidelines for working with adults with Generalized Anxiety Disorder (GAD) stress several well-founded principles of good psychotherapy treatment in general: informing patients of treatment options, giving them a voice in choosing which options, and giving them as much information as possible about GAD and about treatment. Because feelings of powerlessness often accompany GAD, giving the patient complete information and co-ownership of the process, including choosing treatment options, may by itself be an important starting point in encouraging a greater feeling of agency and thereby helping to mitigate the often overpowering feelings of powerlessness that accompany GAD. In accordance with this principle, in 2011 NICE added to the guidelines the advisability of providing a translator when needed. The NICE guidelines also recommend working with the families of the identified patient. Anxiety can make everyone around the patient more anxious, which can create an echo chamber of anxiety. Therefore, NICE recommends not only involving family but also giving patients local resources such as self-help groups and encouraging patients to utilize them as well as seeking therapy.

NICE recommends a stepped (or algorithm) model for treating GAD. Step One reminds psychotherapists and physicians that GAD does not always present itself clearly as anxiety but may be masked by somatic or psychological comorbid symptoms. People who come in complaining about a variety of symptoms should be assessed for GAD, even if they are not specifically complaining about anxiety. This does not mean that, if the psychotherapist identified GAD as an underlying or unexpressed disorder, the psychotherapist should target GAD for treatment. Instead, those symptoms which the client complains about, including substance abuse, should be primarily addressed. But as part of the assessment, therapists should inquire about any past conditions and treatments the client has had and assess their effectiveness. A history of a wide variety of complaints and of ineffective treatments may help confirm the existence of GAD. In such cases, without ignoring or overriding those symptoms which the client complains about, psychoeducation about GAD might be utilized. Following an assessment of GAD, clients should be what NICE refers to as “actively monitored.” Paying attention to the symptoms on a regular basis may be sufficient enough to effectively treat milder cases of GAD.

If the combination of active monitoring and psychoeducation does not sufficiently treat the GAD, NICE recommend moving to the second step of low intensity CBT psychological interventions. Thee may include self-help, often delivered via the internet or workbooks (with such limited psychotherapist contact as an occasional under five-minute phone call), guided self-help (eg., closer monitoring by a psychotherapist), and/or psychoeducational group therapy. The guided self-help should include five to seven weekly or biweekly face-to-face, telephone or video sessions of about 20 to 30 minutes each. The psychoeducational groups should consist of one therapist for approximately 12 group members and six weekly sessions of two hours each.

If there is not sufficient improvement, Step Three involves more intensive psychotherapy utilizing CBT and/or relaxation training. The therapy should consist of 12-15 one hour weekly sessions. If the client prefers medication, NICE recommends an SSRI, preferably sertraline. A second alternative is an SSNRI. As with all medications, one should inquire about any past experiences, especially negative ones) with the med and monitor clients carefully for worsening of the anxiety or suicidal thoughts. Significantly, NICE does not recommend minor tranquilizers, benzodiazepines or antipsychotic medications for treating GAD.

In the unlikely event that Steps One through three do not produce sufficient results, Step Four recommends a GAD specialist. The specialist should do a complete review and assessment, including an assessment of the family, home, and community. NICE cautions that in cases in which GAD has not been alleviated by Steps One through Three, the treatment and the disorder require such complexity of understanding and treatment that only thoroughly trained specialist in dealing with GAD should be utilized.

NICE also presents a stepped treatment model for Panic Disorder (PD). As with the step model for GAD, it stresses giving the client as much information as possible about the disorder, including treatment options. It advises including the client’s family in this psychoeducation. NICE cautions against over-medicalizing treatment of PD. If clients complain of chest pain and a cardiac examination reveals no heart problems, the patient should be encouraged to seek psychological treatment in Step Two.

Step Two should involve psychotherapy, medication and/or self-help, all of which have solid empirical support for treating PD. The psychotherapy, according to NICE, should be CBT delivered in weekly sessions of one to two hours. Regarding medications, as with GAD, NICE recommends an SSRI and does not recommend benzodiazepines or antipsychotic medications. If the SSRI does not work, imipramine or clomipramine, older tricyclic antidepressants, should be used.

For the complete NICE guidelines for GAD and PD, see https://www.nice.org.uk/guidance/cg113/chapter/1-Guidance