Generalised anxiety disorder and panic disorder (with or without ...

NICE clinical guideline 113

Generalised anxiety disorder and panic disorder (with or without agoraphobia)
in adults: management in primary, secondary and community care

Ordering information
You can download the following documents from www.nice.org.uk/guidance/CG113
The NICE guideline (this document) – all the recommendations.
A quick reference guide – a summary of the recommendations for healthcare
professionals.
‘Understanding NICE guidance’ – a summary for patients and carers.
The full guideline – all the recommendations, details of how they were developed,
and reviews of the evidence they were based on.
For printed copies of the quick reference guide or ‘Understanding NICE guidance’,
phone NICE publications on 0845 003 7783 or email publications@nice.org.uk and
quote:
N2409 (quick reference guide)
N2410 (‘Understanding NICE guidance’).

Issue date: January 2011

NICE clinical guidelines are recommendations about the treatment and care of
people with specific diseases and conditions in the NHS in England and Wales.
This guidance represents the view of NICE, which was arrived at after careful
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consideration of the evidence available. Healthcare professionals are expected to
take it fully into account when exercising their clinical judgement. However, the
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discrimination and to have regard to promoting equality of opportunity. Nothing in this
guidance should be interpreted in a way that would be inconsistent with compliance
This updates and replaces NICE clinical
with those duties.
guideline 22
National Institute for Health and Clinical Excellence

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© National Institute for Health and Clinical Excellence, 2011. All rights reserved. This material
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written permission of NICE.

NICE clinical guideline 113
Developed by the National Collaborating Centre for Mental Health and
the National Collaborating Centre for Primary Care

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This guidance updates and replaces NICE clinical guideline 22 (published
December 2004; amended April 2007).
New and updated recommendations are included on the management of
generalised anxiety disorder in adults.
Recommendations are marked [2004], [2004, amended 2011] or [new 2011].
[2004] indicates that the evidence has not been updated and reviewed since
2004.
[2004, amended 2011] indicates that the evidence has not been updated
and reviewed since 2004 but a small amendment has been made to
the recommendation.
[new 2011] indicates that the evidence has been reviewed and the
recommendation has been updated or added.

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Contents
Introduction ...................................................................................................... 4
Person-centred care ........................................................................................ 6
Key priorities for implementation ...................................................................... 7
1
Guidance ................................................................................................ 10
1.1
Principles of care for people with generalised
anxiety disorder (GAD) .................................................................. 10
1.2
Stepped care for people with GAD ................................................... 12
1.3
Principles of care for people with panic disorder ............................... 24
1.4
Stepped care for people with panic disorder ..................................... 25
2
Notes on the scope of the guidance ....................................................... 37
3
Implementation ....................................................................................... 37
4
Research recommendations ................................................................... 38
5
Other versions of this guideline ............................................................... 44
6
Related NICE guidance .......................................................................... 45
7
Updating the guideline ............................................................................ 46
Appendix A: The Guideline Development Groups and NICE project team .... 47
Appendix B: The Guideline Review Panels .................................................... 52
Appendix C: Assessing generalised anxiety disorder .................................... 55
NHS Evidence has accredited the process used by the Centre for Clinical Practice at
NICE to produce guidelines. Accreditation is valid for 3 years from April 2010 and is

applicable to guidance produced using the processes described in
More information on accreditation can be viewed at
www.evidence.nhs.uk

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Introduction
Generalised anxiety disorder (GAD) is one of a range of anxiety disorders that
includes panic disorder (with and without agoraphobia), post-traumatic stress
disorder, obsessive–compulsive disorder, social phobia, specific phobias (for
example, of spiders) and acute stress disorder. Anxiety disorders can exist in
isolation but more commonly occur with other anxiety and depressive
disorders. This guideline covers both ‘pure’ GAD, in which no comorbidities
are present, and the more typical presentation of GAD comorbid with other
anxiety and depressive disorders in which GAD is the primary diagnosis.
NICE is developing a guideline on case identification and referral for common
mental health disorders that will provide further guidance on the identification
and treatment of comorbid conditions1.
GAD is a common disorder, of which the central feature is excessive worry
about a number of different events associated with heightened tension. A
formal diagnosis using the DSM-IV classification system requires two major
symptoms (excessive anxiety and worry about a number of events and
activities, and difficulty controlling the worry) and three or more additional
symptoms from a list of six2. Symptoms should be present for at least
6 months and should cause clinically significant distress or impairment in
social, occupational or other important areas of functioning.
According to the DSM-IV-TR3, a fundamental characteristic of panic disorder
is the presence of recurring, unforeseen panic attacks followed by at least
1 month of persistent worry about having another panic attack and concern
about the consequences of a panic attack, or a significant change in

1 Common mental health disorders: identification and pathways to care. NICE clinical
guideline. Publication expected Summer 2011.

2 American Psychiatric Association (1994) Diagnostic and statistical manual of mental
disorders (fourth edition). Washington DC: American Psychiatric Association. This guideline
uses DSM-IV criteria because the evidence for treatments is largely based on this system.

3 American Psychiatric Association (2000) Diagnostic and statistical manual of mental
disorders (fourth edition, text revision). Washington DC: American Psychiatric Association.

NICE clinical guideline 113 – Generalised anxiety disorder and panic disorder
(with or without agoraphobia) in adults
4

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behaviour related to the attacks. At least two unexpected panic attacks are
necessary for diagnosis and the attacks should not be accounted for by the
use of a substance, a general medical condition or another psychological
problem. Panic disorder can be diagnosed with or without agoraphobia.
GAD and panic disorder vary in severity and complexity and this has
implications for response to treatment. Therefore it is important to consider
symptom severity, duration, degree of distress, functional impairment,
personal history and comorbidities when undertaking a diagnostic
assessment.
GAD and panic disorder can follow both chronic and remitting courses. Where
possible, the goal of an intervention should be complete relief of symptoms
(remission), which is associated with better functioning and a lower likelihood
of relapse.
The guideline assumes that prescribers will use a drug’s summary of product
characteristics (SPC) to inform their decisions made with individual service
users.
This guideline recommends some drugs for indications for which they do not
have a UK marketing authorisation at the date of publication, if there is good
evidence to support that use. Where recommendations have been made for
the use of drugs outside their licensed indications (‘off-label use’), this is
indicated in the recommendation or in a footnote.


NICE clinical guideline 113 – Generalised anxiety disorder and panic disorder
(with or without agoraphobia) in adults
5

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Person-centred care
This guideline offers best practice advice on the care of adults with
generalised anxiety disorder and panic disorder (with or without agoraphobia).
Treatment and care should take into account people’s needs and preferences.
People with generalised anxiety disorder or panic disorder (with or without
agoraphobia) should have the opportunity to make informed decisions about
their care and treatment, in partnership with their healthcare professionals. If
people do not have the capacity to make decisions, practitioners should follow
the Department of Health’s advice on consent (available from
www.dh.gov.uk/consent) and the code of practice that accompanies the
Mental Capacity Act (summary available from www.publicguardian.gov.uk). In
Wales, healthcare professionals should follow advice on consent from the
Welsh Assembly Government (available from www.wales.nhs.uk/consent).
Good communication between practitioners and people with generalised
anxiety disorder or panic disorder is essential. It should be supported by
evidence-based written information tailored to the person’s needs. Treatment
and care, and the information people are given about it, should be culturally
appropriate. It should also be accessible to people with additional needs such
as physical, sensory or learning disabilities, and to people who do not speak
or read English.
If the person agrees, families and carers should have the opportunity to be
involved in decisions about treatment and care.
Families and carers should also be given the information and support they
need.

NICE clinical guideline 113 – Generalised anxiety disorder and panic disorder
(with or without agoraphobia) in adults
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Key priorities for implementation
The following recommendations have been identified as priorities for
implementation. They have been chosen from the updated recommendations
on the management of GAD.
Step 1: All known and suspected presentations of GAD
Identification
Identify and communicate the diagnosis of GAD as early as possible to
help people understand the disorder and start effective treatment promptly.
[new 2011]
Consider the diagnosis of GAD in people presenting with anxiety or
significant worry, and in people who attend primary care frequently who:
have a chronic physical health problem or
do not have a physical health problem but are seeking reassurance
about somatic symptoms (particularly older people and people from
minority ethnic groups) or
are repeatedly worrying about a wide range of different issues. [new
2011]

Step 2: Diagnosed GAD that has not improved after step 1 interventions
Low-intensity psychological interventions for GAD
For people with GAD whose symptoms have not improved after education
and active monitoring in step 1, offer one or more of the following as a
first-line intervention, guided by the person’s preference:
individual non-facilitated self-help
individual guided self-help
psychoeducational groups. [new 2011]

NICE clinical guideline 113 – Generalised anxiety disorder and panic disorder
(with or without agoraphobia) in adults
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Step 3: GAD with marked functional impairment or that has not
improved after step 2 interventions
Treatment options
For people with GAD and marked functional impairment, or those whose
symptoms have not responded adequately to step 2 interventions:
Offer either:
an individual high-intensity psychological intervention (see 1.2.17–
1.2.21) or
drug treatment (see 1.2.22–1.2.32).
Provide verbal and written information on the likely benefits and
disadvantages of each mode of treatment, including the tendency of
drug treatments to be associated with side effects and withdrawal
syndromes.
Base the choice of treatment on the person’s preference as there is no
evidence that either mode of treatment (individual high-intensity
psychological intervention or drug treatment) is better. [new 2011]
High-intensity psychological interventions
If a person with GAD chooses a high-intensity psychological intervention,
offer either cognitive behavioural therapy (CBT) or applied relaxation. [new
2011]
Drug treatment
If a person with GAD chooses drug treatment, offer a selective serotonin
reuptake inhibitor (SSRI). Consider offering sertraline first because it is the
most cost-effective drug, but note that at the time of publication (January
2011) sertraline did not have UK marketing authorisation for this indication.
Informed consent should be obtained and documented. Monitor the person
carefully for adverse reactions. [new 2011]
Do not offer a benzodiazepine for the treatment of GAD in primary or
secondary care except as a short-term measure during crises. Follow the
advice in the ‘British national formulary’ on the use of a benzodiazepine in
this context. [new 2011]

NICE clinical guideline 113 – Generalised anxiety disorder and panic disorder
(with or without agoraphobia) in adults
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Do not offer an antipsychotic for the treatment of GAD in primary care.
[new 2011]
Inadequate response to step 3 interventions
Consider referral to step 4 if the person with GAD has severe anxiety with
marked functional impairment in conjunction with:
a risk of self-harm or suicide or
significant comorbidity, such as substance misuse, personality disorder
or complex physical health problems or
self-neglect or
an inadequate response to step 3 interventions. [new 2011]

NICE clinical guideline 113 – Generalised anxiety disorder and panic disorder
(with or without agoraphobia) in adults
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1
Guidance
The following guidance is based on the best available evidence. The full
guideline (www.nice.org.uk/guidance/CG113) gives details of the methods
and the evidence used to develop the guidance.
1.1
Principles of care for people with generalised anxiety
disorder (GAD)
Information and support for people with GAD, their families and carers
1.1.1
When working with people with GAD:
build a relationship and work in an open, engaging and
non-judgemental manner
explore the person’s worries in order to jointly understand the
impact of GAD
explore treatment options collaboratively with the person,
indicating that decision making is a shared process
ensure that discussion takes place in settings in which
confidentiality, privacy and dignity are respected. [new 2011]
1.1.2
When working with people with GAD:
provide information appropriate to the person’s level of
understanding about the nature of GAD and the range of
treatments available
if possible, ensure that comprehensive written information is
available in the person’s preferred language and in audio format
offer independent interpreters if needed. [new 2011]

1.1.3
When families and carers are involved in supporting a person with
GAD, consider:
offering a carer’s assessment of their caring, physical and
mental health needs

NICE clinical guideline 113 – Generalised anxiety disorder and panic disorder
(with or without agoraphobia) in adults
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