Anxiety disorder

#Anxiety disorder, new
The patient meets criteria for anxiety disorder, specifically...
***generalized anxiety disorder given functional impairment from excessive unconrollable worry about a number of concerns, with*** agoraphobia. Screen with GAD-7: ***.
***panic disorder given recurrent out of the blue panic attacks with concern about recurrences. Screen with panic disorder severity scale: ***.
***social anxiety disorder given excessive anxiety related to social situations and potential scrutiny of others. Screen with Mini-SPIN: ***.
***specific phobia given excessive fear about *** with avoidance and/or enduring distress.

No personal history of PTSD or manic episodes, significant famhx of bipolar, and no psychotic features. Given new onset, consider secondary causes including hypoglycemia, hyperthyroid, anemia, withdrawal (EtOH, opioids, BZD, antidepressants), SUD, excess caffeine.
Dx:
- TSH, CBC, BMP, consider Utox
- psychiatry referral for suicidality, thought d/o, unclear dx, psychotic features, bipolar, refractory to multiple therapiest
Non-Pharm Tx:
- psychotherapy referral for CBT and/or exposure therapy
- biofeedback, yoga, meditation
Pharm Tx: (uptitrate qweekly to qmonthly as tolerated; anxiolytic effect may require higher doses than for depression; trial slow taper off 6-9 months post-remission)
- start SSRI [escitalopram 5mg qd, then increase to 20-30 mg qd as tolerated] [sertraline (more stimulating, more diarrhea) start 50mg qd, uptitrate by 25-50mg qweekly as tolerated to 200mg qd max]
-- if comorbid panic attacks or inability to tolerate low dose SSRIs, can start with liquid formulation of eg escitalopram 1mg qd and increase by 1mg weekly
- consider starting other classes of meds instead in special circumstances:
-- consider SNRI (esp duloxetine start 30mg qd -> 60-120mg qd max) if chronic pain
-- consider TCA eg nortryptyline (25mg->50-150mg qd) if chronic pain/migraine or amitriptyline (25mg->100-300mg qd) if significant insomnia (caution: TCA lethal in OD)
-- avoid buproprion
- can augment with buspirone 10-60mg in 2-3 divided doses
- can augment with gabapentin/pregabalin (slow uptitration to max 3600mg total daily / 300mg total daily)
- consider propranolol 20-40mg BID PRN especially for social or performance anxiety; occasional PRN BZD reasonable for specific phobias
- reasonable for SHORT bridge of eg clonazepam 0.25-0.5mg BID PRN during SSRI uptitration but long term BZD should be reserved for patients who have failed first line treatments;

- f/u 4 weeks