High risk groups 1,2

  • Family history of anxiety
  • Physical or emotional stress
  • History of physical, sexual or emotional trauma
  • Female gender
  • Comorbid chronic condition
  • People with alcohol or benzodiazepine use disorders
  • Those with variation in their cerebral functions (neurodivergence) e.g. ADHD, dyslexia, autism
  • Intellectual disability

Considerations in pregnancy 2,3

  • Anxiety is common during and after pregnancy (up to 25%)
  • Consider the risks and benefits of psychotropic drug use in pregnancy
  • See Resource 1. for drug use in pregnancy and breastfeeding

Urgent referral

1. What is an anxiety disorder? 4–6

  • Relates to the anticipation of a future or perceived threat
  • Anxious feelings:
    • are a common response to a situation where a person feels under pressure
    • quickly pass once the stressor is removed
  • While anxiety may improve performance, high levels can lead to diminished performance and ability to function
  • Anxiety becomes a disorder when it is excessive or cannot be controlled
  • Types of anxiety disorders include:
    • Generalised anxiety disorder (GAD): generalised and persistent fatigue, muscle tension, headaches, irritability, restlessness, sleep disturbance and gastrointestinal symptoms, affecting ability to function. More common in women than men and has a chronic course that often spans a persons life
    • Panic Disorder: abrupt unexpected surges of intense fear or discomfort that reach a peak within minutes and are associated with several symptoms. Attacks are not restricted to any particular situation or circumstance and can cause significant distress or disability. See Table 1.
    • Post traumatic stress disorder (PTSD): intrusive nightmares, flashbacks and thoughts. Avoiding memories of events leading to sleep disturbance, irritability, hyperarousal and anger. Arises as a delayed or protracted response (> 6 months) to a stressful event involving actual or threatened death, a serious injury, or threats to a persons physical integrity
    • Obsessive compulsive disorder (OCD): recurring and distressing intrusive thoughts, urges, or obsessions and repetitive behaviours (e.g. hand washing, counting, checking) to reduce anxiety. Patients typically recognise their behaviour is excessive or unreasonable which can lead them to feel ashamed and attempt to conceal their symptoms from others
    • Social anxiety disorder: fear of scrutiny or judgement, doing or saying something embarrassing, or being seen as inappropriately anxious in social situations. Social situations are either avoided or endured with anguish having a significant impact on quality of life
    • Specific phobia: intense and persistent fear of specific situations or objects such as: certain animals or insects, blood, injections, flying, thunder or heights. Confronting these phobic situations can set off overwhelming fear, panic and avoidance responses

Table 1. Criteria for a panic attack 5

A distinct period of intense fear or discomfort, in which ≥ 4 of the following symptoms develop abruptly and reach a peak within 10 minutes

  • Palpitations, pounding heart or accelerated heart rate
  • Numbness or tingling sensations
  • Fear of losing control or going crazy
  • Feeling dizzy, unsteady, lightheaded or faint
  • Derealisation (feelings of unreality) or depersonalisation (being detached from oneself)
  • Sensations of shortness of breath or smothering
  • Trembling or shaking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling of choking
  • Fear of dying
  • Chills or hot flushes
  • Sweating

2. Diagnosis of anxiety disorders 4,5

  • Made after health assessment, physical examination and mental health history
  • Important to exclude medical conditions and substance use and withdrawal as a cause of symptoms
  • Anxiety disorders are highly comorbid
  • Identifying situations that are feared or avoided and associated thought, helps to define the anxiety disorder and informs the management strategy
  • Validated assessment tools are used by suitably qualified clinicians to make a diagnosis. See Resource 2.

3. Management of anxiety disorders

  • The goals of managing anxiety focuses on:
    • psychotherapy (specifically cognitive behaviour therapy)
    • optimal use of medicines
    • identifying and managing co-existing  Depression
For management strategies to be successful, it is important to identify and address all possible psychological and lifestyle factors that may cause or exacerbate the disorder
  1. Support patient self-management 7
    • Provide information and resources about anxiety disorders. See Resource 3.
    • Reassure the person that anxiety disorders are real medical conditions
    • Help the patient identify the signs and symptoms of anxiety and panic attacks and recognise triggering factors. See Table 1.
    • Discuss the role that modifying lifestyle behaviours has in improving general health
    • Encourage the patient to identify barriers to adequate lifestyle modification and medical adherence and create goals to overcome those barriers. See Engaging our patients
    • Be aware of cultural factors that could influence the way symptoms are expressed or understood
  2. Social-emotional support 2,5
    • Anxiety and depression can be screened for by using a self or clinician-rated mood scale. See Resource 2.

    Build strong therapeutic relationships that will form the basis of continuing care. See Engaging our patients and Social-emotional wellbeing

  3. Psychotherapy 2,5,6,8
    • Cognitive behaviour therapy (CBT) is considered first line treatment for anxiety disorders and any associated sleep dysfunction
    • Requires referral to an appropriately trained therapist e.g. social worker, mental health worker, psychologist or GP/NP
    • CBT has been associated with lower relapse rates after 2 to 3 years. CBT:
      • can be as effective as medicines for anxiety disorders
      • provides skills that reduce risk of relapse
      • requires commitment from the patient
    • General principles of psychotherapy are to:
      • problem-solve stressors at the time they occur
      • resist thoughts of pessimism and self-criticism and replace them with realistic thoughts
      • practise behavioural activity tasks to improve mood
  4. Physical activity 1,2,7,8
    • Exercise programs are a treatment option for anxiety disorders
    • High intensity exercise is more effective than low intensity
    • Encourage community exercise programs e.g. walking, fishing or hunting groups
    • See Physical activity and sleep
  5. Relaxation training 1,2,8,10
    • Can reduce mild to moderate anxiety especially in youth
    • Can improve sleep
    • Examples include progressive muscle relaxation, mindfulness, imagery/autogenic training and deep breathing
    • Can be self-taught or by a professional. See Resource 4.
  6. Internet based treatment 4,10
    • Involves online learning materials with exercises that individuals can choose to use by themselves or with professional guidance. See Resources 5. and 6.
    • Internet self-help tools:
      • are effective for specific phobias
      • may suit patient preferences
      • can be supported by a therapist
  7. Sleep hygiene 1–4,6,10
    • Sleep disturbances are common in anxiety disorders due to the condition itself and the medicines used to treat it
    • Assess a patient’s daytime sleepiness and OSA risk by using a validated tool. If they score highly refer to a sleep specialist. See Resource 7.

4. Medicines for anxiety disorders 4,8,9,11

  • Psychotherapy is considered first line treatment
  • Medicines are useful to control symptoms where psychotherapy:
    • is not available
    • is inappropriate due to patient’s low motivation or acceptance of psychotherapy
    • is not working for the patient
  • Selective serotonin reuptake inhibitors (SSRIs) are the recommended first-line choice, however:
    • there are potential side effects
    • anxiety symptoms may worsen for a short time when starting medicines or increasing doses
    • improvement in symptoms takes up to 2 weeks after starting medicines
    • abrupt cessation of SSRIs may result in withdrawal effects
    • there is an increased risk of suicidal behaviour in people < 25 years of age taking SSRIs. Close monitoring of side effects is essential in this age group
  • See Resource 8. for psychotropic medicine consumer information
  • Table 2. outlines medicines used for anxiety
  • Table 3. summarises management of specific anxiety disorders
  • Refer all children and adolescents to Child and Youth Mental Health Services (CYMHS). See Resource 9.

Table 2. Medicines for anxiety disorders1,4,5,9,11

Selective serotonin reuptake inhibitors (SSRIs)

  • Sertraline is preferred in both pregnancy and breastfeeding. Avoid paroxetine and fluoxetine
  • Side effects include nausea, diarrhoea, insomnia, orthostatic hypotension, dizziness, hyponatraemia, increased risk of GI bleeding, sedation, sexual dysfunction, loss of libido, anorgasmia, ejaculatory disturbance
  • Weight gains > 6 kgs may occur
  • If drowsiness occurs, give in the evening
  • Careful titration and follow up is required. Doses used for anxiety disorders are typically higher than used for depression
  • Escitalopram 10–20 PO mg mane
  • Fluoxetine 20–60 PO mg mane
  • Paroxetine 20–50 PO mg mane
  • Sertraline starting mane dose 25 mg PO (panic disorder), 50 mg PO (in OCD to a max. 200 mg)

Serotonin noradrenaline reuptake inhibitors (SNRIs)*

  • May cause palpitations, tachycardia, increased BP and orthostatic hypotension
  • Treatment with a monoamine oxidase inhibitor (MAOI), or within 14 days of stopping a MAOI, is contraindicated due to serotonin toxicity risk
  • Duloxetine 30–120 mg PO mane or
  • Venlafaxine CR 75–150 PO mg mane after food (doses up to 225 mg may be required)

Tricyclic antidepressants (TCAs)

  • May be used as second line e.g. imipramine, clomipramine, and amitriptyline (for PTSD)
  • Use with caution if co-existing depression or ideas of self-harm
  • Toxic in overdose quantities

Benzodiazepines

  • Avoid repeated doses in pregnancy and breastfeeding
  • Reduces tension and increases relaxation
  • Use only for treatment during crises or if anxiety is causing unnecessary distress
  • Addictive, ensure no previous history of problem drug or alcohol use
  • For short-term use only. Prescribe in small quantities. Review regularly
  • Long-term use associated with dependence, motor vehicle accidents and memory problems
  • At the end of a treatment taper off over several weeks to avoid withdrawal symptoms
  • In the elderly, there is increased risk of oversedation, ataxia, confusion, memory impairment, falls and respiratory depression. If benzodiazepine necessary, use short term and in low doses, and avoid long-acting agents

Diazepam 2–5 mg PO stat. May be repeated up to bd

*See LAM and PBS for medicine indications and restrictions

Table 3. Management for specific anxiety disorders4,5,9,11

Anxiety disorder

Psychotherapy

(treatment of choice)

First line medicines

Second line/ other medicines

General anxiety disorder

  • CBT
  • SSRI (escitalopram) OR SNRI* (duloxetine, venlafaxine)
  • Trial another SSRI or SNRI
  • Benzodiazepine

Panic disorder

  • CBT
  • SSRI (paroxetine, sertraline) OR SNRI* (venlafaxine)
  • Trial another SSRI or SNRI
  • TCA e.g. clomipramine

Post traumatic stress disorder

  • Trauma-focused or eye movement desensitisation and reprocessing CBT
  • SSRI (paroxetine)
  • Trial another SSRI or SNRI
  • TCA e.g. amitriptyline

Obsessive compulsive disorder

  • CBT
  • SSRI (fluoxetine, sertraline, paroxetine)
  • Trial another SSRI or SNRI

Social anxiety disorder

  • Exposure-based CBT and social skills training
  • SSRI (escitalopram, paroxetine) or SNRI* (venlafaxine)
  • Propranolol for control of physiological symptoms

Specific phobias

  • Psychological interventions for all specific phobias
  • Benzodiazepine
 

*SNRIs are non-LAM and non-PBS for treatment of anxiety disorders

5. Cycle of care

Cycle of care summary for anxiety disorders

Action

Dx

Frequency

Full physical health check

12 mthly

TFT, FBC, LFTs, UEC, venous glucose, syphilis serology, fasting lipids

Dependent on any underlying medical condition and medicine use

Weight

Wkly for 6 wks then at 6 mths and 12 mthly. May need to be more regular based on clinical presentation

BP

Medicine review

Lifestyle modification

Electrocardiogram

Frequency determined by clinical condition on advice of MO/NP

Self-harm risk assessment

At each review

Medicine review

Each visit by clinician.

12 mthly review by pharmacist

MHAOD service review

As required

Mental Health Worker Review

Wkly until stable

Mental Health team

As required

MO/NP

Wkly until stable and with medicine review

Psychiatrist

For moderate/severe anxiety disorders or immediately if self-harm is an issue

6. References

7. Resources

  1. Drug use in pregnancy and breastfeeding
  2. The DASS tool –  the DASS scoring tool – The GAI-20 validated screening tool for older adults – The Hospital Anxiety and Depression Scale – The KICA-dep validated in Aboriginal and Torres Strait Islander communities available – The DMI-10 and K10 validated in people with chronic illnesses – The Geriatric Depression Scale–Short Form – The Edinburgh Postnatal Depression Scale
  3. Beyondblue anxiety resources – headspace anxiety resources – Rainbows support for children – the Black Dog Institute anxiety resources – Clear fear: app designed for teenagers – Chill Panda: app designed for children and adults
  4. BeyondBlue relaxation exercises - Autogenic training and Imagery
  5. This way up: Anxiety and Depression Program – MindEd: e-learning resource
  6. moodgym: a self help online guide to manage symptoms of depression and anxiety
  7. The Epworth Sleepiness Scale and STOP-Bang questionnaire
  8. Psychotropic medicine information for consumers and/or carers receiving health care
  9. Child and Youth Mental Health Services – Rural and remote specific support

Last updated: January 2025

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