Yellow zone Psikiyatri / Kronik Hastalık Yönetimi

Anxiety Disorders Long-Term Management — Avoidance Is What Sustains the Disease, and Benzodiazepine Reinforces Avoidance

Anxiety disorders are those in which PATIENTS OFTEN CONSULT THE EMERGENCY ROOM, CARDIOLOGY, AND GASTROENTEROLOGY, not PSYCHIATRY; BECAUSE THE COMPLAINTS ARE PHYSICAL: PALPITATIONS, CHEST PAIN, SHORTNESS OF BREATH, FEELING LIKE SUFFOCATING, DIZZINESS, SWEATING, STOMACH-INTESTINAL COMPLAINTS and NUMBNESS.

IN THESE PATIENTS, THE EXAMINATIONS ARE REPEATED, THEY ARE NORMAL EVERY TIME AND THE PATIENT IS TOLD "YOU HAVE NOTHING". THIS SENTENCE IS WELL-INTENTIONED, BUT IT DOES NOT WORK AND OFTEN HARMS:

THE PATIENT THINKS THAT HIS COMPLAINT IS NOT TAKEN SERIOUSLY, GOES TO ANOTHER PHYSICIAN AND THE EXAMINATION CYCLE STARTS AGAIN. THE MAIN MECHANISM THAT KEEPS THE DISEASE ALIVE IS AVOIDANCE:

THE PATIENT BEGINS TO STAY AWAY FROM ENVIRONMENTS, EVENTS AND SITUATIONS WHERE THE COMPLAINT OCCURS; EVERY AVOIDANCE RELIEVES IN THE SHORT TERM, BUT IN THE LONG TERM IT ENLARGES THE DISEASE BECAUSE THE OPPORTUNITY TO LEARN THAT WHAT IS FEARED DOES NOT HAPPEN DISAPPEARS and THE LIVING SPACE SHRINKS STEP BY STEP. THEREFORE, THE ESSENCE OF TREATMENT IS THE REVERSAL OF AVOIDANCE.

BENZODIAZEPINES RELIEVE QUICKLY, BUT THEY ARE A TRAP FOR THIS VERY REASON: THE PATIENT LEARNS THAT "I SURVIVED THANKS TO THE DRUG", AVOIDANCE IS REINFORCED, ADDICTION DEVELOPS and THE EFFECT OF THE ACTUAL TREATMENT DECREASES.

ALL DOSES SHOULD BE VALIDATED FROM THE INSTITUTIONAL PROTOCOL.

Rapid management

THE PATIENT GOES TO THE EMERGENCY, CARDIOLOGY, AND GASTROENTEROLOGY, NOT PSYCHIATRY because THE COMPLAINTS ARE PHYSICAL:
PALPITATIONS, CHEST PAIN, SHORTNESS OF BREATH, FEELING OF CHOKING, DIZZINESS, SWEATING, SHAKING, GASTROINTESTINAL COMPLAINTS, NUMBNESS, and FEELINGS OF 'I WILL GO CRAZY' OR 'I WILL DIE.' THIS DIAGNOSIS SHOULD BE CONSIDERED IN PATIENTS WHO HAVE REPEATED TESTS AND EACH TIME THE RESULTS ARE NORMAL.
THE SENTENCE 'YOU HAVE NOTHING' DOES NOT WORK AND IS HARMFUL: the patient THINKS THEY ARE NOT TAKEN SERIOUSLY, GOES TO ANOTHER DOCTOR, and THE CYCLE RESTARTS → THE CORRECT SENTENCE IS IN THE FORM OF 'YOUR TESTS ARE NORMAL, BUT YOUR COMPLAINTS ARE REAL AND HAVE A NAMED REASON.' THE MECHANISM THAT MAINTAINS THE ILLNESS IS AVOIDANCE: each avoidance PROVIDES SHORT-TERM RELIEF but IN THE LONG TERM INCREASES THE ILLNESS because THE OPPORTUNITY TO LEARN THAT THE FEARED THING DID NOT HAPPEN IS REMOVED → THE LIVING SPACE GRADUALLY NARROWS, and the patient DOES NOT VOLUNTEER THIS, they say 'I JUST DON'T FEEL LIKE IT ANYMORE' → WHAT THEY HAVE STOPPED DOING SHOULD BE ASKED CONCRETELY.
SAFETY BEHAVIORS serve the same function and SHOULD BE ASKED ABOUT: carrying WATER, MEDICATION, or BAG with them, NOT GOING OUT ALONE, SITTING CLOSE TO THE DOOR, CONSTANTLY CHECKING THE PULSE, and RESEARCHING ON THE INTERNET.
THE CORE OF THE TREATMENT IS REVERSING AVOIDANCE, and COGNITIVE-BEHAVIORAL THERAPY WITH EXPOSURE IS THE FIRST OPTION; MEDICATION IS ALSO A FIRST OPTION and CAN BE COMBINED.
THE BENZODIAZEPINE TRAP:
IT RELIEVES QUICKLY but THE PATIENT LEARNS 'I GOT THROUGH IT THANKS TO THE MEDICATION' → AVOIDANCE IS REINFORCED, TOLERANCE AND DEPENDENCE DEVELOP, THE EFFECT OF EXPOSURE THERAPY IS REDUCED; LONG-TERM USE IS NOT RECOMMENDED and THERE IS A RISK OF FALLS AND COGNITIVE IMPAIRMENT IN THE ELDERLY.
WHEN THE SELECTED MEDICATION IS STARTED, IN THE FIRST DAYS THERE MAY BE AN INCREASE IN RESTLESSNESS AND COMPLAINTS → START WITH LOW DOSE, THIS SITUATION IS EXPLAINED IN ADVANCE, and IT IS TOLD THAT IT TAKES WEEKS TO TAKE EFFECT; IF NOT EXPLAINED, THE PATIENT DISCONTINUES THE MEDICATION IN THE FIRST DAYS.
ORGANIC CAUSES MUST BE RULED OUT:
THYROID (relevant protocol), ARRHYTHMIAS (relevant protocol), ASTHMA (relevant protocol), ANEMIA, LOW BLOOD SUGAR, CAFFEINE AND ENERGY DRINKS, STIMULANTS, SOME MEDICATIONS AND ALCOHOL WITHDRAWAL (relevant protocol).
DEPRESSION OFTEN ACCOMPANIES AND SHOULD BE ASSESSED (relevant protocol).
ALL DOSES SHOULD BE VERIFIED FROM THE INSTITUTIONAL PROTOCOL.

Drug	Adult	Pediatric	Route	Duration
'YOU HAVE NOTHING' DOES NOT WORK The harm of the phrase 'you have nothing' is the main reason for treatment to be blocked in these patients before it starts. The physician wants to reassure the patient when the tests are normal and says this phrase with good intentions. However, when the patient hears this phrase, they do not feel reassured; because palpitations, shortness of breath, and fear of death are real and still ongoing. The conclusion the patient reaches is this: either the physician missed something or they are not being believed. Both conclusions lead them to another doctor and the test cycle starts over again. The correct approach is not to invalidate the complaint, but to clearly acknowledge the reality of the complaint while stating that the tests are normal, and to explain how the symptoms occur.	This diagnosis SHOULD BE CONSIDERED in patients whose TESTS ARE REPEATED and are NORMAL EACH TIME. The sentence "YOU HAVE NOTHING" is well-intentioned but USELESS and MOST OFTEN HARMFUL: the patient thinks their COMPLAINTS ARE NOT TAKEN SERIOUSLY, goes to ANOTHER DOCTOR, and the TEST CYCLE STARTS AGAIN. The correct phrase: "YOUR TESTS CAME OUT NORMAL. THIS DOES NOT MEAN YOUR COMPLAINTS AREN'T REAL; WHAT YOU ARE EXPERIENCING IS REAL and THERE IS A NAME AND A TREATMENT FOR IT." IT SHOULD BE EXPLAINED HOW THE SYMPTOMS OCCURRED because a patient who UNDERSTANDS THE MECHANISM IS LESS AFRAID OF THE SYMPTOM, and THIS IS THE FIRST STEP OF TREATMENT	Abdominal pain and headache are the most common complaints in children	—	In the first consultation
AVOIDANCE — the mechanism that maintains the illness The fact that avoidance is the mechanism that keeps the illness going explains why treatment cannot be carried out with medication alone. The patient experiences intense anxiety in an environment and feels relieved once they leave it; this relief is immediately learned and the behavior is reinforced. Next time, they do not enter that environment at all and again feel relieved. In the short term, this solution seems to work. However, each avoidance takes away one more thing: the opportunity to learn by experiencing that the feared outcome did not actually occur. Thus, fear remains untested and grows. Over time, the number of avoided situations increases; first public transportation, then crowded environments, then going outside alone. The patient describes this not as a symptom of illness, but as a choice.	THE PATIENT BEGINS TO STAY AWAY FROM ENVIRONMENTS, ACTIVITIES, AND SITUATIONS WHERE THE COMPLAINT OCCURS. EACH AVOIDANCE BRIEFLY RELIEVES BUT IN THE LONG TERM ENLARGES THE ILLNESS because THE OPPORTUNITY TO LEARN THAT THE FEARED THING DID NOT HAPPEN IS REMOVED → LIVING SPACE NARROWS STEP BY STEP. THE PATIENT DOES NOT EXPLAIN THIS SPONTANEOUSLY; they say "I DON'T WANT TO ANYMORE" or "IT'S NO LONGER NECESSARY". IT SHOULD BE ASKED CONCRETELY: "WHAT DID YOU DO A YEAR AGO THAT YOU NO LONGER DO?", "DO YOU GO OUT ALONE?", "DO YOU AVOID PUBLIC TRANSPORT, ELEVATOR, CROWDED PLACE OR LONG JOURNEYS?" IF POSSIBLE, QUESTIONS SHOULD ALSO BE ASKED TO RELATIVES	School avoidance and separation anxiety should be questioned in children	—	At each assessment
SAFETY BEHAVIORS should be asked about The fact that safety behaviors are as effective as overt avoidance is a point often overlooked in treatment. If the patient can enter the feared environment, it is thought that progress has been made. However, the patient often enters it with a crutch; carrying medication, accompanied by someone, or sitting in the spot closest to the exit. What they learn when they safely exit the environment is not that the environment is safe, but that they survived because of the precaution. Thus, fear is not disproved, it is merely postponed, and anxiety returns when the precaution is removed. The same mechanism can be reinforced by the physician; constantly providing reassurance and repeating tests temporarily relieves the patient's anxiety but reinforces dependency.	SAFETY BEHAVIORS are as effective as overt avoidance and can be overlooked: carrying water, medication, or a bag, not going out alone and always going with someone, sitting near the door or exit, choosing a route close to the hospital, constantly measuring pulse and blood pressure, researching symptoms online, and constantly seeking reassurance. These behaviors allow the patient to enter the environment but prevent learning because the patient attributes the good outcome not to their own ability but to that behavior. These should also be gradually eliminated in treatment. Additionally, providing constant reassurance and repeating tests feeds the same cycle through the physician.	In children, the family's reassurance behavior should also be addressed	—	When planning treatment
THE BENZODIAZEPINE TRAP The rapid relief from benzodiazepines is the source of long-term harm, and this inverse relationship is one of the most important points of treatment. The medication reduces anxiety within minutes; the patient relaxes, the physician sees that it helps, and it seems like the correct choice for both. The problem is hidden precisely in this speed. When the patient gets through the moment, they attribute it to the medication rather than their own resilience and cannot dare to face the situation next time without the drug. Thus, the medication itself becomes a safety behavior; even having it in the bag provides relief. Meanwhile, the main healing process—staying in the feared situation and seeing anxiety decrease on its own—never occurs. This is compounded by tolerance and dependence.	BENZODIAZEPINES PROVIDE RAPID RELIEF and PRECISELY FOR THIS REASON, THEY ARE A TRAP. THE PATIENT LEARNS TO SAY 'I GOT THROUGH IT THANKS TO THE MEDICATION' → AVOIDANCE and SAFETY BEHAVIORS ARE REINFORCED, HAVING THE MEDICATION WITH THEM BECOMES A SAFETY BEHAVIOR ON ITS OWN. ADDITIONALLY, TOLERANCE and DEPENDENCE DEVELOP, WITHDRAWAL AND INCREASED ANXIETY OCCUR WHEN DISCONTINUED, AND THE EFFECTIVENESS OF EXPOSURE THERAPY IS REDUCED. LONG-TERM USE IS NOT RECOMMENDED. IN THE ELDERLY, THERE IS ALSO A RISK OF FALLS, FRACTURES, CONFUSION, AND COGNITIVE IMPAIRMENT. COMBINATION WITH ALCOHOL AND OPIOIDS IS DANGEROUS DUE TO RESPIRATORY DEPRESSION. THE DECISION TO USE, TIME LIMITS, AND REDUCTION PLAN MUST BE VERIFIED BY THE INSTITUTIONAL PROTOCOL	It is not used in children and adolescents; the decision belongs to the specialist	—	In medication selection
THE ESSENCE OF TREATMENT — reversing avoidance The spontaneous decrease of anxiety is the observation on which exposure therapy is based and should be explained clearly to the patient. The patient believes that anxiety will continually rise when they are afraid and will eventually become unbearable; this belief makes escaping necessary. However, anxiety is the body's alarm response, and the alarm cannot sound indefinitely; after remaining high for a certain period, it naturally diminishes because the danger does not occur. The patient can only experience this by staying in the situation. Therefore, the duration is critical in exposure therapy; if the patient leaves the situation before anxiety decreases, they learn that they escaped to be safe, and the treatment works in the opposite direction. This is why the steps should be gradual and start at a level the patient can manage.	COGNITIVE BEHAVIORAL THERAPY and EXPOSURE ARE THE FIRST CHOICES and THEIR EFFECT LASTS EVEN AFTER THE TREATMENT ENDS. PRINCIPLE: GRADUALLY, PLANNED, AND LONG ENOUGH EXPOSURE TO AVOIDED SITUATIONS; IF EXITED BEFORE ANXIETY DECREASES IN THE ENVIRONMENT, AVOIDANCE IS REINFORCED. THE PATIENT IS TOLD: 'ANXIETY DECREASES ON ITS OWN, IT PASSES EVEN IF YOU DON'T RUN.' MEDICATION TREATMENT CAN ALSO BE A FIRST OPTION AND CAN BE COMBINED WITH THERAPY; NAMES, DOSES, AND DURATIONS OF MEDICATION MUST BE VERIFIED BY THE INSTITUTIONAL PROTOCOL. LIFESTYLE IS PART OF TREATMENT: REGULAR EXERCISE, SLEEP REGULATION, REDUCTION OF CAFFEINE AND ENERGY DRINKS, ABSTINENCE FROM ALCOHOL, AND BREATHING AND RELAXATION EXERCISES	In children and adolescents, psychotherapy is the first choice	—	Throughout the treatment
A TEMPORARY INCREASE may occur when STARTING MEDICATION A temporary increase in complaints in the first days, if the patient is unprepared, can lead to complete discontinuation of the treatment. The patient has already presented with palpitations, restlessness, and inability to sit still; an increase in exactly these symptoms in the first days of medication implies to them that the illness has worsened. Their conclusion is logical: the medication is harming them. They stop the medication and often never accept medication treatment again. However, this increase is an expected and temporary situation; it can largely be prevented by starting at a low dose and increasing slowly. Therefore, warnings should be given when prescribing the medication and the patient should be told concretely what will happen, how long it will last, and when the main effect will start.	WHEN INITIATING A SELECTED MEDICATION TREATMENT, IN THE FIRST DAYS THERE MAY BE TEMPORARY INCREASES IN RESTLESSNESS, INABILITY TO SIT STILL, SLEEP DISTURBANCES, and COMPLAINTS. FOR THIS REASON, TREATMENT STARTS AT A LOW DOSE and IS INCREASED SLOWLY; THE SITUATION IS EXPLAINED IN ADVANCE. IT SHOULD ALSO BE EXPLAINED THAT THE EFFECT DOES NOT START IMMEDIATELY and TAKES WEEKS. IF THIS IS NOT EXPLAINED, THE PATIENT MAY STOP THE MEDICATION IN THE FIRST DAYS, SAY 'THE MEDICATION MADE ME WORSE,' and LOSE TRUST IN MEDICATION TREATMENT FOR THE FUTURE. SENTENCE TO GIVE THE PATIENT: 'RESTLESSNESS MAY INCREASE IN THE FIRST FEW DAYS, THIS IS AN EXPECTED SITUATION AND TEMPORARY; THE MAIN EFFECT EMERGES WITHIN WEEKS.' THE DECISION TO STOP IS MADE WITH THE PHYSICIAN and THE MEDICATION IS GRADUALLY REDUCED	The decision and follow-up for medication in children and adolescents belong to the specialist	—	At the start of medication
ORGANIC CAUSES and CO-OCCURRING CONDITIONS Asking about alcohol is a point that changes both diagnosis and treatment in these patients. Many people with anxiety notice that alcohol calms them and gradually start using this method; this use is seen as an attempt to get rid of the disease and is not expressed unless the patient is asked. However, while alcohol reduces anxiety in the short term, it increases anxiety as its effect wears off, and in regular use, withdrawal periods themselves cause anxiety, palpitations, and trembling. Thus, the patient is feeding their illness with what they think is their treatment. If this picture is not noticed, it is interpreted as treatment resistance and the medication is changed. Therefore, alcohol use should be asked about along with the amount, without judgment.	EXCLUSIONS: THYROID DYSFUNCTION (relevant protocol), HEART RHYTHM DISORDERS (relevant protocol), ASTHMA and RESPIRATORY DISEASES (relevant protocol), ANEMIA, LOW BLOOD SUGAR, HEART VALVE DISEASES (relevant protocol), and RARE HORMONE-SECRETING TUMORS. EXPOSURE TO STIMULANTS SHOULD BE ASKED: CAFFEINE and ENERGY DRINKS, WEIGHT LOSS PRODUCTS, NASAL DECONGESTANTS, ASTHMA MEDICATIONS, and STIMULANTS (relevant protocol). ALCOHOL USE SHOULD BE ASKED because IT IS USED BOTH TO TEMPORARILY REDUCE ANXIETY AND ITS WITHDRAWAL CAUSES ANXIETY (relevant protocol). DEPRESSION FREQUENTLY ACCOMPANIES and ALSO SHOULD BE INQUIRED (relevant protocol); SUICIDAL THOUGHTS ARE ASKED DIRECTLY	Energy drink use in children should be specifically asked	—	At the diagnostic stage

Alternative

Thyroid dysfunction causes palpitations and restlessness (relevant protocol).
Heart rhythm disorders are the main differential diagnosis of palpitations (relevant protocol).
Acute coronary syndrome should be excluded in chest pain (relevant protocols).
Asthma and respiratory diseases should be differentiated in shortness of breath (relevant protocols).
Low blood sugar causes sweating and palpitations (relevant protocol).
Alcohol and substance withdrawal mimics anxiety (relevant protocol).
Exposure to caffeine and stimulants is the most frequently overlooked cause.
Depression frequently accompanies and should also be inquired (relevant protocol).
Sleep apnea causes nighttime awakenings and palpitations (relevant protocol).
Pheochromocytoma is rare but should be considered in resistant cases.

Red flags

Saying "YOU HAVE NOTHING" → the doctor wants to RELIEVE the patient and forms THIS SENTENCE WITH GOOD INTENT; however, the patient does not feel RELIEVED because PALPITATIONS, SHORTNESS OF BREATH, and FEAR OF DEATH are REAL and STILL CONTINUE → the conclusion drawn: "either the doctor MISSED SOMETHING or I AM NOT BELIEVED" and BOTH DIRECT THEM TO ANOTHER DOCTOR. CORRECT SENTENCE: "YOUR TESTS ARE NORMAL, BUT WHAT YOU ARE EXPERIENCING IS REAL and HAS A NAME, WITH A TREATABLE CAUSE."
Not explaining HOW SYMPTOMS DEVELOP → a patient who UNDERSTANDS THE MECHANISM FEARS SYMPTOMS LESS, and THIS IS THE FIRST STEP OF TREATMENT.
Not asking about AVOIDANCE → the patient EXPERIENCES HIGH ANXIETY in an environment and RELAXES when LEAVING IT; THIS RELAXATION IS LEARNED IN THE MOMENT, and BEHAVIOR IS REINFORCED → every avoidance REMOVES THE OPPORTUNITY TO LEARN THAT THE FEARED OUTCOME DID NOT HAPPEN, and FEAR GROWS WITHOUT TESTING. The patient explains this as a CHOICE, NOT A DISEASE SYMPTOM: "I JUST DON’T FEEL LIKE IT ANYMORE" → THE SPECIFIC ACTION THEY HAVE STOPPED DOING IS ASKED.
Overlooking SAFETY BEHAVIORS → the patient enters a feared environment WITH A CANE (with MEDICATION, COMPANION, or SITTING NEAR THE EXIT) → WHEN THEY SURVIVE THE ENVIRONMENT, WHAT THEY LEARN IS NOT THAT THE ENVIRONMENT IS SAFE BUT THAT THEY SURVIVED THANKS TO THE PRECAUTION → FEAR IS NOT EXTINGUISHED, IT IS ONLY POSTPONED.
The doctor continuously GIVING REASSURANCE and REPEATING TESTS → temporarily reduces the patient's anxiety but REINFORCES DEPENDENCY; THE SAME CYCLE IS FED BY THE DOCTOR.
CONTINUING BENZODIAZEPINE → the drug reduces anxiety IN MINUTES, and it SEEMS LIKE THE RIGHT CHOICE FOR BOTH PARTIES; THE PROBLEM IS HIDDEN AT THIS SPEED → when the patient gets through the moment, they ATTRIBUTE it TO THE DRUG, NOT THEIR OWN ENDURANCE, and CANNOT FACE THE SITUATION NEXT TIME WITHOUT THE MEDICATION → THE DRUG ITSELF BECOMES A SAFETY BEHAVIOR, and EVEN HAVING IT IN THE BAG RELIEVES; meanwhile, THE REAL HEALING PROCESS DOES NOT HAPPEN. Additionally, TOLERANCE, DEPENDENCY, and INCREASED ANXIETY occur when stopped.
Use of BENZODIAZEPINES IN THE ELDERLY → risk of FALLING, FRACTURE, CONFUSION, and COGNITIVE IMPAIRMENT.
Using BENZODIAZEPINES WITH ALCOHOL or OPIOIDS → RESPIRATORY DEPRESSION.
EXITING THE SITUATION WITHOUT REDUCING ANXIETY DURING EXPOSURE → the patient LEARNS THAT HE/SHE ESCAPED AND SURVIVED AGAIN and THE TREATMENT WORKS IN THE OPPOSITE DIRECTION. It should be explained to the patient: ANXIETY IS THE BODY'S ALARM REACTION and THE ALARM CANNOT SOUND INDEFINITELY; SINCE THE DANGER DID NOT OCCUR, IT WILL SUBSIDE ON ITS OWN.
NOT EXPLAINING THE TEMPORARY INCREASE IN THE FIRST DAYS WHEN STARTING MEDICATION → the patient ALREADY CAME WITH PALPITATIONS AND RESTLESSNESS; THE INCREASE OF THESE SYMPTOMS EXACTLY MEANS TO HIM/HER THAT THE DISEASE IS WORSENING and THE CONCLUSION DRAWN IS LOGICAL: 'THE MEDICATION IS HARMING ME' → the patient stops the drug and MOST OF THE TIME DOES NOT ACCEPT MEDICATION TREATMENT AGAIN.
NOT STARTING AT A LOW DOSE and NOT SAYING THAT THE EFFECT TAKES WEEKS.
NOT ASKING ABOUT ALCOHOL USE → a person with anxiety REALIZES THAT ALCOHOL CALMS HIM/HER and THIS USE IS SEEN AS AN EFFORT TO ESCAPE THE DISEASE, IT IS NOT EXPLAINED UNLESS ASKED → however, alcohol REDUCES ANXIETY IN THE SHORT TERM BUT INCREASES IT AS THE EFFECT WEARS OFF, and WITHDRAWAL PERIODS ALONE CAUSE ANXIETY, PALPITATIONS, AND TREMORS → the patient, THINKING IT IS HIS/HER OWN TREATMENT, IS FEEDING THE DISEASE and this is interpreted as TREATMENT UNRESPONSIVENESS.
NOT ASKING ABOUT EXPOSURE TO CAFFEINE, ENERGY DRINKS AND STIMULANTS.
NOT ASKING ABOUT ACCOMPANYING DEPRESSION AND SUICIDAL THOUGHTS (relevant protocol).

Disposition and follow-up

Green zone: Mild case, preserved functionality, limited avoidance patient: explanation of the mechanism, lifestyle suggestions, offering psychotherapy option, and scheduled follow-up.
Yellow zone: Marked avoidance and loss of functionality, non-responsive case, ongoing benzodiazepine use and need for tapering, accompanying depression, accompanying alcohol-substance use, treatment decision during pregnancy and breastfeeding: psychiatric evaluation.
Red zone: Chest pain, newly arisen or changed-type palpitations and shortness of breath: first, cardiac and respiratory causes should be excluded (relevant protocols). Suicidal thought and plan: emergency psychiatric evaluation (relevant protocol). Seizure or severe withdrawal due to benzodiazepine discontinuation: emergency evaluation (relevant protocol). Alcohol withdrawal and delirium signs: emergency evaluation (relevant protocol). Newly started neurological symptom or change in consciousness: emergency evaluation. Patient with impaired self-care, who has stopped eating and drinking: emergency evaluation.

Key clinical points

READ FIRST — avoidance maintains the disease.

THE PATIENT COMES TO THE EMERGENCY, CARDIOLOGY, AND GASTROENTEROLOGY, NOT PSYCHIATRY — COMPLAINTS ARE PHYSICAL | PALPITATIONS | CHEST PAIN | SHORTNESS OF BREATH | FEELING LIKE CHOKING | DIZZINESS | SWEATING | SHAKING | GASTROINTESTINAL COMPLAINTS | NUMBNESS | "FEELING LIKE I'M GOING CRAZY OR DYING" | THE SENTENCE 'YOU HAVE NOTHING' DOES NOT WORK AND MOST OF THE TIME HURTS | When the physician finds the tests normal, they want to reassure the PATIENT and say this sentence with good intentions | HOWEVER, THE PATIENT DOES NOT CALM DOWN: PALPITATIONS, SHORTNESS OF BREATH, and FEAR OF DYING ARE REAL and CONTINUE | THE CONCLUSION THE PATIENT REACHES: 'Either the physician MISSED SOMETHING or I am NOT BELIEVED' → BOTH LEAD THEM TO ANOTHER PHYSICIAN, and THE TESTING CYCLE RESTARTS | CORRECT SENTENCE: 'YOUR TESTS CAME BACK NORMAL. THIS DOES NOT MEAN YOUR COMPLAINTS DO NOT EXIST; WHAT YOU ARE EXPERIENCING IS REAL, HAS A NAME, and HAS A TREATABLE CAUSE' | THE PATIENT IS EXPLAINED HOW THE SYMPTOMS DEVELOP — A patient who understands the mechanism fears the symptom less, and THIS IS THE FIRST STEP OF TREATMENT | AVOIDANCE IS THE MECHANISM THAT MAINTAINS THE ILLNESS | The patient experiences INTENSE ANXIETY in a situation and RELAXES WHEN LEAVING → THIS RELAXATION IS LEARNED AND BEHAVIOR IS REINFORCED | Next time, THEY AVOID THAT SITUATION COMPLETELY and RELAX AGAIN → IN THE SHORT TERM, THE SOLUTION SEEMS TO WORK | HOWEVER, EACH AVOIDANCE TAKES AWAY ONE MORE THING: THE OPPORTUNITY TO LEARN THROUGH EXPERIENCE THAT THE FEARED OUTCOME DID NOT ACTUALLY HAPPEN → FEAR REMAINS UNTESTED AND GROWS | Over time, the number of avoided situations increases: FIRST PUBLIC TRANSPORT, THEN CROWDED PLACES, THEN GOING OUT ALONE → THE LIVING SPACE NARROWS GRADUALLY | THE PATIENT DESCRIBES THIS NOT AS A SYMPTOM OF ILLNESS BUT AS A CHOICE: 'I JUST DON'T FEEL LIKE IT ANYMORE' | 'THERE IS NO NEED NOW' | RULE — ASK CONCRETELY: 'WHAT DID YOU DO A YEAR AGO BUT NO LONGER DO?' | 'DO YOU GO OUT ALONE?' | 'DO YOU AVOID PUBLIC TRANSPORT, ELEVATOR, CROWDED PLACES, OR LONG TRIPS?' | IF POSSIBLE, ASK CLOSE ONES TOO

The patient comes to emergency and cardiology with physical complaints; the sentence 'you have nothing' does not work because the patient thinks either something was missed or they are not believed, and the cycle restarts. The mechanism that maintains the illness is avoidance: each avoidance moment relaxes and reinforces, but removes the opportunity to learn that the feared outcome did not happen, allowing fear to grow untested and the living space to shrink. The patient describes this as a choice, so questions should be asked concretely.

Safety Behaviors and Benzodiazepine Trapping

SAFETY BEHAVIORS ARE JUST AS EFFECTIVE AND OVERLOOKED AS OVERT AVOIDANCE | IF THE PATIENT CAN ENTER THE ENVIRONMENT HE FEARS, PROGRESS IS CONSIDERED | HOWEVER, THE PATIENT OFTEN ENTERS THERE WITH A CRUTCH: HE HAS MEDICINE WITH HIM | SOMEONE ACCOMPANIES HIM | SITS CLOSEST TO THE EXIT | EXAMPLES: CARRYING WATER, MEDICINE OR SACHETS WITH YOU | NOT GOING OUT ALONE | CLOSE TO DOOR LIVING | CHOOSING A ROUTE CLOSE TO THE HOSPITAL | CONTINUOUS HEART RATE AND BLOOD PRESSURE MEASUREMENT | ONLINE RESEARCH | REQUESTING CONTINUOUS ASSURANCE | WHAT HE LEARNS WHEN HE SURVIVES THE ENVIRONMENT IS NOT THAT THE ENVIRONMENT IS SAFE, BUT THAT HE IS SAVED THANKS TO THAT PRECAUTION → FEAR IS NOT REFUTED, IT IS ONLY POSTPONED, AND WHEN THE PRECAUTION IS TAKEN AWAY, ANXIETY RETURNS AS IT WAS | THE SAME MECHANISM IS FED BY THE HAND OF THE DOCTOR: CONSTANTLY REASSURING AND REPEATING THE EXAMINATIONS CALMS ANXIETY FOR A SHORT TIME but REINFORCES ADDICTION | BENZODIAZEPINE TRAP — QUICK RELIEF IS THE SOURCE OF ITS LONG-TERM HARM | The drug reduces anxiety in MINUTES: THE PATIENT IS RELIEVED, THE DOCTOR SEES THAT IT HELPS, and IT SEEMS LIKE THE RIGHT CHOICE FOR BOTH PARTIES | THE PROBLEM IS HIDDEN AT THIS VERY SPEED | When the patient gets through that moment, HE ATTRIBUTES IT TO THE DRUG, NOT HIS OWN ENDURANCE, AND THE NEXT TIME HE CANNOT AFFORD TO BE IN THAT SITUATION WITHOUT THE DRUG, → THE DRUG ITSELF BECOMES A SAFETY BEHAVIOR and EVEN SITTING IN THE BAG IS RELIEVING | IN THE MEANTIME, THE REAL HEALING PROCESS — STAYING IN THE FEARED SITUATION AND SEEING THE ANXIETY DECREASE ON ITS OWN — IS NEVER EXPERIENCED | TOLERANCE AND DEPENDENCE ARE ADDED TO THIS; WHEN IT IS STOPPED, there is an increase in withdrawal and anxiety | LONG-TERM USE IS NOT RECOMMENDED | ALSO IN THE ELDERLY: FALL | BROKEN | BLUR OF CONSCIOUSNESS | COGNITIVE IMPAIRMENT | USE WITH ALCOHOL AND OPIOIDS IS DANGEROUS IN TERMS OF RESPIRATORY SUPPRESSION | THE DECISION TO USE, THE TIME LIMIT AND THE MITIGATION PLAN MUST BE VALIDATED FROM THE INSTITUTIONAL PROTOCOL

Safety behaviors are as effective as explicit avoidance: the patient enters the environment with crutches and what he learns is not that the environment is safe, but that he is saved by that measure, so the fear is postponed. The same cycle is fed by the physician's constant assurance and repetition of the examination. The rapid relief of the benzodiazepine is the source of its long-term harm; the drug turns into a safety behavior and the actual healing process never happens.

Exposure, drug initiation, and alcohol

THE ESSENCE OF THE TREATMENT IS THE REVERSAL OF AVOIDANCE | COGNITIVE BEHAVIORAL THERAPY AND EXPOSURE ARE THE FIRST CHOICE AND THEIR EFFECT PERSISTS EVEN AFTER THE TREATMENT ENDS | MEDICATION TREATMENT IS ALSO THE FIRST CHOICE AND CAN BE COMBINED | ANXIETY DECREASES ON ITS OWN — THE OBSERVATION ON WHICH EXPOSURE IS BASED IS CLEARLY EXPLAINED TO THE PATIENT | The patient believes that in a situation they fear, THE ANXIETY WILL CONTINUOUSLY INCREASE and WILL EVENTUALLY BECOME UNBEARABLE → THIS BELIEF MAKES ESCAPING MANDATORY | HOWEVER, ANXIETY IS THE BODY’S ALARM RESPONSE and AN ALARM CANNOT SOUND INDEFINITELY: AFTER REMAINING HIGH FOR A CERTAIN PERIOD, IT DIES DOWN ON ITS OWN SINCE THE DANGER DOES NOT MATERIALIZE | THE PATIENT CAN ONLY EXPERIENCE THIS BY STAYING IN THE SITUATION | FOR THIS REASON, DURATION IS CRITICAL: IF THE PATIENT LEAVES THE SITUATION BEFORE THE ANXIETY DECREASES, they LEARN THAT ESCAPING SAVED THEM AGAIN and THE TREATMENT WORKS IN REVERSE | STEPS SHOULD BE GRADUAL AND START FROM A LEVEL THE PATIENT CAN HANDLE | SAFETY BEHAVIORS SHOULD ALSO BE GRADUALLY ABANDONED | WHEN STARTING MEDICATION, THERE MAY BE A TEMPORARY INCREASE IN THE FIRST DAYS — AN UNPREPARED PATIENT MAY ABANDON THE TREATMENT COMPLETELY | The patient already came with complaints of PALPITATIONS, RESTLESSNESS, and INABILITY TO STAY STILL; AN INCREASE IN THESE SYMPTOMS IN THE FIRST DAYS OF MEDICATION means to them THAT THE DISEASE IS WORSENING | The conclusion they draw is logical: "THE MEDICATION IS HARMING ME" → THEY STOP THE MEDICATION and OFTEN DO NOT ACCEPT MEDICATION TREATMENT AGAIN | HOWEVER, THIS INCREASE IS EXPECTED AND TEMPORARY; IT CAN BE LARGELY PREVENTED BY STARTING WITH A LOW DOSE AND SLOWLY INCREASING | THIS WARNING IS GIVEN WHEN PRESCRIBING THE MEDICATION: "RESTLESSNESS MAY INCREASE IN THE FIRST FEW DAYS, THIS IS EXPECTED AND TEMPORARY; THE MAIN EFFECT APPEARS IN WEEKS" | ALCOHOL MUST ALWAYS BE ASKED ABOUT — IT CHANGES BOTH THE DIAGNOSIS AND THE TREATMENT | Many people with anxiety NOTICE THAT ALCOHOL CALMS THEM and increasingly USE THIS METHOD; this use is SEEN AS AN ATTEMPT TO GET RID OF THE DISEASE and IS NOT MENTIONED UNLESS ASKED | HOWEVER, ALCOHOL REDUCES ANXIETY IN THE SHORT TERM BUT INCREASES ANXIETY ONCE ITS EFFECT WEARS OFF, and REGULAR USE CAUSES WITHDRAWAL PERIODS RESULTING IN ANXIETY, PALPITATIONS, AND TREMORS → THE PATIENT IS FEEDING THEIR DISEASE WITH WHAT THEY THINK IS THEIR TREATMENT | IF THIS PATTERN GOES UNNOTICED, THIS IS INTERPRETED AS NON-RESPONSE TO TREATMENT AND THE MEDICATION IS CHANGED → alcohol is ASKED ABOUT together with AMOUNT, WITHOUT JUDGMENT | ADDITIONALLY, EXCLUDE: THYROID (relevant protocol) | ARRHYTHMIAS (relevant protocol) | ASTHMA (relevant protocol) | ANEMIA | LOW BLOOD SUGAR | CAFFEINE AND ENERGY DRINKS | WEIGHT LOSS PRODUCTS | NASAL DECONGESTANTS AND ASTHMA MEDICATIONS | STIMULANTS | DEPRESSION FREQUENTLY CO-OCCURS and SUICIDAL THOUGHTS ARE DIRECTLY ASKED (relevant protocol) | LIFESTYLE IS PART OF THE TREATMENT: REGULAR EXERCISE | SLEEP REGULATION | REDUCTION OF CAFFEINE | BREATHING and RELAXATION EXERCISES

Anxiety is an alarm response and cannot sound indefinitely; the patient can only learn this by staying in the situation, so if the situation is left before anxiety decreases, the treatment works in the opposite direction. If the temporary increase in the first days after starting medication is not explained, the patient concludes that the medication is harmful and will not accept drug treatment again. Alcohol must be asked because the patient is feeding their illness with what they consider their treatment, and this situation is interpreted as nonresponse.

Featured external sources

NICE CG113: Generalised Anxiety Disorder and Panic DisorderCBT/exposure, drug treatment, benzodiazepine limitation, and follow-up.
NICE CG113 full guidelineStepped treatment approach in GAD and panic disorder.

Detailed assessment

Diagnostic and decision reasoning

Clinical framework

Overview

Anxiety disorders are illnesses for which patients mostly go not to psychiatry but to the emergency room, cardiology, or gastroenterology because the complaints are bodily. In patients whose tests are repeated and normal, this diagnosis should be considered.

The statement 'you have nothing' does not work and is harmful; the correct approach is to accept the reality of the complaint and explain the mechanism. The main mechanism keeping the illness standing is avoidance, and safety behaviors serve the same function.

The essence of the treatment is reversing avoidance. Benzodiazepines relieve quickly but precisely for this reason strengthen avoidance and cause dependence.

A temporary increase may occur in the first days after starting medication, and this should be explained beforehand.

Differential diagnosis and assessment

Key considerations

Thyroid dysfunction causes palpitations and restlessness (relevant protocol).
Heart rhythm disorders are the main differential diagnosis of palpitations (relevant protocol).
Acute coronary syndrome should be excluded in chest pain (relevant protocols).
Asthma and respiratory diseases should be differentiated in shortness of breath (relevant protocols).
Low blood sugar causes sweating and palpitations (relevant protocol).
Alcohol and substance withdrawal mimics anxiety (relevant protocol).
Exposure to caffeine and stimulants is the most frequently overlooked cause.
Depression frequently accompanies it (relevant protocol).
Sleep apnea causes nighttime awakenings (relevant protocol).
Pheochromocytoma is rare but should be considered in resistant cases.

Clinical decision reasoning

Why it matters

In this illness, the points determining the clinical outcome are related to communication, mechanism, and drug selection. The first point is that the statement 'you have nothing' feeds the cycle.

The second point is that avoidance keeps the illness standing, and the patient presents it as a choice. The third point is that safety behaviors are as effective as explicit avoidance.

The fourth point is that the rapid effect of benzodiazepines is the source of long-term harm. The fifth point is that the duration in exposure therapy is decisive.

The sixth point is that the temporary increase at the start of medication should be explained beforehand. The last point is asking about alcohol use.

Safety and monitoring

Complications and safety

Critical complications

There is loss of functionality and narrowing of life space.
Benzodiazepine dependence develops.
Alcohol and substance use disorder may develop (relevant protocol).
Depression develops and suicidal risk arises (relevant protocol).
Exposure to unnecessary tests and interventions occurs.
Disruption of work and school life is observed.
Chronic insomnia develops.
Digestive system complaints become chronic (relevant protocol).
Deterioration of family and social relationships occurs.
Early discontinuation of treatment and failure to return are seen.

Special patient populations

Special considerations

During pregnancy and breastfeeding, the medication decision is made by comparing the risks.
Benzodiazepines should be avoided in the elderly; there is a risk of falls and cognitive impairment.
Newly onset anxiety in the elderly should be evaluated for organic causes.
In children and adolescents, the first choice is psychotherapy; school avoidance is questioned.
In patients with heart disease, chest pain should always be re-evaluated (relevant protocol).
Benzodiazepines are not used in individuals with alcohol use disorder (relevant protocol).
Benzodiazepines may be risky in patients with respiratory failure and sleep apnea (relevant protocol).
In patients with chronic pain, anxiety increases the pain and should be addressed together.
Evaluation is different in individuals with a history of trauma and requires a specialist.

Follow-up and reassessment

Follow-up plan

In anxiety disorders, follow-up should be based more on functionality and avoidance than on symptom severity. At each check-up, what the patient is able to do and what they still avoid should be concretely asked, and the avoidance list should be compared over time.

Safety behaviors should be asked again, and the gradual discontinuation plan should be reviewed. If benzodiazepine is used, the duration and tapering plan should be considered at each visit.

In the first weeks of medication therapy, check-ups should be frequent, and it should be asked whether the temporary increase has passed. Accompanying depression and suicidal thoughts should be re-evaluated.

Use of alcohol, caffeine, and stimulants should be asked at every visit. Warning signs should be given; changes in the nature of chest pain, first-time fainting, new neurological findings, emergence of suicidal thoughts, and severe symptoms due to benzodiazepine discontinuation require immediate consultation.