anxiety manual

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Clinical Practice Guideline

or Treatment o Patientswith Anxiety Disordersin Primary Care

CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS

MINISTRY OF HEALTH AND CONSUMER AFFAIRS


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Clinical Practice Guideline

or Treatment o Patientswith Anxiety Disordersin Primary Care

CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS

MINISTRY OF HEALTH AND CONSUMER AFFAIRS


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This CPG is a healthcare decisin making supprt. It is nt mandatr, and it is nt a substitute r the clinical

judgement healthcare persnnel.

Published b:

Agencia Lan Entralg. Unidad de Evaluacin de Tecnlgas Sanitarias

Gran Va, 2728013 Madrid

Espaa-Spain

r this editin: Ministr Health and Cnsumer Aairs

r cntent: Health and Cnsumptin Bard. Regin Madrid

Laut and printing: www.cege.es El Gnzal, 25, 1 izda. 28010 Madrid


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This CPG has been unded thrugh the agreement signed b the Carls

III Health Institute, an independent bd the Ministr Health and

Cnsumer Aairs, and the Health Technlg Assessment Unit the LanEntralg Agenc (Regin Madrid) within the ramewrk cllabratin

as part the Qualit Plan r the Natinal Health Sstem.

This guideline must be quted:

Guideline Wrking Grup r the Treatment Patients with Aniet Disrders in Primar Care. Madrid: Natinal Plan rthe NHS the MSC. Health technlg Assessment Unit. Lan Entralg Agenc. Cmmunit Madrid; 2008. Clinical

Practice Guidelines in the NHS. UETS N 2006/10.


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CLINICAL PRACTICE GUIDELINE oR TREATMENT o PATIENTS WITH ANxIETy DISoRDERS IN PRIMARy CARE 5

Table of contents

Ofcial presentation 7

Authors and collaborators 9

Questions to be answered 11

Summary of recommendations 13

1. Introduction 20

2. Scope and objectives 25

3. Methodology 26

4. Denition, clinical features and classications 28

4.1. Nrmal and pathlgical aniet 28

4.2. Classifcatins 29

5. Diagnosing anxiety 32

5.1. Diagnstic criteria 32

5.2. Semi-structured interview 45

5.3. Use scales 46

5.4. Diagnstic algrithm 49

6. Treating anxiety 506.1. Pschlgical treatment 50

6.1.1. Generalized Aniet Disrder (GAD) 52

6.1.2. Panic Disrder with r withut agraphbia (PD) 56

6.1.3. Panic attack 61

6.2. Pschlgical techniques r Primar Care setting 62

6.3. Pharmaclgical treatment 66

6.3.1. Generalized Aniet Disrder (GAD) 66



6.4. Cmbined treatment: pschlgical and pharmaclgical therapies 826.4.1. Generalized Aniet Disrder (GAD) 83



6.5. other treatments 88

6.5.1. Sel-help treatment 88

6.5.2. Herbal medicine 91

7. Information/communication with the patient 94


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CLINICAL PRACTICE GUIDELINES IN THE SPANISH NHS 6

8. Diagnostic and therapeutic strategies 96

8.1 Generalized Aniet Disrder (GAD) 97

8.2. Panic Disrder (PD) 99

8.3. Panic Attack 101

9. Dissemination and implementation 102

10. Recommendations for future research 105

11. Appendices 108

Appendi 1. Levels evidence and grades recmmendatin (SIGN) 108

Appendi 2. Aniet measurement instruments 109

Appendi 3. Interview questins t screen r aniet smptms and specifcaniet disrders 112

Appendi 4. Inrmatin r the patient 113

Appendi 5. Glssar and abbreviatins 129Appendi 6. Declaratin interest 134

12. Bibliography 138


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Ocial presentation

Care practice is becoming more and more complicated due to many dierent actors. One o themost relevant actors is the exponential increase o scientic inormation.

To make clinical decisions that are adequate, sae and eective, practitioners need to devotea lot o eort in continuously updating their knowledge.

In 2003, the Interterritorial Council o the Spanish NHS created the GuiaSalud Projectwhose nal aim is to improve clinical decision-making based on scientic evidence, via trainingactivities and the conguration o a registry o Clinical Practice Guidelines (CPG). Since then, theGuiaSalud project has assessed dozens o CPGs in agreement with explicit criteria stipulated byits scientic committee, it has registered them and has disseminated them over the Internet.

At the beginning o 2006, the Directorate General o the Quality Agency o the National

Health System prepared the Quality Plan or the National Health System, which was divided into12 strategies. The purpose o this Plan is to increase the cohesion o the National Health Systemand help guarantee maximum quality health care or all citizens regardless o their place o resi-dence.

Within that context, the GuiaSalud Project was renewed in 2007 and the Clinical PracticeGuideline Library was created. This project developed into the preparation o the CPGs and in-cluded other Evidence-Based Medicine services and products. It also aims to avour the imple-mentation and assessment o the use o CPGs in the National Health System.

A rst step was to commission dierent agencies and expert groups in prevalent pathologiesrelated to health strategies to prepare eight CPGs. This Anxiety guideline is the consequence o

this assignment.The denition o a common methodology to prepare the CPG or the NHS was also re-

quested and this has been prepared as a collective eort o consensus and coordination amongthe Spanish CPG expert groups. This methodology was used as the basis to prepare this Anxietyguideline and the other CPGs driven by the Quality Plan.

It is widely acknowledged that mental disorders constitute a signicant social and economicburden due to their requency, coexistence, and comorbidity, in addition to the disability that theygenerate.

Within the area o mental health problems, anxiety disorders are associated with high lev-els o disability and have a considerable impact on personal well-being as well as on social and

labour relations. The aggravating actor o the prevalence o these disorders and the recurrent oreven chronic nature o many o these disorders makes them as incapacitating as any other chronicillness.

Anxiety disorders, alone or associated with other pathologies, are one o the most requentcauses o Primary Care visits, and there is a certain degree o variability in how they are man-aged. The lack o a common pattern o maniestation, somatisation and association with chronicillnesses, as well as the need or specic therapy sometimes prolonged over time, increases thecomplexity o the treatment o these patients.

The purpose o the Clinical Practice Guideline or Treatment o Patients with AnxietyDisorders in Primary Care is to provide proessionals with practical recommendations based onscientic evidence to assist in the detection and eective treatment o these disorders, oering

the ideal therapeutic alternatives in each process. The proessionals involved in providing care,


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as well as the patients themselves and scientic organizations were involved in the preparation othis guideline, which seeks to improve the care provided to patients with anxiety disorders and thequality o lie o those patients.

Dr. Alberto Inante Campos

General Director o the Quality Agency o the NHS


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Authors and collaborators

Guideline Development Group on Treatment of Patients with AnxietyDisorders in Primary Care

Antonio Bulbena Vilarrasa, psychiatrist, director Psychiatric Attention InstituteHospital del Mar, Barcelona

Raael Casquero Ruiz, general practitioner and psychiatrist, coordinator o the Las CortesHealth Centre, Madrid

Mara La de Santiago Hernando, general practitioner, Castilla laNueva Health Centre, Fuenlabrada (Madrid)

Ma Isabel del Cura Gonzlez, general practitioner, Mendigucha Health Centre,

Legans (Madrid)Petra Daz del Campo Fontecha, sociologist, Health Technology Assessment Unit(UETS), Agencia Lan Entralgo, Council or Healthcare and Consumption, Madrid

Mercedes Fontecha Cabezas, patient, Madrid

Ana Garca Laborda, mental health nurse, Parla MentalHealth Centre, Madrid

Javier Gracia San Romn, Preventive medicine and public health physician, HealthTechnology Assessment Unit (UETS), Agencia Lan Entralgo,

Council or Healthcare and Consumption, Madrid

Manuel Pereira Fernndez, psychiatrist, head o Latina Mental Health Services,Galiana Mental Health Centre, Madrid

Ma Concepcin Pozo Pino, primary care social worker, Campo de la Paloma HealthcareCentre, Madrid

Violeta Surez Blzquez, clinical psychologist, Majadahonda Healthcare Centre,Madrid

Ma Eugenia Tello Bernab, primary care nurse, El Naranjo Healthcare Centre,Fuenlabrada (Madrid)

Victoria Torralba Castell, primary care nurse, Parque Europa Healthcare Centre, Pinto(Madrid)


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Coordination

Francisco Javier Gracia San Romn and Petra Daz del Campo Fontecha,

Technical support in the Health Technology Assessment Unit (UETS), Madrid

External reviewers

Javier Garca Campayo, psychiatrist and associate proessor at the Miguel ServetUniversity Hospital and the University o Zaragoza

Jos Antonio Castro Gmez, general practitioner,Almanjyar Healthcare Centre, Granada

Vctor Contreras Garca, Madrid Federation o Mental HealthAssociations, Madrid

Marta Alcaraz Borrajo, primary care pharmacist, area 6, Madrid

Rubn Casado Hidalga, psychologist, Madrid Panic and AgoraphobiaAssociation, Madrid

Collaborating scientic societies and institutions

This CPG was supported by the ollowing institutions:

Spanish Neuropsychiatry Association (AEN)

Madrid Panic and Agoraphobia Association (AMADAG)

Spanish Conederation o Family Groups and Individuals with Mental Illness (FEAFES)Madrid Federation o Mental Health Associations (FEMASAN)

Spanish Society o Primary Care Physicians (SEMERGEN)

Spanish Society o Family and Community Medicine (SEMFYC)

Spanish Psychiatric Society (SEP)

Madrid Society o Family and Community Medicine (SoMaMFYC)

Spanish Union o Scientic Nursing Societies (UESCE)

Members o these societies have taken part in the development and external review o this ClinicalPractice Guideline.

Conict o Interest Statement: All o the members o the Working group, as well as all o thepeople who took part in the external review have signed the declaration o interest included inAppendix 6.


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Questions to be answered

Denition, clinical features, and classications

Whatisthedenitionofanxietyasasymptom/syndrome?

Whatisthedenitionofanxietyasaspecicclinicalprole?

Howareanxietydisordersclassied?

Diagnostic criteria

Whatarethediagnosticcriteriaofthedifferentanxietydisorders?

Whatarethecriteriaforsuspectinganxietydisorders?

Whatstudiesshouldbedoneinitiallywithadultssuspectedtosufferanxietydisordersinorder

toallowearlydetection?

AretherekeyquestionsthatcouldhelpPrimaryCareprofessionalstodetectanxietydisorders

inpatientinterviews?

Whatarethedifferentialdiagnosestobetakenintoaccount?

Treatment

Whatisthemosteffectivetreatmentforgeneralizedanxietydisorder?

Whatisthemosteffectivetreatmentforpanicdisorders?

Whatisthemosteffectivetreatmentforpanicattacks?

Information/communication with patients

Whatisthebasicinformationthatshouldbegiventopatientswithanxietydisorders?

Whatisthebasicinformationthatshouldbegiventothefamiliesofpatientswithanxietydis-orders?

Whatisthebestwaytoinformpatientsoftheirdisorders?

Diagnostic and therapeutic strategies

Whatarethestepstobefollowedinresponsetoananxietydisorder(GAD,PD,andpanicat-tack)?

WhatarethecriteriaforreferralfromPrimaryCaretoMentalHealth?


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Dissemination and implementation

Whatisthestrategytodistributeandimplementtheguideline?

Whataretheindicatorsfortrackingthekeyrecommendations?

REFERENCE: Guideline development Group of the Clinical Practice Guideline for the Treatment of Patients with Anxiety Disordersin Primary Care. Clinical Practice Guideline for the Treatment of Patients with Anxiety Disorders in Primary Care Madrid: National

Plan for the NHS of the MSC. Health Technology Assessment Unit. Lan Entralgo Agency. Community of Madrid; 2008. ClinicalPractice Guideline: UETS N 2006/10.


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Summary o recommendations

Psychological treatment

Cognitive-Behavioral Therapy (CBT) or Generalized Anxiety Disorder (GAD)

General recommendations

A

Cognitive-Behavioral Therapy (CBT) is recommended as one o the treatments o choice or Generalized Anxiety Disorder(GAD) due to its eectiveness at reducing the symptoms o anxiety, worry, and sadness, in both the short and long term,although patient preerences must be taken into consideration.

AActions with CBT must include a combination o measures such as cognitive restructuring, exposure, relaxation, andsystematic desensitization.

ACBT should be applied over the course o approximately 10 sessions (6 months) on average, as greater eectiveness is notachieved by applying the therapy or a longer time.

ACBT can be applied individually or in a group, since the eects are similar, although individual treatment generates lowerabandonment rates.

Primary Care

B

The application o cognitive-behavioral actions (relaxation, recognition o anxiety-causing thoughts, and lack o sel-condence, seeking useul alternatives, and training in problem-solving techniques, techniques to improve sleep and workat home) by trained proessionals in healthcare centres is recommended.

BThe organization o group workshops based on relaxation and applicable cognitive techniques in healthcare centres isrecommended.

Group workshops should run or at least 8 sessions (1 per week), be structured and be directed by trained proessionalsrom the Primary Care teams.

Psychological techniques applicable in the context o Primary Care or Generalized

Anxiety Disorder (GAD)

Brie actions in PC should be carried out by trained proessionals and have a series o common characteristics oapplicability:they should be structured, simple, easy to apply, short, with dened times, specic objectives, and describedeectiveness.

The ollowing are recommended as psychological techniques or possible application in PC to reduce anxiety symptomsassociated with GAD:techniques or relaxation, exposure, sel-control, training in social skills, sel-instruction, trainingin treatment anxiety, cognitive distraction and thought stoppage, resolution o problems, cognitive restructuring, andinterpersonal therapy.


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Cognitive-Behavioral Therapy (CBT) or Panic Disorder (PD)


A

Cognitive-Behavioral Therapy (CBT) is recommended as one o the treatments o choice or Panic Disorder (PD) becauseo its eectiveness in improving panic symptoms, quality o lie, and reducing depression systems, although patient

preerences must be taken into consideration.

ACBT actions should include a combination o actions such as psycho-education, exposure to symptoms or situations,cognitive restructuring, techniques or relaxation, breathing, and treatment panic.

A CBT should be applied, on average, in 8-16 weekly sessions o 1 to 2 hours.

BTo relieve symptoms o PD with average or moderate agoraphobia, CBT actions are recommended, including in vivoexposure.

Primary Care

BThe application o cognitive-behavioral actions are recommended or application in healthcare centres by trainedproessionals, preerably individually, through exposure and cognitive restructuring.

BThe organization o group workshops based on relaxation and applicable cognitive techniques in healthcare centres isrecommended.

Group workshops should run or at least 8 sessions (1 per week), be structured and be directed by trained proessionalsrom the Primary Attention teams.

Psychological techniques applicable in the context o Primary Care or Panic Disorder

(PD)

Brie actions in PC should be carried out by trained proessionals and have a series o common characteristics oapplicability:they should be structured, simple, easy to apply, short, with dened times, specic objectives, and describedeectiveness.

The ollowing are recommended as psychological techniques or possible application in PC to reduce anxiety symptomsassociated with PD:techniques or relaxation, exposure, sel-control, training in social skills, sel-instruction, trainingin treatment anxiety, cognitive distraction and thought stoppage, resolution o problems, cognitive restructuring, andinterpersonal therapy.

Cognitive-Behavioral Therapy (CBT) in PC or Panic Attack

The ollowing psychological techniques are recommended in PC to control symptoms related to panic attacks. Behavioral and support measures that include psycho-education:calm the patient and advised actions in writing. Training in the treatment of symptoms:teaching o relaxation techniques and learning breathing exercises to handle

hyperventilation. Exposure techniques.

The amily should be inormed regarding the type o actions to help in resolving any new attacks.


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Pharmacological treatment

Anti-depressants or Generalized Anxiety Disorder (GAD)

A The use o anti-depressants is recommended as one o the pharmacological treatments o choice or GAD.

BIn terms o anti-depressants recommended or use, SSRI (paroxetine, sertraline, or escitalopram), SNSRI (slow-releasevenlaaxine) and TADs (imipramine).

CThe prescription o venlaaxine is not recommended to patients at high risk o cardiac arrhythmia or recent myocardialinarct, and will only be used in patients with hypertension when the hypertension is controlled.

When the response to the optimal dosage o one o the SSRIs is inadequate or i they are not well tolerated, the patientshould switch to another SSRI.I there is no improvement ater 8-12 weeks, consider using another drug with a dierentmechanism o action (SNSRI, TAD).

BDuring pregnancy, the choice o the treatment must consider whether the potential advantages or the mother o theprescribed SSRIs outweigh the possible risks to the etus.

BTo reduce the potential risk o adverse neonatal eects, the lowest eective dose o SSRIs should be used with the shortest

possible treatment duration, as monotherapy.

In prescribing anti-depressants, patients should be inormed o the therapeutic objectives, the duration o the treatment,possible side eects, and the risks o sudden interruption o the t reatment.

The ollowing must be taken into account when prescribing anti-depressants:age, previous treatments, tolerance,possibility o pregnancy, side eects, patient preerences, and cost as well as eectiveness.

Note:The Technical Dossier from the Spanish Agency for Medications and Healthcare Products (AEMPS)142 for sertralinedoes not include the therapeutic indication for GAD.In the case of imipramine (Technical Dossier unavailable), the pro-spectus does not include this indication either.

Benzodiazepines (BDZ) or Generalized Anxiety Disorder (GAD)

B The short-term use o BDZs not longer than 4 weeks is recommended when rapid control o symptoms is not crucial orwhile waiting ro the response to treatment with anti-depressants or CBT.

B The use of the BDZs alprazolam, bromazepam, lorazepam, and diazepam is recommended.

B

To avoid the potential risk o congenital deects, the lowest eective dosage o BDZ should be used, with the shortestpossible treatment duration, and as monotherapy.I higher concentrations are required, the daily dosage should be dividedinto two or three doses, always avoiding use during the rst trimester.

When prescribing BDZs, patients should be inormed o the therapeutic objectives, the duration o the treatment, and thepossible side eects.

The ollowing should be taken into consideration when prescribing BDZ:age, previous treatments, tolerability, possibility opregnancy, side eects, patient preerences, and cost as well as eectiveness.


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Other drugs or Generalized Anxiety Disorder (GAD)

Other drugs

BAzapirones (buspirone) can be used short term, especially in patients with GAD who have not previously taken BDZ,although its use is very limited in Spain.

The use o other drugs such as pregabline, hydroxicine, atypical anti-psychotics, and others, either due to their limitedclinical experience or indication or reractory GAD, should be prescribed ater the patient has been evaluated in a Centrespecializing in Mental Health.

Not recommended

B The use o Beta-blockers (propranolol) is not recommended to treat GAD.

Anti-depressants or Panic Disorder (PD)

A The use o anti-depressants is recommended as one o the pharmacological treatments o choice or PD.

BIn terms o anti-depressants recommended or use, SSRI (cytalopram, escytalopram, fuoxetine, fuvoxamine, paroxetine,

and sertraline), SNSRIs (slow-release venlaaxine) and TADs (chlorimipramine, imipramine).

CThe prescription o venlaaxine is not recommended to patients at high risk o cardiac arrhythmia or recent myocardialinarct, and will only be used in patients with hypertension when the hypertension is controlled.

When the response to the optimal dosage o one o the SSRIs is inadequate or i they are not well tolerated, the patientshould switch to another SSRI.I there is no improvement ater 8-12 weeks, consider using another drug with a dierentmechanism o action (NSRI, TAD, mirtazapine).

BThe interruption o treatment with anti-depressants poses a risk o relapse, so therapy in many patients should be appliedlong-term (at least 12 months).

BDuring pregnancy, the choice o the treatment must consider whether the potential advantages or the mother o theprescribed SSRIs outweigh the possible risks to the embryo.

BTo prevent potential risk o adverse neonatal eects, the lowest eective dose o SSRIs should be used with the shortestpossible treatment duration, with the possibility o use as monotherapy.

In prescribing anti-depressants, patients should be inormed o the therapeutic objectives, the duration o the treatment,possible side eects, and the risks o sudden interruption o the treatment.

The ollowing must be taken into account when prescribing anti-depressants:age, previous treatments, tolerance,possibility o pregnancy, side eects, patient preerences, and cost as well as eectiveness.

Note142:

The Technical Dossier from the Spanish Agency for Medications and Healthcare Products (AEMPS) for venlafaxine,uoxetine, and uvoxamine does not include the therapeutic indication for PD.

The Technical Dossier for chlorimipramine and the prospectus of imipramine (Technical Dossier not available) includesindication for panic attacks, but not panic disorder.


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Benzodiazepines or Panic Disorder (PD)

BI BDZs are used in PD, short-term use is recommended or when crucial due to acute or serious anxiety or agitation, withthe lowest possible dosage, which must be reduced gradually.

B Use or longer periods must always be supervised.

B The BDZs alprazolam, clonazepem, lorazepam, and diazepam are recommended.

B

To avoid the potential risk o congenital deects, the lowest eective dosage o BDZ should be used, with the shortestpossible treatment duration, and as monotherapy i possible. I higher concentrations are required, the daily dosage shouldbe divided into two or three doses, always avoiding use during the rst trimester.

When prescribing BDZs, patients should be inormed o the therapeutic objectives, the duration o the treatment, and thepossible side eects.

The ollowing should be taken into consideration when prescribing BDZs:age, previous treatments, tolerance, possibility opregnancy, side eects, patient preerences, and cost as well as eectiveness.

Note: The Technical Dossier from the Spanish Agency for Medications and Healthcare Products (AEMPS) 142 for clon-azepam does not include the therapeutic indication for PD.

Other drugs or Panic Disorder (PD)

Other drugs

B The use o azapirones (buspirone) is not recommended or treating PD.

The use o other drugs such as pindolol, gabapentin, sodium valproate, and slow-release bupriopion, due to their indicationor reractory PD should be prescribed ater the patient has been evaluated by a Centre specialized in Mental Health.

Not recommended

B The use o tradozone, propanolol, and carbamazepine is not recommended.

Pharmacological treatment or Panic Attack

The BDZs alprazolam and lorazepam may be used or the immediate treatment o serious panic attacks.

B The use o SSRI and TAD anti-depressants is recommended or pharmacological treatment o panic attacks.


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Combined treatment:psychological and pharmacological

Combination treatment (CBT and medication) or Generalized Anxiety Disorder(GAD)

Application within the scope of Primary Care

BThe combined treatment o CBT and diazepam or CBT alone, versus the use o diazepam alone, due to its advantage interms o gravity and overall change o symptoms is recommended, although patient preerences must be taken into account.

BIn combined treatment, such as CBT in healthcare centres, 7 sessions over 9 weeks are recommended, provided by proessionals trained incognitive therapy and progressive muscular relaxation.The patient should also do work at home.

In healthcare centres, combined therapy that includes group actions, cognitive therapy, and relaxation is recommended, withat least 8 sessions (1 per week), carried out in a structured manner and directed by trained proessionals rom the PrimaryCare teams.

Combined treatment (CBT and medication) or Panic Disorder (PD)


AThe combination o CBT (exposure and cognitive restructuring techniques) and anti-depressants (TADs and SSRIs) isrecommended, depending on patient preerences.

ATreatment with anti-depressants alone is not recommended as rst-line treatment, when the appropriate resources toprovide CBT are available.

BIn long-term treatments, i anti-depressant drugs are added to the CBT, they should be monitored to ensure that they do notinterere with the benecial eects o the CBT alone.

Application within the scope of Primary Care

B

In healthcare centres, in combined treatment, the application o cognitive-behavioral actions is recommended in 6-8sessions over the course o 12 weeks, provided by trained proessionals, through brie CBT that includes techniques oexposure and treatment o panic.

In healthcare centres, combined therapy that includes group actions, cognitive therapy, and relaxation is recommended, withat least 8 sessions (1 per week), carried out in a structured manner and directed by trained proessionals rom the PrimaryCare teams.


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Other treatment:bibliotherapy and herbal medicines

Bibliotherapy or Generalized Anxiety Disorder (GAD), Panic Disorder (PD), and Panic

Attack

BThe application o bibliotherapy is recommended based on the principles o CBT in public healthcare centres, by trainedproessionals using sel-help manuals and telephone contact or brie personal contacts.

Herbal Medicine or Generalized Anxiety Disorder (GAD) and Panic Disorder (PD)

B, D

Due to its hepatic toxicity, kava* is recommended only or short-term use and or patients with minor or moderate anxietywho preer to use natural remedies, provided that they do not have any prior hepatic alterations, do not consume alcohol, oruse other medications metabolized by the liver, with medical supervision required.

BThere are not sucient studies on the eectiveness o valerian, passion fower, ginkgo biloba, yellow globefower, and thepreparation o whitethorn, Caliornia poppy, and magnesium to encourage their use.

Proessionals are advised to ask patients regarding any other herbal medicinal products that they are taking or have taken.

* In 2004, the Spanish Agency for Medications and Healthcare Products (AEMPS) 142 included kava in the list of plantsprohibited or restricted for sale to the public due to its hepatic toxicity.

Information/communicationwiththepatient*

Inormation/communication with patients with Generalized Anxiety Disorder (GAD),Panic Disorder (PD), and/or Panic Attack

Inormation or the patient should orm part o the integrated treatment o anxiety disorders at the Primary Care level.

D

The patient, and when appropriate, the amily, should be given inormation based on the evidence regarding theirsymptoms, treatment options, and the possibilities o treating their disorders, taking patient preerences into account toacilitate joint decision-making.

D A contact style based on empathy and understanding is recommended to improve patient satisaction.

DThe possibility o amily support should be assessed, taking into account the available social resources, and suggesting themost appropriate changes in liestyle.

* Source: Workgroup or the Clinical Practice Guideline or the Treatment o Patients with Anxiety Disorders in Primary Care.Clinical Practice Guideline or Treatment o Anxiety Disorders in Primary Care. Madrid: National Plan or the NHS o the

MSC. Health Technology Assessment Unit. Agencia Lain Entralgo. Region o Madrid: 2008. Clinical Practice Guid: HTAU N2006/10.


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1. Introduction

This document is the complete version o the CPG or treatment patients with anxiety disorders in

Primary Care. The CPG is structured into chapters which respond to the questions that appear atthe start o each one. A summary o the evidence and recommendations are presented at the endo each chapter. The right margin will include an indication o the type o study and the possibilityo bias o the bibliography reviewed.

The material that provides a detailed description o the methodological process applied orthe CPG (description o the techniques used in qualitative research, search strategy or each clini-cal question, guideline table) is available at the GuiaSaludwebsite, as well as in the UETS, theHealth Technology Assessment Unit o the Agencia Lan Entralgo. These websites also includethe Methodology Manual or CPG preparation, which covers the general methodology used 1.There is also a summarizedversion o the CPG, which is shorter and includes the main appendi-ces o the complete CPG, a quickguideline with the main algorithms and recommendations and

an inormational brochure or patients. These versions are available on both the aorementionedwebsites as well as in the printed edition.

Prevalence o anxiety and associated burdens

Mental health, as an indivisible part o health, contributes signicantly to quality o lie and ullsocial participation. Mental disorders constitute a signicant social and economic burden dueto their requency, coexistence, and comorbidity, in addition to the disability that they generate.Mental illness is the second leading cause o illness in societies with market economies, withthese gures expected to increase considerably 2 with ew prospects or control.

In our context, it has been conrmed to be one o the categories o causes that most con-tribute to the loss o illness-ree years o lie, using the DALY rate (Disability-Adjusted LieYears)3 as the measure o the burden o illness. For this reason, mental health has required specialattention by the agents involved, refected by the broad lines o action in the document Mental

Health Strategy or the National Health System4:healthcare or patients, coordination amongstinstitutions, scientic societies, and associations, training o healthcare personnel, promotion oresearch and systems o inormation and evaluation.

With mental health problems, anxiety disorders are associated with signicant levels o dis-ability 5. This dysunctionality has a considerable impact on personal well-being, on social rela-tions, and on productivity on the job, with the aggravating actor that its prevalence and the recur-

rent or even chronic nature o many o these disorders makes them as debilitating as any otherchronic physical illness.

Anxiety disorders, along with mood disorders, are the disorders that contribute most to mor-bid-mortality through the suering that they generate and are the ones that have the biggest reper-cussions on national economies 6-8. Pathological panic-anxiety makes it dicult or the subjectto unction anywhere, limiting autonomy, and leaving the person trapped and threatened by thepanic itsel.


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In our context, most studies put the prevalence o mental illness in the general population atbetween 10% and 20%9,10. Figures rom the Eurobarometer give an estimated prevalence or anymental disorder in Spain o 17.6%, higher in women (20.8%) than in men (14.2%)11. The mostrequent disorders are normally anxiety, ollowed by depression, or vice-versa, depending on the

classication used and whether or not the analysis includes phobias.The international prevalence o anxiety disorders varies widely among the dierent epide-

miological studies published, although the variability associated with anxiety disorders consid-ered overall is signicantly lower than the variability associated with the disorders consideredindividually. There are several actors that explain the heterogeneity o the percentages in thesestudies, such as the diagnostic criteria or inclusion, the diagnostic instruments, the size o thesample, the country covered by the study, and the response percentage. The estimated percentageso prevalence-year and prevalence-lie or anxiety disorders were 10.6% and 16.6% respectively12. I the studies are done among users who visit Primary Care acilities, the prevalence increases,varying between 20% and 40%5,6,10,13,14. Anxiety disorders in and o themselves or associated withother pathologies are one o the most requent causes o Primary Care visits and represent one o

the main health problems in Spain. In the context o Spain, the prevalence o anxiety disordersin the community, with the precision diculties mentioned beore, varies around 2.3%-8.9%9,reaching gures between 9% and 19.5%5,8,10,14 when we talk about patients who visit a healthcarecentre because they have the perception that they do not eel good.

Women have a higher risk than men o suering anxiety disorders 11, 15, and the prevalenceo most o the anxiety disorders in the case o women is double the prevalence or men, except inthe case o social phobia, in which the dierences are smaller. The age at which anxiety disordersstart is lower than or depression disorders. This appears to indicate that many people who showsigns o anxiety disorders during childhood, adolescence, and early years o adulthood, have ahigher risk o developing a depression disorder later in lie. This means that a therapeutic ap-proach to anxiety disorders could prevent the later appearance o depression disorders 11,15 (See

tables 1-3).


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Table 1.Prevalence-year o anxiety disorders ollowing the criteria DSM-IV (dataweighted or the Spanish population).2001 - 2002

Anxiety disorders

Total Men Women

Prev (%) CI 95% Prev (%) CI 95% Prev (%) CI 95%

Generalized anxiety 0.50 (0.30-0.70) 0.44 (0.11-0.78) 1.18 (0.81-1.56)

Social phobia 0.60 (0.33-0.87) 0.57 (0.13-1.00) 0.64 (0.32-0.95)

Specic phobia 3.60 (2.82-4.38) 1.19 (0.68-1.70) 4.20 (3.23-5.16)

Post-traumatic stress disorder 0.50 (0.30-0.70) 0.25 (0.02-0.48) 0.94 (0.50-1.39)

Agoraphobia 0.30 (0.10-0.50) 0.15 (0.02-0.29) 0.60 (0.26-0.95)

Panic disorder 0.60 (0.40-0.80) 0.38 (0.14-0.63) 0.98 (0.60-1.36)

Any anxiety disorder 6.20 (4.63-7.77) 2.53 (1.74-3.31) 7.61 (6.41-8.80)

CI: condence interval.

Source15: Study ESEMeD-Espaa.

Table 2.Prevalence-lie o anxiety disorders ollowing the criteria DSM-IV (dataweighted or the Spanish population).2001 - 2002

Anxiety disorders

Total Men Women

Prev (%) CI 95% Prev (%) CI 95% Prev (%) CI 95%

Generalized anxiety 1.89 (1.49-2.29) 1.15 (0.64-1.66) 2.57 (1.49-3.16)

Social phobia 1.17 (0.81-1.54) 1.06 (0.51-1.61) 1.28 (0.83-1.73)

Specic phobia 4.52 (3.82-5.23) 2.32 (1.60-3.05) 6.54 (5.38-7.69)

Post-traumatic stress disorder 1.95 (1.18-2.73) 1.06 (0.00-2.2) 2.79 (1.71-3.87)Agoraphobia 0.62 (0.36-0.89) 0.47 (0.08-0.86) 0.76 (0.39-1.14)

Panic disorder 1.70 (1.32-2.09) 0.95 (0.53-1.37) 2.39 (1.76-3.02)

Any anxiety disorder 9.39 (8.41-10.37) 5.71 (4.57-6.85) 12.76 (11.24-14.29)



Table 3.Prevalence-year o anxiety disorders classied according to DSM-IV by agegroup in the Spanish population.2001 - 2002

Age Any mental disorder Anxiety disorder

Prevalence (CI 95%) Prevalence (CI 95%)

18-24 years old 10.1 (7.3-12.9) 7.8 (5.3-10.4)

25-34 years old 8.5 (6.3-10.8) 4.2 (2.9-5.6)

35-49 years old 8.4 (6.6-10.2) 4.5 (3.2-5.8)

50-64 years old 9.1 (6.8-11.3) 6 (4.3-7.7)

Over 65 years old 6.6 (5.1-8.1) 3.9 (2.8-5.0)




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Variability in clinical practice

Patients with mental disorders or chronic psychosocial conficts repeatedly visit the dierenthealthcare acilities, especially at the level o primary care, mainly due to quick access and the

longitudinality o the care 5,8,16,17.

In general, mental health problems are normally treated initially in Primary Care acilities,and a signicant number o the requests generated by these pathologies are resolved at this level18,19.

Family physicians are the healthcare proessionals, due to their position in the healthcarenetwork, can detect the rst psychiatric symptoms earlier in patients who visit their oces withan anxiety disorder. Some o the studies done in our context indicate a low level o detection opsychiatric disorders, with the prevalence o the detected disorders ranging between 18%-27%versus 36%-47% o probable pathology 9,13,14. The lack o a common pattern in the presentationo dierent anxiety disorders, somatization and association with chronic illnesses, as well as the

limitation o time in amily medicine acilities are some o the reasons that complicate diagnosiswithin the scope o Primary care 20,21.

Anxiety and panic are very requent symptoms in doctor visits, and they are very oten un-specic and can be masked somatically. This makes the treatment o patients with anxiety disor-ders complex, especially i we take into account the diculty o dierential diagnosis, the needor specic therapeutic treatment that at time is extended over time or each orm o the illness, aswell as the need at time or reerral to Specialized Care when the etiology, disorder, or maniesta-tions o the illness require it.

All o these actors generate a certain degree o variability in the treatment o anxiety disor-ders. A study done in Spain, with data rom three regions, evaluates the main actors that infuencethe therapeutic attitudes o doctors in connection with anxiety disorders and the variability in howthey are approached. The type o anxiety disorder was the determining variable or the type otherapy selected the reerral criteria. The probability o reerring patients increased when therewas a prior diagnosis o anxiety. Patients with phobic anxiety, panic, or mixed anxiety were morethan twice as likely to be reerred as patients with generalized anxiety. In general, pharmacologi-cal treatment was done with appropriate and specic drugs, with a high degree o variability thatdepended mainly on the type and other characteristics o the process, the patient, and the proes-sional 22.

The variability in the approaches to anxiety disorders is also the result o an enormous vari-ability in training. Dierent studies have identied a signicant need or continuous training inmental health or Primary Care doctors, particularly in the eld o psychiatric interviews and the

knowledge, abilities, and attitudes to provide psychological assistance, especially in regard tosomatization disorder, psychosexual problems, treatment o stress 17,23-28.

In terms o the use o non-medication treatments, these are covered in a minimal number ostudies, although the low use o psychological actions with proven eectiveness is signicant 6.There are even ewer studies evaluating the work done by Primary Care social workers and nurs-ing sta. These proessionals play a very important role in the therapeutic treatment o anxietydisorders at the primary care level, providing both individual and group therapy, with techniquesthat can be implemented in Primary Care provided that the proessionals involved have receivedthe necessary training.

The search or a common pattern or the detection and treatment o pathological anxiety ina Primary Care acility is not a simple task. This is due in part to the wide variety o ocial diag-

nostic categories that exist, the relatively sort duration o oce visits, the requent somatization


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and association o this type o disorders with other chronic illnesses. For this reason, many studieshave concluded that one o the basic needs is to provide general practitioners with clear, practicalclinical guides based on scientic criteria to assist them in eectively detecting and treating anxi-ety disorders, oering the ideal therapeutic alternatives in each process, at the care level in which

they are available

7,8,29

.This guideline is thereore intended to be a useul tool or all proessionals who work at the

Primary Care level and or patients with these anxiety disorders, including an appendix with spe-cic inormation or patients that was prepared with input rom patients.


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2. Scope and objectives

The main objective o this guideline is to orient healthcare proessionals in the area oPrimary

Care (PC), on one hand in the recognition o anxiety disorders in adultpatients, and on the other,in the selection o recommendations based on the available scientic evidence on therapeutic ac-tions or treating adult patients with anxiety disorders that are treatable rom the point o viewo Primary Care, generalized anxiety disorder (GAD), andpanic disorder (PD), with or withoutagoraphobia. This objective involves an improvement in the quality o the care in the treatment othis process, to consequently improve the quality o lie o these patients.

The guideline is thereore aimed at healthcare proessionals involved in treatment patientswith anxiety disorders and who work in the area o Primary Care (doctors, nursing sta, socialworkers) and is also aimed at patients who suer these anxiety disorders and who turn to primarycare. For the latter, it is a tool that allows them to know the possible strategies and therapies ortheir illnesses, so that they can avoid treatments that are not supported by scientic evidence.

The guideline presents dierent therapeutic alternatives (pharmacological and non-pharma-cological treatment) that can be used in Primary Care depending on the available resources. Inact, the resources that are currently available were taken into consideration beore the nal prepa-ration o the recommendations.

This guideline does not directly cover recommendations or anxiety disorders other thangeneralized anxiety disorder or panic disorder in adults. Since this guideline is ocused nationally,it does not cover organizational questions, but rather tries to establish a basic circuit or patientsbetween the two levels o healthcare Primary Care and Specialized Care so it will also be dis-tributed among the other proessionals involved in providing patient care in an eort to provideintegrated care o patients.


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3. Methodology

The methodology used is covered in the CPG preparation manual rom the Ministry o Healthcare

and Consumption 1.The steps that were ollowed were:

Creationofthegroupto create the guideline,madeupofprofessionalsfrom:Primary

Care (general practitioners, nurses, social workers), Specialized Attention (psychiatrists,psychologists, and nurses), and technicians rom the Health Technology Assessment Unit(UETS). A patient with an anxiety disorder also participated in the preparation o thisguideline as part o the guideline development group, rom the initial work phases.

Formationofasub-group,withmembersfromtheGuidelinedevelopmentgroup,topre-pare inormation aimed at the patients.

Denitionof theguides scope andobjectives, includingthe social viewof the illnessusing qualitative research techniques. Dierent healthcare proessionals were contacted(Primary Care doctors and Specialized Care doctors) and with the help o a questionnaire,the resources o participant observation, and in-depth interviews, inormation was gath-ered on the social, demographic, and health conditions, in addition to the healthcare pathand treatment o patients with anxiety disorders who were treated by those proessionals.A discussion group was also ormed with anxiety disorder patients who voluntarily partici-pated to openly express their interests in the treatment o their illnesses.

FormulationofclinicalquestionsfollowingthePatient/Intervention/Comparison/Outcome

ormat (PICO).

Bibliographic search in: Medline,Embase, Pascal Biomed, CINAHL,CochranePlus,

DARE, HTA, Clinical Evidence, INAHTA, NHS EED, CINDOC. Languages: Spanish,English, and French. Study population: adults. Publication year limitation: only or pri-mary studies. First a search was done to locate practical clinical guides (CPGs) and theirquality was evaluated using the AGREE instrument. Three CPGs were included as second-ary source o evidence in response to specic sections o the guideline (treatment, inorma-tion/communicationwiththepatient,anddiagnosticandtherapeuticstrategies).Inphase

two, a search was done or systematic revisions, meta-analyses, and evaluation reports inthe databases mentioned earlier. In phase three, an expanded search was done on primarystudies (clinical tests, observational studies, diagnostic and prognostic test studies).

Evaluationof thequalityofthestudiesandsummaryoftheevidenceforeachquestion

ollowing the recommendations o SIGN (Scottish Intercollegiate Guidelines Network).

FormulationofrecommendationsbasedonSIGNsformalevaluationorreasonedjudg-ment. Controversial recommendations or those lacking evidence were resolved by con-sensus o the creation group.

Theguidelinewasreviewedexternallybyagroupofprofessionalsselectedfortheirknowl-edge on the methodology o preparing guides, the pathology covered, and the scope o ap-plication. The dierent Scientic Societies involved were contacted: Spanish Family andCommunity Medicine Society (SEMFYC), Spanish Society o Primary Care Physicians(SEMERGEN), Madrid Society or Family and Community Medicine (SoMaMFYC),Spanish Psychiatry Society (SEP), Spanish Neuro-psychiatry Association (AEN) and theSpanish Union o Scientic Nursing Societies (UESCE). In the case o patient partici-

pation, the Spanish Conederation o Family Groups and People with Mental Illnesses


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(FEAFES), the Madrid Federation o Mental Health Associations (FEMASAN), and theMadrid Panic and Agoraphobia Association (AMADAG). All o these societies were rep-resented either as members o the guideline development group or as external reviewers.

Thematerialthatprovidesthedetailedinformationonthemethodologyappliedtoprepare

the CPG (description o the techniques used in the qualitative research, the search strategyor each clinical question, guideline table) is available at www.guiasalud.es.

Updates to the Guideline

The UETS, which is responsible or publishing the Guideline, will also be in charge o updating itwithin 3 to 5 years, or earlier, depending on the new evidence that becomes available. This updatewill be done by adding the updated bibliographic searches and will ocus especially on the aspectsin which recommendations may undergo signicant modications.


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4. Denition, clinical eaturesand classications

This chapter will answer the ollowing questions:

What is the denition of anxiety as a symptom/syndrome?

What is the denition of anxiety as a specic clinical prole?

How are anxiety disorders classied?

4.1. Normal and pathological anxiety

Anxiety can be dened as the anticipation o uture harm or misortune, accompanied by a eelingofdysphoria(unpleasantness)and/orsomaticsymptomsoftension.Theobjectiveoftheantici -pated harm may be internal or external. It is an alert signal that can warn o imminent danger andallows the person to take the necessary measures to conront a threat.

It is important to understand anxiety as a normal eeling or emotional state in response tocertain situations and that it constitutes a common response to dierent daily stressul situations.This means that a certain degree o anxiety is even desirable or the normal treatment o day-to-daydemands.Onlywhenthisexceedsacertainintensityorthepersonsadaptivecapacitydoes

anxiety become pathological, causing signicant discomort with symptoms that aect the personphysically, psychologically, and behaviorally (table 4).

Table 4.Symptoms o anxiety:physical and psychological

Physical symptoms Psychological and behavioral symptoms

Vegetative:sweating, dry mouth, dizziness, instability Worry, apprehension

Neuromuscular:trembling, muscular tension, headache,paresthesia

Feeling o oppressiveness

Cardiovascular:palpitations, accelerated heartbeat, precordialpain

Fear o losing control, o going crazy, or the eeling o imminentdeath

Respiratory:dysnea Diculty concentrating, complaints o memory lossDigestive:nausea, vomiting, dyspepsia, diarrhea, constipation,aerophagia, meteorism

Irritability, restlessness, apprehension

Genito-urinary:requent urination, sexual problems Behavior to avoid certain situations

Inhibition or psychomotor blockageObsessions or compulsions


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Anxiety disorders as such are a group o illnesses characterized by the presence o exces-sive worry, ear, tension, or activation that causes signicant discomort or a clinically signicantdeterioration o the activity o the individual 30.

The causes o anxiety disorders are not ully understood, but biological, environmental, and

psycho-social actors are involved 31,32.The biological actors include alterations in neurobiological gabaergic, and seratoninergic

systems, as well as structural anomalies in the limbic system (paralimbic cortex), one o the most-affectedregionsofthebrain.Certainphysicalalterationsandgreaterfrequencyofusageand/or

withdrawalfrommedicines,alcohol,drugsand/orsedatives,andothersubstances.Lastly,thereis

a certain genetic predisposition in the appearance o these disorders 33-36 .

The environmental actors include the infuence o certain environmental stress agents,greater hypersensitivity, and learned response 36,37. The psychosocial risk actors or these disor-ders include stressul situations, amily environment, threatening lie experiences, and excessiveworry about common subjects. The pre-disposition actors include the infuence o personality

characteristics

32

.It appears that the interaction o multiple determining actors avors the appearance o these

anxiety disorders 38, and comorbity with other mental disorders, such as mood disorders, is com-mon 34,39.

4.2. Classications

Thereareseveraluniversalcriteriafordeterminingwhetherapersonsbehaviorcanbediagnosed

as an anxiety disorder. These criteria are included in the two most important mental (or psycho-pathological) disorder classications:

DSM-IV- TR (American Psychiatric Association, APA).

CIE-10 (World Health Organization, WHO).

The DSM-IV-TR lists twelve anxiety disorders, and in the CIE-10, neurotic disorders (anxi-ety) are grouped with stress-related and somatomorphic disorders (table 5)40,41.

Table 5. Anxiety disorder classications according to the DSM-IV-TR and the CIE-10:

equivalence

DSM-IV-TR CIE-1O

Phobic anxiety disorder

Social phobia Social phobias

Simple phobia specic (isolated) phobias

Agoraphobia without history o panic disorderAgoraphobia

Other anxiety disorders

Panic disorder with agoraphobia Panic disorder

Panic disorder without agoraphobia


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Table 5. Anxiety disorder classications according to the DSM-IV-TR and the CIE-10:

equivalence

DSM-IV-TR CIE-1O

Phobic anxiety disorder

Generalized anxiety disorder Generalized anxiety disorder

Mixed anxiety and depressive disorder

Other mixed anxiety disorders

Other specied anxiety disorders

Obsessive-compulsive disorder Obsessive-compulsive disorder

Reaction to severe stress and adjustmentdisorders

Post-traumatic stress disorder Post-traumatic stress disorder

Acute stress disorder Reaction to severe stress

Adjustment disorders

Dissociative disorders

Anxiety disorder due to medical condition

Substance-induced anxiety disorder

Somatoform disorders

Anxiety disorder not otherwise specied Other neurotic disorders

The ollowing table presents the classication o these anxiety disorders according to theDSM-IV-TR-AP manual30. This manual was prepared between Primary Care and Psychiatry inorder to diagnose mental disorders in PC, and all o the codes included in it are taken rom the

DSM-IV-TR. Table 6 includes the anxiety disorders according to the DSM-IV-TR-AP, along withthe ocial codes o the CIE-9-MC and the CIE-10 codes.

Table 6.Anxiety disorder classication according to the DSM-IV-TR-AP

CIE-10 Disorder (according to DSM-IV-TR-AP) CIE-9

F06.4 Anxiety disorder due to (speciy illness) [293.84]

F10.8 Alcohol-related anxiety disorder [291.89]

F19.8 Other sustance-related anxiety disorder [292.89]

F40.01 Panic disorder with agoraphobia [300.21]

F41.0 Panic disorder without agoraphobia [300.01]

F40.1 Social phobia [300.23]

F40.2 Specic phobia [300.29]

F40.00 Agoraphobia without history o panic disorder [300.22]

F93.0 Separation anxiety disorder [309.21]

F42.8 Obsessive-compulsive disorder [300.3]

F43.1 Post-traumatic stress disorder [309.81]

F43.0 Acute stress disorder [308.3]


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Table 6.Anxiety disorder classication according to the DSM-IV-TR-AP

CIE-10 Disorder (according to DSM-IV-TR-AP) CIE-9

F41.1 Generalized anxiety disorder [300.02]

F43.28 Adjusment disorder with anxiety [309.24]

F41.9 Non-specic anxiety disorder [300.00]

And lastly, the International Primary Care Classication CIAP-2 rom the WONCA42.This classication is based on three-digit alphanumeric codes, which can be expanded i neces-sary. The rst is a letter that represents the organic system or apparatus, and covers the 17 chapterso this classication. Anxiety-related aspects would be represented under the P-psychologicalproblems heading o the abbreviated CIAP-2 codes. The second and third digits are numbers,called components, which are related specically or non-specically with: signs or symptoms;administrative, diagnostic, preventive, or therapeutic procedures; complementary test results; re-errals, tracking, or other visit motives, or illnesses and health problems. The CIAP-2 codes that

correspond to anxiety are shown in the table below as components. The table also species theequivalence with the CIE-10 codes:

Table 7. Abbreviated CIAP-2 codes or anxiety

P. Psychological problems

Component 1: signs and symptomsFeelings of anxiety/tension/nervousness: P01Equivalence with the CIE-10: F41.9, R45.0

Component 7: health problems and illnessesAnxious-state/anxiety disorders: P74Equivalence with the CIE-10: F41.0, F41.1, F41.3 to F41.9


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5. Diagnosing anxiety

This chapter will answer the ollowing questions:

What are the diagnostic criteria of the different anxiety disorders?

What are the criteria for suspecting anxiety disorders?

What studies should be done initially with adults suspected to suffer anxiety disorders in order to allow early detection?

Are there key questions that could help Primary Care professionals to detect anxiety disorders in patient interviews?

What are the differential diagnoses to be taken into account?

5.1. Diagnostic criteria

This section describes the diagnostic criteria with which anxiety disorders must conorm as speci-ed in the DSM-IV-TR 40. The proposed system is the one described in the DSM-IV-TR AP 30manual, in the orm o steps, although it has been modied. The criteria o the DSM-IV-TR weretaken into account in cases in which they were summarized in the DSM-IV-TR-AP:

Step 1

Consider the role o a medical illness or the consumption o substances and take into ac-

count whether the anxiety is better explained by another mental disorder:

1A. Consider the role of medical illnessesAnxiety disorder due to a general medical condition

A. Prominent anxiety, Panic Attacks, or obsessions or compulsions predominate in the clini-cal picture.

B. There is evidence rom the history, physical examination, or laboratory ndings that thedisturbance is the direct physiological consequence o a general medical condition.

C. The disturbance is not better accounted or by another mental disorder (e.g., AdjustmentDisorder With Anxiety in which the stressor is a serious general medical condition).

D. The disturbance does not occur exclusively during the course o a Delirium.

E. The disturbance causes clinically signicant distress or impairment in social, occupa-tional, or other important areas o unctioning.


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1B. If the subject takes abused substances or medication, consider thefollowing:

Substance-induced anxiety disorder (including medication)

A. Prominent anxiety, Panic Attacks, or obsessions or compulsions predominate in the clini-cal picture.

B. There is evidence rom the history, physical examination, or laboratory ndings o either(1) or (2):

(1) the symptoms in Criterion A developed during, or within 1 month o, SubstanceIntoxication or Withdrawal.

(2) medication use is etiologically related to the disturbance.

C. The disturbance is not better accounted or by an Anxiety Disorder that is not substanceinduced. Evidence that the symptoms are better accounted or by an Anxiety Disorderthat is not substance induced might include the ollowing: the symptoms precede the on-

set o the substance use (or medication use); the symptoms persist or a substantial periodo time (e.g., about a month) ater the cessation o acute withdrawal or severe intoxicationor are substantially in excess o what would be expected given the type or amount o thesubstance used or the duration o use; or there is other evidence suggesting the existenceo an independent non-substance-induced Anxiety Disorder (e.g., a history o recurrentnon-substance-related episodes)

D. The disturbance does not occur exclusively during the course o a Delirium.

E. The disturbance causes clinically signicant distress or impairment in social, occupa-tional, or other important areas o unctioning.

1C. Consider the role of other mental disorders that could explain theanxiety symptoms better

Additional comments:

Differentialdiagnosis:

In the case o a patient that presents a dierential diagnosis with an anxiety disorder, sys-temic illnesses should be reasonably ruled out. To do this, you should take into account thephysical symptoms that predominate, the knowledge o the prior medical and psychologi-calhistoryofboththepatientandthepatientsfamilyandtheillnessesthatgenerateanxi-ety disorders, as well as the probability o the ones that may be aecting the patient. Do

not orget high capacity o toxins such as caeine, cannabis, or cocaine and other syntheticdrugs to induce anxiety attacks and panic in predisposed subjects. It is also necessary toconsider the importance o alcohol or many o the people who suer anxiety (especiallygeneralized anxiety, panic disorder, and social phobia) since it is used as a tranquilizer torelieve the anxiety symptoms. Based on all o these actors, determine the additional teststhat should be carried out, depending on the level o suspicion and the immediacy withwhich the tests must be carried out, depending on the symptoms and the evaluation.


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Medicalcomorbidityinanxietydisorders:

A wide range o medical illnesses can produce symptoms o anxiety, although this eld comorbidity is likely to change because an increasing number o somatic disorders arebeing described in patients aected by pathological anxiety. The current dierentiation

between primary disorders or those due to a medical illness will give way to those thatare associated with somatic pathology. As is the case o depression or bipolar disorder,the coexistence o auto-immune thyroid pathology, asthma, migraines, etc. progressivelyhighlights the probability that these are dierent maniestations o a single systemic source43. In the case o patients with diagnosed anxiety disorders, several studies have shown ahigher prevalence o gastrointestinal, genitourinary, osteomuscular, thyroid, and allergicdisorders, as well as migraines, cardipathy, and hyperlaxitude in joints, in comparison withpatients without anxiety disorders 44-47.

Step 2

Panic attack

Panic attacks are dened as ollows:

A discrete period o intense ear or discomort, in which our (or more) o the ollowing symp-toms developed abruptly and reached a peak within 10 minutes:

Cardiopulmonary symptoms:

1. chest pain or discomort.

2. sensations o shortness o breath or smothering.

3. palpitations, pounding heart, or accelerated heart rate.

Autonomic symptoms:

4. Sweating.

5. chills or hot fushes.

Gastrointestinal symptoms:

6. Feeling o choking.

7. Nausea or abdominal distress.

Neurological symptoms:

8. trembling or shaking.

9. paresthesias (numbness or tingling sensations).

10. eeling dizzy, unsteady, lightheaded, or aint.


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Psychiatric symptoms:

11. derealization (eelings o unreality) or depersonalization (being detached rom onesel).

12. Fear o losing control or going crazy.

13. Fear o dying.

2A. If panic attacks are unexpected (they occur out of the blue andare not related to a situational trigger) and they are clinically signi-cant, consider the following:

Panic disorder with agoraphobia

A. Both (1) and (2):

(1) recurrent unexpected Panic Attacks.

(2) at least one o the attacks has been ollowed by 1 month (or more) o one (or more) othe ollowing:

(a) persistent concern about having additional attacks.

(b) worry about the implications o the attack or its consequences (e.g., losing control,having a heart attack, going crazy).

(c) A signicant change in behavior related to the attacks.

B. The presence o agoraphobia:

(1) Anxiety about being in places or situations rom which escape might be dicult (orembarrassing) or in which help may not be available in the event o having an unex-pected or situationally predisposed Panic Attack or panic-like symptoms. Agoraphobicears typically involve characteristic clusters o situations that include being outsidethe home alone; being in a crowd or standing in a line; being on a bridge; and travelingin a bus, train, or automobile.

Note: Consider the diagnosis o Specic Phobia i the avoidance is limited to one or onlya ew specic situations, or Social Phobia i the avoidance is limited to social situa-tions.

(2) The situations are avoided (e.g., travel is restricted) or else are endured with markeddistress or with anxiety about having a Panic Attack or panic-like symptoms, or re-quire the presence o a companion.

(3) The anxiety or phobic avoidance is not better accounted or by another mental disor-der, such as Social Phobia (e.g., avoidance limited to social situations because o earo embarrassment), Specic Phobia (e.g., avoidance limited to a single situation likeelevators), Obsessive-Compulsive Disorder (e.g., avoidance o dirt in someone withan obsession about contamination), Posttraumatic Stress Disorder (e.g., avoidance ostimuli associated with a severe stressor), or Separation Anxiety Disorder (e.g., avoid-ance o leaving home or relatives).


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C. The Panic Attacks are not due to the direct physiological eects o a substance (e.g., adrug o abuse, a medication) or a general medical condition (e.g., hyperthyroidism).

D. The Panic Attacks are not better accounted or by another mental disorder, such as SocialPhobia (e.g., occurring on exposure to eared social situations), Specic Phobia (e.g., on

exposure to a specic phobic situation), Obsessive-Compulsive Disorder (e.g., on ex-posure to dirt in someone with an obsession about contamination), Posttraumatic StressDisorder (e.g., in response to stimuli associated with a severe stressor), or SeparationAnxiety Disorder (e.g., in response to being away rom home or close relatives).

OR

Panic disorder without agoraphobia

A. Criterion A o panic disorder with agoraphobia is ullled.

B. Absence o agoraphobia.

C and D. Same as in the case o panic disorder with agoraphobia.

2B. If the panic attack is related to a situational trigger associated withanother mental disorder, consider the following:

Panic attacks that occur in the context o other anxiety disorders (e.g. social phobia, specicphobia, post-traumatic stress disorder, obsessive-compulsive disorder).

Step 3

I the symptom is ear, avoidance, or anxious anticipation o one or more specifc situations,

consider 3A, 3B, and 3C:

3A. If the symptoms are related to social situations or actions in whichthe individual is exposed to people from outside the family circle orthe possible evaluation by others, consider:

Social phobia

A. A marked and persistent ear o one or more social or perormance situations in which theperson is exposed to unamiliar people or to possible scrutiny by others. The individualears that he or she will act in a way (or show anxiety symptoms) that will be humiliating

or embarrassing.Note: In children, there must be evidence o the capacity or age-appropriate social re-lationships with amiliar people and the anxiety must occur in peer settings, not just ininteractions with adults.

B. Exposure to the eared social situation almost invariably provokes anxiety, which maytake the orm o a situationally bound or situationally predisposed Panic Attack. Note: Inchildren, the anxiety may be expressed by crying, tantrums, reezing, or shrinking romsocial situations with unamiliar people.


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CliniCal PraCtiCe Guideline for treatment of Patients with anxiety disorders in Primary Care 37

C. The person recognizes that the ear is excessive or unreasonable. Note: In children, this

eature may be absent.

D. The eared social or perormance situations are avoided or else are endured with intense

anxiety or distress.

E. The avoidance, anxious anticipation, or distress in the eared social or perormance

situation(s) intereres signicantly with the persons normal routine, occupational (aca-

demic) unctioning, or social activities or relationships, or there is marked distress about

having the phobia.

F. In individuals under age 18 years, the duration is at least 6 months.

G. The ear or avoidance is not due to the direct physiological eects o a substance (e.g.,

a drug o abuse, a medication) or a general medical condition and is not better account-

ed or by another mental disorder (e.g., Panic Disorder With or Without Agoraphobia,

Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental

Disorder, or Schizoid Personality Disorder).

H. I a general medical condition or another mental disorder is present, the ear in Criterion

A is unrelated to it, e.g., the ear is not o Stuttering, trembling in Parkinsons disease, or

exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.

3B. Ifthesymptomsincludetheavoidanceofspecicsituationsorob-jects,considerthefollowing:

Specifc phobia

A. Marked and persistent ear that is excessive or unreasonable, cued by the presence or

anticipation o a specic object or situation (e.g., fying, heights, animals, receiving an

injection, seeing blood).

B. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety re-

sponse, which may take the orm o a situationally bound or situationally predisposed

Panic Attack.

Note: In children, the anxiety may be expressed by crying, tantrums, reezing, or cling-

ing.

C. The person recognizes that the ear is excessive or unreasonable. Note: In children, this

eature may be absent.

D. The phobic situation(s) is avoided or else is endured with intense anxiety or distress.

E. The avoidance, anxious anticipation, or distress in the eared situation(s) intereres sig-nicantly with the persons normal routine, occupational (or academic) unctioning, or

social activities or relationships, or there is marked distress about having the phobia.

F. In individuals under age 18 years, the duration is at least 6 months.

G. The anxiety, Panic Attacks, or phobic avoidance associated with the specic object or

situation are not better accounted or by another mental disorder, such as Obsessive-

Compulsive Disorder (e.g., ear o dirt in someone with an obsession about contamina-

tion), Posttraumatic Stress Disorder (e.g., avoidance o stimuli associated with a severe


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stressor), Separation Anxiety Disorder (e.g., avoidance o school), Social Phobia (e.g.,avoidance o social situations because o ear o embarrassment), Panic Disorder withAgoraphobia, or Agoraphobia Without History o Panic Disorder.

3C. If the anxiety or avoidance is related to situations in which escapemay be difcult or situations in which there is no help available if apanic attack occurs and there is no history of panic attacks, con-sider the following:

Panic disorder with agoraphobia

3D. If the symptom is related to a situation in which escape may bedifcult or situations in which there is no help available if a panic

attack occurs and there is no history of panic attacks, consider thefollowing:

Agoraphobia without history o panic disorder

A. The presence o Agoraphobia related to ear o developing panic-like symptoms (e.g.,dizziness or diarrhea).

B. Criteria have never been met or Panic Disorder.

C. The disturbance is not due to the direct physiological eects o a substance (e.g., a drugo abuse, a medication) or a general medical condition.

D. I an associated general medical condition is present, the ear described in Criterion A isclearly in excess o that usually associated with the condition.


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Step 4

4. If the apprehension or anxiety are related to persistent thoughts

(obsessions) and/or rituals or recurrent mental acts (compulsions),consider the following:

Obsessive-compulsive disorder

A. Either obsessions or compulsions: Obsessions as dened by (1), (2), (3), and (4):

(1) recurrent and persistent thoughts, impulses, or images that are experienced, at sometime during the disturbance, as intrusive and inappropriate and that cause markedanxiety or distress.

(2) the thoughts, impulses, or images are not simply excessive worries about real-lieproblems.

(3) the person attempts to ignore or suppress such thoughts, impulses, or images, or toneutralize them with some other thought or action.

(4) the person recognizes that the obsessional thoughts, impulses, or images are a producto his or her own mind (not imposed rom without as in thought insertion).

Compulsions as dened by (1) and (2):

(1) repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g.,praying, counting, repeating words silently) that the person eels driven to perorm inresponse to an obsession, or according to rules that must be applied rigidly.

(2) the behaviors or mental acts are aimed at preventing or reducing distress or preventingsome dreaded event or situation; however, these behaviors or mental acts either are notconnected in a realistic way with what they are designed to neutralize or prevent or areclearly excessive.

B. At some point during the course o the disorder, the person has recognized that the obses-sions or compulsions are excessive or unreasonable. Note: This does not apply to chil-dren.

C. The obsessions or compulsions cause marked distress, are time consuming (take morethan1houraday),or signicantlyinterferewiththepersonsnormalroutine,occupa-tional (or academic) unctioning, or usual social activities or relationships.

D. I another Axis I disorder is present, the content o the obsessions or compulsions is notrestricted to it (e.g., preoccupation with ood in the presence o an Eating Disorders; hairpulling in the presence o Trichotillomania; concern with appearance in the presence oBody Dysmorphic Disorder; preoccupation with drugs in the presence o a Substance Use

* The multi-axis classication o the DSM-IV-TR 40 includes ve axes:

Axis I Clinical disorders. Other conditions that may be a ocus o clinical attention

Axis II Personality disorders. Mental retardation

Axis III General medical conditions

Axis IV Psychosocial and environmental problems

Axis V Global assessment o unctioning


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Disorder; preoccupation with having a serious illness in the presence o Hypochondriasis;preoccupation with sexual urges or antasies in the presence o a Paraphilia; or guilty ru-minations in the presence o Major Depressive Disorder)

E. The disturbance is not due to the direct physiological eects o a substance (e.g., a drug

o abuse, a medication) or a general medical condition.

Step 5

I the symptoms are related to reexperiencing o highly traumatic events, consider 5A and

5B:

5A. If the symptoms are related to the reexperience of highly traumaticevents and the symptoms last less than 4 weeks, consider:

Post-traumatic stress disorder

A. The person has been exposed to a traumatic event in which both o the ollowing werepresent:

(1) the person experienced, witnessed, or was conronted with an event or events that in-volved actual or threatened death or serious injury, or a threat to the physical integrityo sel or others.

(2)thepersonsresponseinvolvedintensefear,helplessness,orhorror.Note:Inchildren,

this may be expressed instead by disorganized or agitated behavior.

B. The traumatic event is persistently reexperienced in one (or more) o the ollowingways:

(1) recurrent and intrusive distressing recollections o the event, including images,thoughts, or perceptions. Note: In young children, repetitive play may occur in whichthemes or aspects o the trauma are expressed.

(2) recurrent distressing dreams o the event. Note: In children, there may be righteningdreams without recognizable content.

(3) acting or eeling as i the traumatic event were recurring (includes a sense o relivingthe experience, illusions, hallucinations, and dissociative fashback episodes, includ-ing those that occur on awakening or when intoxicated). Note: In young children,trauma-specic reenactment may occur.

(4) intense psychological distress at exposure to internal or external cues that symbolizeor resemble an aspect o the traumatic event.

(5) physiological reactivity on exposure to internal or external cues that symbolize orresemble an aspect o the traumatic event.


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C. Persistent avoidance o stimuli associated with the trauma and numbing o general re-sponsiveness (not present beore the trauma), as indicated by three (or more) o the ol-lowing:

(1) eorts to avoid thoughts, eelings, or conversations associated with the trauma.

(2) eorts to avoid activities, places, or people that arouse recollections o the trauma.

(3) inability to recall an important aspect o the trauma.

(4) markedly diminished interest or participation in signicant activities.

(5) eeling o detachment or estrangement rom others.

(6) restricted range o aect (e.g., unable to have loving eelings).

(7) sense o a oreshortened uture (e.g., does not expect to have a career, marriage, chil-dren, or a normal lie span).

D. Persistent symptoms o increased arousal (not present beore the trauma), as indicated by

two (or more) o the ollowing:(1) diculty alling or staying asleep.

(2) irritability or outbursts o anger.

(3) diculty concentrating.

(4) hypervigilance.

(5) exaggerated startle response.

E. Duration o the disturbance (symptoms in Criteria B, C, and D) is more than 1 month.

F. The disturbance causes clinically signicant distress or impairment in social, occupa-tional, or other important areas o unctioning.

5B. If the symptoms persist for at least 2 weeks but not more than 4weeks, consider:

Acute stress disorder

A. The person has been exposed to a traumatic event in which both o the ollowing werepresent:

(1) the person experienced, witnessed, or was conronted with an event or events that in-volved actual or threatened death or serious injury, or a threat to the physical integrityo sel or others.

(2)thepersonsresponseinvolvedintensefear,helplessness,orhorror.


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B. Either while experiencing or ater experiencing the distressing event, the individual hasthree (or more) o the ollowing dissociative symptoms:

(1) a subjective sense o numbing, detachment, or absence o emotional responsiveness.

(2) a reduction in awareness o his or her surroundings (e.g., being in a daze).

(3) Derealization.

(4) Depersonalization.

(5) dissociative amnesia (i.e., inability to recall an important aspect o the trauma).

C. The traumatic event is persistently reexperienced in at least one o the ollowing ways:recurrent images, thoughts, dreams, illusions, fashback episodes, or a sense o relivingthe experience; or distress on exposure to reminders o the traumatic event.

D. Marked avoidance o stimuli that arouse recollections o the trauma (e.g., thoughts, eel-ings, conversations, activities, places, people).

E. Marked symptoms o anxiety or increased arousal (e.g., diculty sleeping, irritability,poor concentration, hypervigilance, exaggerated startle response, motor restlessness).

F. The disturbance causes clinically signicant distress or impairment in social, occupa-tional,orotherimportantareasoffunctioningorimpairstheindividualsabilitytopur -sue some necessary task, such as obtaining necessary assistance or mobilizing personalresources by telling amily members about the traumatic experience.

G. The disturbance lasts or a minimum o 2 days and a maximum o 4 weeks and occurswithin 4 weeks o the traumatic event.

H. The disturbance is not due to the direct physiological eects o a substance (e.g., a drugo abuse, a medication) or a general medical condition, is not better accounted or by

Brie Psychotic Disorder, and is not merely an exacerbation o a preexisting Axis I orAxis II disorder.


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Step 6

If the symptoms of intense anxiety and worry are related to a variety of

events or situations, consider the following:Generalized anxiety disorder

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than notor at least 6 months, about a number o events or activities (such as work or school per-ormance).

B. The person nds it dicult to control the worry.

C. The anxiety and worry are associated with three (or more) o the ollowing six symptoms(with at least some symptoms present or more days than not or the past 6 months). Note:Only one item is required in children:

(1) restlessness or eeling keyed up or on edge.(2) being easily atigued.

(3) diculty concentrating or mind going blank.

(4) Irritability.

(5) muscle tension.

(6) sleep disturbance (diculty alling or staying asleep, or restless unsatisying sleep).

D. The ocus o the anxiety and worry is not conned to eatures o an Axis I disorder,e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), be-ing embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-

Compulsive Disorder), being away rom home or close relatives (as in Separation AnxietyDisorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints(as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and theanxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.

E. The anxiety, worry, or physical symptoms cause clinically signicant distress or impair-ment in social, occupational, or other important areas o unctioning.

F. The disturbance is not due to the direct physiological eects o a substance (e.g., a drugo abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and doesnot occur exclusively during a Mood Disorder, a Psychotic Disorder, or a PervasiveDevelopmental Disorder.


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Step 7

If the symptoms appear in response to specic psycho-social stress,

consider:Adjustment Disorder with anxiety

A. The development o emotional or behavioral symptoms in response to an identiablestressor(s) occurring within 3 months o the onset o the stressor(s).

B. These symptoms or behaviors are clinically signicant as evidenced by either o the ol-lowing:

(1) marked distress that is in excess o what would be expected rom exposure to the stres-sor.

(2) signicant impairment in social or occupational (academic) unctioning.

C. The stress-related disturbance does not meet the criteria or another specic Axis I disor-der and is not merely an exacerbation o a preexisting Axis I or Axis II disorder.

D. The symptoms do not represent Bereavement.

E. Once the stressor (or its consequences) has terminated, the symptoms do not persist ormore than an additional 6 months.

Step 8

If the anxiety is clinically signicant and the criteria are not fullled for anyof the specic disorders described above, consider:

Non-specifc anxiety disorder

This includes disorders with prominent symptoms o anxiety or phobic avoidance that do no ulllthe diagnostic criteria or any o the specic disorders described above. The ollowing are severalexamples:

(1) Mixed anxiety-depressive disorder: this is a persistent or recurring dysphoric mood statethat lasts at least 1 month and is accompanied or at least 1 month by other anxious anddepressive symptoms (e.g. diculty concentrating or having your mind blank, sleepdisorders, atigue or lack o energy, irritability, worry, crying easily, hypervigilance, an-ticipation o danger, desperation, and low sel-esteem or eelings o uselessness). Thesesymptomscancausedeteriorationoftheindividualssocialorworkrelationsorother

important areas o their activities.

(2) Clinically signicant social phobic symptoms that are related to the social impact ohavingageneralmedicalconditionormentaldisorder(e.g.,Parkinsonsdisease,derma-tological conditions, stuttering, anorexia nervosa, body dysmorphic disorder.


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(3) Situations in which the alteration is serious enough to require a diagnosis o anxietydisorder, even though the individual does

anxiety manual

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