Anxiety Disorders for the NP Exam: GAD-7, Panic, First-Line Drugs and When Benzodiazepines Are Wrong

Anxiety disorders on the NP exam come down to three decisions: whether to screen, which disorder the vignette describes, and which first-line treatment fits. The USPSTF (2023) gives a grade B to anxiety screening in adults 64 and younger, including pregnant and postpartum patients, and an I statement for adults 65 and older; the GAD-7 with a cut-off of 10 is the standard tool. First-line therapy for generalized anxiety disorder and panic disorder is cognitive behavioral therapy or an SSRI or SNRI, and a benzodiazepine is almost always the distractor.

Screening: who and how

Adults

The June 2023 USPSTF statement recommends screening adults 64 and younger, including pregnant and postpartum persons (grade B). For adults 65 and older the evidence was insufficient (grade I), largely because screening accuracy in older adults has not been studied well. No interval is specified; screen adults not previously screened and use judgment for higher-risk patients, with ongoing assessment during pregnancy and the postpartum period.

Children and adolescents

The 2022 USPSTF statement recommends anxiety screening for ages 8 to 18 (grade B). Evidence for children 7 and younger is insufficient.

The GAD-2 and GAD-7

The GAD-2 is the first two GAD-7 items (nervousness and uncontrollable worry over the past 2 weeks), scored 0 to 6. A score of 3 or higher is the usual positive screen. The GAD-7 has seven items scored 0 to 3, for a total of 0 to 21.

In the USPSTF evidence review, a GAD-7 cut-off of 10 had a pooled sensitivity of about 0.79 and specificity of about 0.89 for generalized anxiety disorder. Despite its name, the GAD-7 also picks up panic, social anxiety and PTSD reasonably well, so a positive score still needs a diagnostic interview to name the disorder.

Naming the disorder

Generalized anxiety disorder (DSM-5)

• Excessive anxiety and worry about several events or activities, more days than not, for at least 6 months.
• The worry is hard to control.
• At least three of six symptoms in adults (one in children): restlessness, easy fatigue, poor concentration, irritability, muscle tension, sleep disturbance.
• Clinically significant distress or impairment, not due to a substance or medical condition, not better explained by another disorder.

Panic disorder (DSM-5)

• Recurrent unexpected panic attacks: an abrupt surge of intense fear peaking within minutes with at least four of 13 symptoms (palpitations, sweating, trembling, dyspnea, choking, chest pain, nausea, dizziness, chills or heat, paresthesias, derealization or depersonalization, fear of losing control, fear of dying).
• At least one attack followed by 1 month or more of persistent worry about further attacks or a maladaptive change in behavior, such as avoiding exercise or places.
• Agoraphobia is now a separate diagnosis that often coexists.

Rule out medical and substance causes

Before labeling anxiety as primary, consider:

• Endocrine: hyperthyroidism (check a TSH), hypoglycemia, pheochromocytoma in the right story.
• Cardiopulmonary: arrhythmias, angina, asthma or COPD exacerbations, pulmonary embolism when chest pain and dyspnea are new.
• Substances: caffeine, nicotine, decongestants, stimulants, cannabis, thyroid hormone excess, and withdrawal from alcohol, benzodiazepines or opioids.
• Coexisting conditions: depression coexists with anxiety disorders often enough that a PHQ-9 belongs in the workup, and any suicidal thinking needs assessment; the 988 Suicide and Crisis Lifeline (call or text 988) belongs in the plan for any patient with suicidal thoughts.

First-line treatment

The stepped-care model

NICE CG113 lays out a stepped approach for generalized anxiety disorder that matches what the exam rewards:

1. Identification, education and active monitoring.
2. Low-intensity psychological interventions: guided self-help, psychoeducation groups.
3. For marked impairment or no improvement: a high-intensity psychological intervention (CBT or applied relaxation) or drug treatment, chosen with the patient.
4. Complex, treatment-refractory or high-risk cases: specialist mental health care.

For panic disorder, NICE also places CBT and an SSRI at the front and advises that benzodiazepines should not be prescribed because they are associated with a worse long-term outcome.

Medication choices

SSRIs and SNRIs are first-line drugs for both disorders. NICE names sertraline as the first drug to offer for generalized anxiety disorder on cost-effectiveness grounds, with an alternative SSRI or an SNRI if it does not help, and pregabalin if SSRIs and SNRIs are not tolerated.

Dosing principles

• Start the SSRI at a low dose and increase after about 1 to 2 weeks if tolerated. In panic disorder, start at roughly half the usual depression starting dose because early activation can mimic an attack. Confirm specific milligram doses in current labeling.
• Expect partial benefit in the first weeks and judge the trial after about 8 to 12 weeks at an effective dose; NICE uses 12 weeks for its panic disorder decision point.
• Once the patient responds, continue the drug for a prolonged period, commonly at least 6 to 12 months, before a gradual taper. Confirm the duration in the current guideline for the specific disorder.

Psychotherapy

CBT is first-line for both disorders and is as effective as medication for many patients, with more durable benefit after treatment ends. For panic disorder it includes psychoeducation about the fear cycle, interoceptive exposure and gradual exposure to avoided situations. Combined therapy is reasonable for severe symptoms.

When benzodiazepines are wrong

On the exam, a benzodiazepine is rarely the right answer for an anxiety disorder. The specific situations where it is clearly wrong are worth memorizing:

• Older adults. The 2023 Beers Criteria list all benzodiazepines to avoid in adults 65 and older because of cognitive impairment, delirium, falls, fractures and motor vehicle crashes.
• Concurrent opioids. Benzodiazepines with opioids carry an FDA boxed warning for profound sedation, respiratory depression, coma and death. Beers also flags the combination.
• Alcohol or other substance use disorders. High risk of misuse, dependence and overdose.
• Respiratory compromise. Untreated sleep apnea, severe COPD.
• Long-term maintenance. Tolerance and physical dependence develop, withdrawal can include seizures, and long-term use does not treat the underlying disorder.
• Panic disorder. NICE advises against benzodiazepines because of worse long-term outcomes.
• Pregnancy. Weigh neonatal sedation and withdrawal; refer for specialist input.

When a patient already takes a benzodiazepine long term, abrupt discontinuation is also wrong. The 2025 joint benzodiazepine tapering guideline led by ASAM calls for shared decision-making and a gradual, individualized taper, commonly reducing by about 5 to 10 percent every 2 to 4 weeks and generally not more than 25 percent every 2 weeks, with slowing or pausing if withdrawal symptoms appear. Confirm the exact rates in the guideline before using them. CBT for anxiety improves taper success.

Monitoring and follow-up

• Repeat the GAD-7 at each visit to track response, with PHQ-9 if depression coexists.
• Early contact within the first few weeks after starting an SSRI or SNRI to check adverse effects, adherence and any suicidal thinking (the antidepressant boxed warning applies to patients under 25 regardless of the indication).
• Check blood pressure on venlafaxine and sodium in older adults on SSRIs or SNRIs, especially with diuretics.
• Reassess the diagnosis if there is no response to two adequate trials, and look again for substance use and missed medical causes.

Referral triggers

• Suicidal ideation with intent or a plan, or recent suicidal behavior: emergency evaluation; give the 988 Lifeline number.
• No response after two adequate medication trials, or after combined therapy.
• Coexisting bipolar disorder, psychosis, severe PTSD, eating disorder or active substance use disorder.
• Severe functional impairment, such as being unable to leave home because of agoraphobia.
• Patients on long-term benzodiazepines who are unable to taper in primary care.

Patient and family education

• Anxiety disorders are common and treatable; panic attacks are frightening but not dangerous to the heart once a cardiac cause has been excluded.
• SSRIs take weeks to work; early jitteriness usually settles.
• Limit caffeine, nicotine and alcohol, which worsen anxiety and sleep.
• Regular aerobic exercise and good sleep habits reduce symptoms but complement, rather than replace, treatment.
• Do not stop an SSRI or SNRI suddenly, and never stop a long-used benzodiazepine abruptly.
• Family members can support exposure work by not reinforcing avoidance.

How the exam tests this

• Age-based screening. A 70-year-old asking for anxiety screening: the USPSTF statement is an I, not a B. A 15-year-old: grade B (ages 8 to 18).
• Panic versus cardiac. The first visit for chest pain and palpitations needs a cardiac and thyroid workup; the third visit with a negative workup and fear of the next episode is panic disorder.
• Buspirone for panic. A classic wrong answer. It is a GAD option only.
• "Give lorazepam as needed." Wrong in older adults, with opioids or alcohol, in substance use disorders and as long-term therapy. The right first move is an SSRI or SNRI and CBT.
• Hydroxyzine in older adults. Anticholinergic, on Beers.
• Stopping too early. A patient improved at 8 weeks still needs months of continuation.
• Missing the mimic. Weight loss, tremor and heat intolerance point to hyperthyroidism; new anxiety after starting pseudoephedrine or a stimulant points to the drug.

Practice question

A 72-year-old woman reports a year of constant worry about her finances and her grandchildren, poor sleep, muscle tension and trouble concentrating. Her GAD-7 is 13. She takes hydrochlorothiazide and oxycodone 5 mg twice daily for chronic back pain. TSH, CBC and basic metabolic panel are normal. She has no suicidal ideation. Which of the following is the most appropriate initial treatment?

• A. Alprazolam 0.25 mg three times daily as needed
• B. Hydroxyzine 25 mg three times daily as needed
• C. CBT referral and sertraline started at a low dose, with a sodium level in the first weeks
• D. Buspirone plus lorazepam at bedtime until buspirone takes effect

Answer: C. Her symptoms meet criteria for generalized anxiety disorder, and CBT with an SSRI is first-line; sertraline is the drug NICE names first, and a sodium check is prudent because an SSRI with a thiazide in an older adult raises the risk of hyponatremia. Option A is a benzodiazepine in an adult over 65 who also takes an opioid, which violates the Beers Criteria and the opioid-benzodiazepine boxed warning. Option B is a strongly anticholinergic antihistamine that Beers advises avoiding in older adults. Option D still adds a benzodiazepine with the same risks, even though buspirone alone would be a reasonable GAD option.

Key points

Related NPPace guides

• Depression in Primary Care: PHQ-9 Screening, Starting an SSRI and the Follow-Up Schedule
• Insomnia: Why CBT-I Comes First, Which Drugs When, and the Older-Adult Rules
• Substance Use in Primary Care: Screening Tools, Alcohol Withdrawal Risk, Buprenorphine and When to Refer
• How to Read a Primary-Care Vignette Like a Provider: The 5-Step Method
• AANP vs ANCC: Which NP Certification Exam Should You Take?