Definitions:
Anxiety disorder : Disorder in which the patient has excessive or disproportionately long- lasting fear and subjective suffering or impediment of daily function.
Panic attack : Intense fear during a limited period of time.
Panic disorder : repeated panic attacks, with fear of getting another panic attack in between.
Agoraphobia : Fear and avoidance of situations from which one thinks it will be hard to get away or in which one wouldn’t be able to get help.
Specific Phobia : Intense and persistent fear and avoidance of a specific object or situation.
Social Phobia : Intense and persistent fear and avoidance of situations in which one is possibly subjected to the critical eye of others. Social phobia can be subdivided into specific forms in which the fear is connected to a specific situation, such as stage fright, and in a general form in which the fear manifests in a variety of situations.
Obsessive Compulsive Disorder : Recurrent and intrusive thoughts, impulses, or images
(obsessions), or compulsive acts (compulsions).
Post Traumatic Stress Disorder : Re-experiencing of a traumatic event, the avoidance of stimuli that are associated with the trauma, heightened irritability, exaggerated startle response, muscle tension and sleep disturbance.
Generalized Anxiety Disorder : Excessive, persistent fear or anxiety accompanied by symptoms such as worry, agitation, fatigue, concentration problems, irritability, muscle tension, and sleep disturbance.
Hypochondria : persistent unfounded fear or conviction of suffering from a serious illness.
Diagnostic guidelines :
Anxiety disorder should be considered if the patient:

Comes to see the doctor often with varying complaints;

Has persistent non-specific complaints, such as tension, irritability, feeling unstable, concentration problems, listlessness, or sleeping disturbances;
 Has complaints about ‘hyperventilation’;

Has persistent functional physical problems;

Requests sleeping pills or tranquilizers;

Has alcohol or substance abuse problems;

Is depressed.

Anamnesis

Do you feel afraid? Do you worry a lot?;

Do you think this fear or worry is justified?;

Do these feelings have a negative effect on your home life, your job or your free time?
If you suspect anxiety disorder ask about:

Duration and development of the complaints (continuously or occurring in attacks), duration and frequency of possible attacks, severity of the complaints, degree of suffering;

Situations that trigger the fear;

Possible causes of the anxiety disorder;

Accompanying symptoms: Palpitations, transpiration, dizziness, trembling, tightness of the chest, pains, stomach complaints, tingling sensations, numbness, sensations of heat or cold, feelings of unreality or depersonalization, restlessness, being easily fatigued, concentration problems, irritability, sleep disturbances;

Focus of the anxiety: loss of control, going crazy, dying (panic disorder), helplessness in case of being indisposed (agoraphobia), specific objects or situations (specific phobia), negative judgment by others (social phobia), various miseries that can happen in life (generalized anxiety disorder), re-experiencing of a traumatic event (post traumatic stress disorder), serious physical illness
(hypochondria), compulsive thoughts (obsessive compulsive disorder);

Compulsive acts (obsessive compulsive disorder);

Effect of the complaints on daily functioning;

Relationship with stress, overburdening, marital or relationship problems, work problems.
Perform a careful anamnesis when specific physical complaints are present.
Check for other psychological complaints (depression, hallucinations or delusions, alcohol or drug problems).
Physical and Additional examination
Examine further if anamnestic indicators point to somatic pathology.
Evaluation
Check if the patient is suffering from one of the anxiety disorders that is mentioned under
‘Definitions’. For the differential diagnosis, take into account:

Real life stress-related problems;

Somatization disorder: persistent functional physical complaints that do not have fear as a primary component;

Psychotic disorder, psychotic depression, delirium: when hallucinations or delusions are present;

Personality disorder;

Information:
Anxiety disorders are common. Prognosis is improved by suitable treatment.
Explanations of the vicious circle, triggering, and enabling factors can help reduce the complaints
Non-pharmaceutical and pharmaceutical treatment:
The choice of treatment depends on:
 type of anxiety disorder;
 degree of suffering;
 presence of a depressive disorder;
 the patients wishes and the availability of different treatments.
In general it can be said that non-pharmaceutical treatment in the shape of cognitivebehavioral therapy, as well as pharmaceutical treatment are good first choices.
See Table 1 for medication appropriate for anxiety disorders. Additionally, in the initial phase of the treatment: A benzodiazepine (Diazepam 5-10 mg/day, maximum 40 mg/day;
Oxazepam 30 mg/day, maximum 100-150 mg/day) for 2 – 4 weeks maximum.
Exceptions are:

Presence of a depressive disorder : pharmaceutical treatment or a combination of pharmaceutical and non-pharmaceutical treatment (Pharmaceutical treatment first, followed by cognitive-behavioral therapy);

Specific form of social phobia such as stage fright : incidental beta-blockers
(propanolol, maximum 40 mg);

Panic disorder without agoraphobia ; specific phobia and frequent occurrence of the specific form of social phobia: cognitive-behavioral treatment;

Panic disorder with agoraphobia and post-traumatic stress disorder : a combination of pharmaceutical and non-pharmaceutical treatment;

Hypochondria : cognitive-behavioral therapy.
Table 1
SSRI

Fluvoxamine

Paroxetine
Starting dose during 2 weeks
(mg/day)
50 a.n.
Gradual increase to target dose*
(mg/day)
100-150 a.n.
20-40 in the morning
100-150 a.n.
100-150 a.n.
Maximum dose
(mg/day)
300 a.n.
60 in the morning
TCA

Clomipramine

Imipramine
10-20 in the morning
25 a.n.
25 a.n.
250 a.n.
300 a.n.
SSRI = selective serotonin reuptake inhibitors; TCA = Tricyclic Anti-Depressants
*The target dose is the dose that has been shown to be effective for most patients.

If a SSRI or a TCA does not have the desired effect on a generalized anxiety disorder, venlafaxine (75 mg XR/day, maximum 225 mg/day) or buspirone (30 mg/day, maximum
50 mg/day) can be prescribed.
Follow up and Referral
Initially check in with the patient on a weekly or bimonthly basis. Offer follow up appointments at increasingly longer intervals for chronic anxiety disorder. Preferably, refer patients to therapists with experience in cognitive-behavioral therapy.
Indications for consult or referral are:

Diagnostic problems;

Insufficient effects of the pharmaceutical treatment after 8 to 12 weeks;

Severe complaints or problems or severe social dysfunction;

Obsessive Compulsive Disorder.