Anxiety, panic and agoraphobia

Generalised Anxiety, Panic Disorder, PTSD & Obsessive-Compulsive Disorder

Anxiety, trauma-related, and obsessive-compulsive disorders represent a high-prevalence spectrum of psychiatric conditions frequently encountered in Australian emergency departments and general practice. Clinicians must be skilled in differentiating pathological anxiety from medical emergencies, implementing evidence-based psychological and pharmacological therapies, and practicing strict benzodiazepine stewardship.

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Generalised Anxiety Disorder (GAD)

Generalised Anxiety Disorder is characterized by pervasive, chronic, uncontrollable worry about widespread everyday domains, accompanied by significant somatic and psychic tension.

Diagnostic Criteria (DSM-5)

• Core Feature: Excessive anxiety and worry (apprehensive expectation) occurring more days than not for at least 6 months, concerning multiple events, circumstances, or activities (such as work performance, family health, finances, and everyday logistics).
• Uncontrollability: The individual finds it difficult to control the worry or disengage from catastrophic ruminations.
• Associated Somatic/Cognitive Symptoms: Must feature at least 3 of the following 6 symptoms (only 1 symptom required in children), present for more days than not over the preceding 6 months:
  1. Restlessness or feeling keyed up or on edge.
  2. Easy fatigability (physical exhaustion from sustained hyperarousal).
  3. Difficulty concentrating or mind going blank.
  4. Irritability.
  5. Muscle tension (myofascial tightness, chronic tension headaches, jaw clenching).
  6. Sleep disturbance (difficulty falling or staying asleep, or restless, unrefreshing sleep).
• Screening Tool: The GAD-7 questionnaire is widely used across Australian general practice to stratify severity (5–9: mild, 10–14: moderate, $\ge 15$: severe) and monitor therapeutic progress.

Evidence-Based Management

• First-Line Psychotherapy: Cognitive Behavioural Therapy (CBT) is the psychological treatment of choice. Components include psychoeducation regarding autonomic arousal, cognitive restructuring (identifying cognitive distortions such as catastrophic thinking and probability overestimation), applied relaxation, and behavioural worry exposure.
• First-Line Pharmacotherapy: SSRIs (escitalopram $10\text{ to }20\text{ mg}$, sertraline $50\text{ to }150\text{ mg}$) or SNRIs (venlafaxine $75\text{ to }225\text{ mg}$, duloxetine $30\text{ to }60\text{ mg}$). Therapeutic effects typically require 4 to 6 weeks to manifest fully.
• Second-Line Agents: Pregabalin (calcium channel alpha-2-delta ligand) or buspirone (partial 5-HT1A agonist).
• Benzodiazepine Stewardship: The Royal Australian College of General Practitioners (RACGP) and RANZCP explicitly recommend against long-term benzodiazepine prescribing (e.g., diazepam, alprazolam, temazepam). Benzodiazepines induce rapid GABA-A receptor down-regulation within 2 to 4 weeks, leading to tolerance, severe physiological dependence, withdrawal rebound anxiety, increased risk of falls and hip fractures in older patients, cognitive blunting, and life-threatening withdrawal seizures upon abrupt cessation. Their use is strictly restricted to short-term crisis management (maximum 1 to 2 weeks) while awaiting SSRI onset.

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Panic Disorder & Agoraphobia

Clinical Presentation

A panic attack is an abrupt surge of intense fear or extreme discomfort that reaches a crescendo within minutes. Physical symptoms are driven by acute sympathetic nervous system hyperactivation and hyperventilation-induced respiratory alkalosis (causing hypocapnia, cerebral vasoconstriction, and acute ionized hypocalcaemia manifested as peripheral and perioral paraesthesias or carpopedal spasm).

Diagnostic Rule-Outs in Acute Practice

In the emergency department, panic presentations frequently mimic life-threatening organic disease. Clinicians must systematically rule out:

• Cardiovascular: Acute coronary syndromes (STEMI/NSTEMI), supraventricular tachycardia (AVNRT/AF), aortic dissection, or myocarditis.
• Respiratory: Pulmonary embolism, acute asthma exacerbation, or tension pneumothorax.
• Endocrine & Metabolic: Hypoglycaemia, hyperthyroidism (thyrotoxicosis), and pheochromocytoma.
• Toxicological: Caffeine toxicity, amphetamine/cocaine intoxication, cannabis hyperarousal, or alcohol/sedative withdrawal.

Agoraphobia

Agoraphobia is characterized by marked fear or anxiety about at least 2 of the following 5 situations:

1. Using public transportation (buses, trains, planes, ferries).
2. Being in open spaces (parking lots, bridges, marketplaces).
3. Being in enclosed spaces (shops, cinemas, elevators).
4. Standing in line or being in a crowd.
5. Being outside of the home alone. Psychological Mechanism: The individual fears or avoids these situations because they believe that escape might be difficult, or that help might not be available in the event of developing panic-like or embarrassing symptoms.

Management of Panic Disorder

• Emergency Management of Hyperventilation: Reassurance, breathing control techniques (slow diaphragmatic breathing at 6 to 8 breaths per minute; rebreathing into paper bags is historically obsolete and contraindicated due to risk of hypoxaemia).
• First-Line Psychotherapy: CBT incorporating interoceptive exposure. The clinician guides the patient through voluntary, controlled provocation of feared bodily sensations (e.g., hyperventilating for 60 seconds, spinning in a swivel chair, breathing through a straw) to demonstrate that physiological sensations are harmless, systematically breaking the conditioned panic spiral.
• First-Line Pharmacotherapy: SSRIs (sertraline, escitalopram, citalopram) or SNRIs (venlafaxine). Doses must be initiated at half the standard starting dose because panic patients are exquisitely sensitive to transient, anxiogenic side effects during the first week of titration.

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Obsessive-Compulsive Disorder (OCD)

Obsessive-Compulsive Disorder is characterized by the presence of obsessions, compulsions, or both, causing severe functional distress and consuming more than 1 hour per day.

Primary references (checked 7 October 2026): Phoenix Australia trauma guidelines.