Clinical Guide > Neuropsychiatric Disorders > Anxiety Disorders

Anxiety Disorders

January 2011

Chapter Contents


Anxiety symptoms are common and can develop or recur for many reasons, including a patient's worries about HIV infection and treatment, or issues unrelated to HIV. Symptoms can range from mild distress to full-blown anxiety disorders. Symptoms of anxiety can mimic symptoms of physical illness, and an appropriate workup should be performed to rule out other illnesses. Use of illicit drugs (e.g., amphetamines, cocaine) or alcohol can cause or substantially worsen anxiety symptoms; all patients should be screened for substance use.

Anxiety disorders include generalized anxiety disorder, obsessive-compulsive disorder, specific phobia, social phobia, acute stress disorder, posttraumatic stress disorder (PTSD), and panic disorder. This chapter focuses primarily on anxiety symptoms and generalized anxiety disorder. See chapters Panic Disorder and Posttraumatic Stress Disorder for further information about these conditions.

S: Subjective

The criteria for a diagnosis of generalized anxiety disorder include unrealistic or excessive worry about two or more life circumstances for >6 months, and at least three of the following subjective complaints:

Other subjective complaints may include the following:

Ask about the symptoms indicated above, and about the following:

O: Objective

Measure vital signs, with particular attention to heart rate (tachycardia) and respiratory rate (shortness of breath, hyperventilation).

Perform a physical examination, including mental status and neurologic, cardiopulmonary, and thyroid examinations.

A: Assessment

A differential diagnosis may include the following medical conditions:

P: Plan

Diagnostic Evaluation

Perform the following tests:


Once medical disorders have been ruled out, and the diagnosis of an anxiety disorder is established, several options are available:


Options include cognitive-behavioral therapy, interpersonal therapy, exposure therapy, a stress-management group, relaxation therapy, visualization, guided imagery, supportive psychotherapy, and psychodynamic psychotherapy. Long-term psychotherapy may be indicated if experienced professionals are available and the patient is capable of forming an ongoing relationship. If possible, refer to an HIV-experienced therapist. The type of psychotherapy available to the patient often depends on the skills and training of the practitioners in a given health care system or region. In addition, the patient may be referred to available community-based support.


Medications, with or without psychotherapy, may alleviate symptoms of anxiety. Patients with advanced HIV disease, like geriatric patients, may be more vulnerable to the CNS effects of certain medications. Medications that affect the CNS should be started at low dosage and titrated slowly. Similar precautions should apply to patients with liver dysfunction.


Selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRI) are effective in treating patients with anxiety. They are favored for long-term use when a specific anxiety disorder is present and persistent. These medications do not cause tolerance or pose a risk of addiction. Below is a list of antidepressants that includes their U.S. Food and Drug Administration (FDA) approvals for specific anxiety disorders and the usual recommended dosages. FDA recommendations are based on availability of specific study data, but all SSRIs (regardless of whether they have an FDA indication for anxiety) may be helpful for a broad range of anxiety disorders.

Common adverse effects of SSRIs and SNRIs include sexual dysfunction, sleep disturbance, and nausea. For patients who are medically ill, these medications should be started at low dosage and titrated up slowly; a low dosage may be effective. These medications also should be down-tapered slowly; SSRI/SNRI discontinuation syndrome may occur if they are discontinued abruptly.

See chapter Major Depression and Other Depressive Disorders for further information about antidepressant medications, including adverse effects.


Short-term use of benzodiazepines sometimes is appropriate for mild and brief situational anxiety symptoms, even without the presence of a specific anxiety disorder. For longer-term use, non-benzodiazepines (e.g., buspirone [see below], SSRIs, or SNRIs) are preferred.

Potential ARV Interactions

Interactions may occur between certain ARVs and agents used to treat anxiety. Some combinations may be contraindicated and others may require dosage adjustment. Refer to medication interaction resources or consult with an HIV expert, psychiatrist, or pharmacist before prescribing.


  • Some ARV medications (particularly PIs) may affect the metabolism of some antidepressants via cytochrome P450 interactions. For most SSRIs and SNRIs, interactions with ARVs generally are not clinically significant; in the case of tricyclics, their levels may be significantly increased by ritonavir. On the other hand, some PIs may decrease levels of paroxetine and sertraline, and efavirenz also lowers sertraline levels. See chapter Major Depression and Other Depressive Disorders for further information.


  • PIs and nonnucleoside reverse transcriptase inhibitors (NNRTIs) may raise blood concentrations of many benzodiazepines. Consider using a benzodiazepine metabolized by glucuronidation (e.g., lorazepam, oxazepam), particularly in patients with liver disease. For benzodiazepines metabolized by the CYP system, start at low dosages and titrate slowly. Other CNS depressants and alcohol should be avoided in patients taking these benzodiazepines.
    • Midazolam (Versed) and triazolam (Halcion) are contraindicated for use with all PIs and with delavirdine and efavirenz.
  • Buspirone levels may be increased by ritonavir-boosted PIs, and may be decreased by CYP inducers. Monitor patients for adverse effects and for efficacy.

Patient Education


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