____________________________________________________________________________ Anxiety Disorders
Medical Conditions Careful history taking and physical examination are warranted for all patients to rule out medical causes of anxiety symptoms. Conditions that can mimic or cause anxiety complaints include hyperthyroidism and hypothyroidism, asthma, cardiac arrhyth- mias, pheochromocytoma, and temporal lobe epilepsy. As noted, screening for depression is very important, given its high comorbidity rate and associated risk of suicidal behavior [129]. Laboratory Tests and Imaging Although usually negative in the absence of other suggestive evidence, laboratory testing or imaging studies may be indi- cated to help rule out medical cause. For example, a routine blood panel with thyroid-stimulating hormone and blood glucose levels may help to identify or rule out conditions such as hyperthyroidism or hypoglycemia that may be responsible for intense, persistent anxiety and panic. Toxicology screening may also be indicated to determine whether illicit substances are contributing to the clinical presentation. An electrocardiogram is required in all patients presenting with chest pain (to exclude cardiac causes), and pulmonary function tests are used to rule out pulmonary disease in patients with shortness of breath. It is important to note that cardiopulmonary disorders can co-occur with anxiety disorders [2].
A diagnosis of SAD should rule out avoidant personality disorder. Some symptoms of avoidant personality disorder resemble SAD, such as a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evalu- ation. However, avoidant personality disorder is distinguished by non-social avoidance that extends to novel situations and positive affect. Roughly 36% of patients with SAD are comor- bid for avoidant personality disorder, and some believe avoid- ant personality disorder is a more severe variant of SAD [130;
When assessing an adult with possible social anxiety disorder, the National Collaborating Centre for Mental Health recommends that clinicians be aware of comorbid disorders, including avoidant personality disorder, alcohol and substance
131]. misuse, mood disorders, other anxiety disorders, psychosis, and autism. (https://www.nice.org.uk/guidance/cg159/resources/ social-anxiety-disorder-recognition-assessment-and- treatment-pdf-35109639699397. Last accessed April 27, 2025.) Level of Evidence : Expert Opinion/Consensus Statement Medication or Substance Use It is important to rule out medication side effects as the under- lying cause of anxiety by obtaining a complete list of currently used prescribed, over-the-counter, and herbal medications. Examples of common medications with anxiety side effects are asthma medications (e.g., albuterol, theophylline), herbal medicines (St. John’s wort, ginseng, ma huang ), corticosteroids, and antidepressants [2]. Patients should also be assessed for current use of alcohol, nicotine, stimulants, benzodiazepines, and opioids, because the direct, adverse, or withdrawal effects can mimic anxiety or panic symptoms [132]. Illicit or illicitly used drugs with acute effects most commonly associated with anxiety include cocaine, methamphetamine, prescription amphetamines (e.g., lisdexamfetamine), methylphenidate, and MDMA (“Ecstasy”) [2]. Caffeine may also provoke anxiety in sensitive patients, including those with anxiety disorders [28]. Alcohol use disor- der is highly prevalent among persons with anxiety disorders. Acute anxiety relief may powerfully reinforce alcohol use, but frequent or heavy drinking commonly exacerbates the anxiety disorder symptoms. When these two disorders co-occur, treat- ment can be complicated.
GENERAL TREATMENT CONSIDERATIONS
Information in this section is derived from published research, meta-analyses, and clinical practice guidelines. The most recent anxiety disorder guideline (on panic disorder) by the Ameri- can Psychiatric Association was published in 2009. The 2014 Anxiety Disorders Association of Canada (ADAC) guidelines are the most recent and comprehensive North American publication and are emphasized accordingly [120]. Successful treatment requires tailoring options to individuals and may often include a combination of modalities [121]. When select- ing a treatment regimen, clinicians should consider current and prior treatments, comorbid conditions, age, cost of and access to care, and patient preference [350]. The two recommended first-line modes of therapy for anxiety disorder are psychotherapy (principally CBT) and pharmaco- therapy. CBT, which includes an exposure therapy component when there are triggered episodes (e.g., SAD, specific phobia), is designed to work through maladaptive beliefs and avoidance behaviors that reinforce pathology surrounding fear-eliciting stimuli. CBT with some variant of exposure is the first-line psy- chotherapy approach for most adult patients and all childhood cases of anxiety disorder. Selecting CBT as treatment option has two limitations: it requires patient willingness to engage
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