Executive summary
- Differentiation: GAD = Constant worry/tension. Panic = Episodic autonomic surge.
- Treatment: SSRIs are first line for BOTH. (Benzodiazepines are for short-term crisis only, max 2-4 weeks).
- Symptom control: Beta-blockers (Propranolol) help autonomic symptoms (palpitations/tremor) but do not treat the psychic anxiety.
Stepwise Management (GAD)
- Step 1: SSRI
- Sertraline: Start 50mg od. (Warn about initial "jitteriness" - can start 25mg for 1 week).
- Escitalopram: Start 10mg od -> Max 20mg. (Often better tolerated/faster onset than Sertraline).
- Paroxetine: Licensed but avoided due to severe withdrawal/discontinuation syndrome.
- Step 2: SNRI
- Venlafaxine XL: 75mg -> 150mg -> 225mg.
- Duloxetine: 60mg -> 120mg.
- Step 3: Pregabalin (Controlled Drug)
- Indication: If SSRI/SNRI ineffective or not tolerated.
- Dose: Start 75mg bd -> Max 300mg bd.
- Warning: High abuse potential. Avoid in history of substance misuse.
Panic Disorder Specifics
- SSRI: Start LOW (e.g., Sertraline 25mg) and go slow. Panic patients are hypersensitive to side effects.
- Tricyclics: Clomipramine or Imipramine (specialist use) if SSRIs fail.
- Safety Netting: Explain that "heart attack" sensation is panic, not cardiac (after ruling out pathology).
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.