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REVIEW Open Access
Canadian clinical practice guidelines for the
management of anxiety, posttraumatic stress and
obsessive-compulsive disorders
Martin A Katzman
1*
, Pierre Bleau
2
, Pierre Blier
3
, Pratap Chokka
4
, Kevin Kjernisted
5
, Michael Van Ameringen
6
,
the Canadian Anxiety Guidelines Initiative Group on behalf of the Anxiety Disorders Association of Canada/
Association Canadienne des troubles anxieux and McGill University
Abstract
Background: Anxiety and related disorders are among the most common mental disorders, with lifetime
prevalence reportedly as high as 31%. Unfortunately, anxiety disorders are under-diagnosed and under-treated.
Methods: These guidelines were developed by Canadian experts in anxiety and related disorders through a
consensus process. Data on the epidemiology, diagnosis, and treatment (psychological and pharmacological) were
obtained through MEDLINE, PsycINFO, and manual searches (1980–2012). Treatment strategies were rated on
strength of evidence, and a clinical recommendation for each intervention was made, based on global impression
of efficacy, effectiveness, and side effects, using a modified version of the periodic health examination guidelines.
Results: These guidelines are presented in 10 sections, including an introduction, principles of diagnosis and
management, six sections (Sections 3 through 8) on the specific anxiety-related disorders (panic disorder,
agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder,
and posttraumatic stress disorder), and two additional sections on special populations (children/adolescents,
pregnant/lactating women, and the elderly) and clinical issues in patients with comorbid conditions.
Conclusions: Anxiety and related disorders are very common in clinical practice, and frequently comorbid with
other psychiatric and medical conditions. Optimal management requires a good understanding of the efficacy and
side effect profiles of pharmacological and psychological treatments.
Introduction
Anxiety and related disorders are among the most com-
mon of mental disorders. Lifetime prevalence of anxiety
disorders is reportedly as high as 31%; higher than the
lifetime prevalence of mood disorders and substance use
disorders (SUDs) [1-5]. Unfortunately, anxiety disorders
are under-diagnosed [6] and under-treated [5,7,8].
These guidelines were developed to assist clinicians,
including primary care physicians and psychiatrists, as
well as psychologists, social workers, occupational thera-
pists, and nurses with the diagnosis and treatment of
anxiety and related disorders by providing practical,
evidence-based recommendations. This guideline docu-
ment is not focused on any individual type of clinician
but rather on assessing the data and making recommen-
dations. Subsequent “user friendly”tools and other
initiatives are planned.
The guidelines include panic disorder, agoraphobia,
specific phobia, social anxiety disorder (SAD), generalized
anxiety disorder (GAD), as well as obsessive-compulsive
disorder (OCD), and posttraumatic stress disorder
(PTSD). Also included are brief discussions of clinically
relevant issues in the management of anxiety and related
disorders in children and adolescents, women who are
pregnant or lactating, and elderly patients, and patients
with comorbid conditions.
* Correspondence: mkatzman@startclinic.ca
1
Department of Psychiatry, University of Toronto, Toronto, ON, M5S 1A1,
Canada
Full list of author information is available at the end of the article
Katzman et al.BMC Psychiatry 2014, 14(Suppl 1):S1
http://www.biomedcentral.com/1471-244X/14/S1/S1
© 2014 Katzman et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Methods
These guidelines are based on a thorough review of
the current literature and were developed by a panel of
Canadian experts in anxiety and related disorders
through a consensus process. Data on the epidemiology,
diagnosis, and treatment (psychological and pharmacolo-
gical) were obtained through MEDLINE searches of
English language citations (1980–2012), using search
terms encompassing the specific treatments and specific
anxiety and related disorders. These searches were supple-
mented with data from PsycINFO and manual searches of
the bibliographies of efficacy studies, meta-analyses, and
review articles. Treatment strategies were rated on
strength of evidence for the intervention (Table 1). A clini-
cal recommendation for each intervention was then made,
based on global impression of efficacy in clinical trials,
effectiveness in clinical practice, and side effects, using a
modified version of the periodic health examination guide-
lines (Table 2).
The guidelines were initiated prior to the introduction
of the American Psychiatric Association’s (APA) fifth edi-
tion of the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5) and the committee was sensitive to
potential changes to the nosology of anxiety and related
disorders and its impact on the guidelines. However, it
was agreed that, since the evidence for treatment is based
on studies using DSM-IV criteria (or earlier), the intro-
duction of the DSM-5 would not fundamentally alter the
evidence and recommendations at this time. Whether
using DSM-5 diagnostic criteria for the inclusion patients
in clinical trials in the future will have an impact on out-
comes, remains to be seen.
The panel of Canadian experts in anxiety and related
disorders responsible for the development of these
guidelines via consensus process included 10 psychia-
trists and seven psychologists who were organized into
subpanels based on their expertise in particular anxiety
or related disorders as well as in treating specific patient
populations. Preliminary treatment recommendations
and the evidence upon which they had been based were
reviewed at a meeting of the panel in December 2012;
subsequently, draft guidelines were prepared by the sub-
panels which were then circulated to the entire group
for consensus ratification during 2013. Preliminary
recommendations were also presented to the Canadian
psychiatric community for input in September 2012 at
the Canadian Psychiatric Association annual conference.
These guidelines are presented in 10 sections, the first
of which is this introduction. In the following section, the
principles of diagnosis and management of anxiety and
related disorders are covered. That section provides an
overview of the differential diagnoses associated with
anxiety and related disorders in general, discusses issues
that affect all anxiety disorders, and presents the general
advantages and disadvantages of psychological treatment
and pharmacotherapy options. In the subsequent six sec-
tions (Sections 3 through 8), the specific diagnosis and
management of the individual anxiety and related disor-
ders (panic disorder, specific phobia, SAD, OCD, GAD,
and PTSD) are reviewed and recommendations are made
for psychological and pharmacological treatments. Sec-
tion 9 discusses issues that may warrant special attention
pertaining to anxiety and related disorders in children
and adolescents, pregnant or lactating women, and the
elderly. The last section of these guidelines addresses
clinical issues that may arise when treating patients with
anxiety and related disorders who are also diagnosed
with comorbid psychiatric conditions such as major
depressive disorder (MDD), bipolar disorder, or other
psychoses, and attention deficit/hyperactivity disorder
(ADHD), or medical comorbidities, such as pain syn-
dromes, cardiovascular disease, and diabetes/metabolic
syndrome.
Principles of diagnosis and management of
anxiety and related disorders
Epidemiology
Prevalence and impact
Anxiety and related disorders are among the most com-
mon mental disorders, with lifetime prevalence rates as
high as 31% [1-5] and 12-month prevalence rates of
about 18% [3,4]. Rates for individual disorders vary
widely. Women generally have higher prevalence rates
Table 1 Levels of evidence
1Meta-analysis or at least 2 randomized controlled trials (RCTs) that
included a placebo condition
2At least 1 RCT with placebo or active comparison condition
3Uncontrolled trial with at least 10 subjects
4Anecdotal reports or expert opinion
Levels of evidence do not assume positive or negative or equivocal results,
they merely represent the quality and nature of the studies that have been
conducted.
Level 1 and Level 2 evidence refer to treatment studies in which randomized
comparisons are available. Recommendations involving epidemi ological or risk
factors primarily arise from observational studies, hence the highest level of
evidence for these is usually Level 3. Recommendations, such as principles of
care, reflect consensus opinion based on evidence from various data sources,
and therefore are primarily Level 4 evidence.
Table 2 Treatment recommendation summary
First-line Level 1 or Level 2 evidence plus clinical support for
efficacy and safety
Second-line Level 3 evidence or higher plus clinical support for
efficacy and safety
Third-line Level 4 evidence or higher plus clinical support for
efficacy and safety
Not
recommended
Level 1 or Level 2 evidence for lack of efficacy
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for most anxiety disorders, compared with men [4,5,9].
Anxiety and related disorders are associated with an
increased risk of developing a comorbid major depres-
sive disorder [10-12].
Anxiety and related disorders put a significant burden
on patients and their family members [13]. They are
associated with substantial functional impairment, which
increases as the severity of anxiety [14] or the number of
comorbid anxiety disorders increases [7,15]. In addition,
studies have demonstrated quality of life impairments in
patients with various anxiety and related disorders
[16,17]. Anxiety has a considerable economic impact on
society as well, being associated with greater use of health
care services [5,18] and decreased work productivity
[18,19].
Importantly, studies report that about 40% of patients
diagnosed with anxiety and related disorder are
untreated [5,7].
Suicide risk
In large surveys, anxiety and related disorders were
independently associated with a significant 1.7-2.5 times
increased risk of suicide attempts [20-23]; however, data
are conflicting as to whether the risk is moderated by
gender [20,23]. Increased risk of suicide attempts or
completed suicide has been reported for patients with
panic disorder, PTSD [20,24], and GAD [24], even in
the absence of a comorbid mood disorder. These data
indicate that patients with an anxiety disorder warrant
explicit evaluation for suicide risk. The presence of a
comorbid mood disorder significantly increases the risk
of suicidal behavior [22,25].
Initial assessment of patients with anxiety
The management of patients presenting with anxiety
symptoms should initially follow the flow of the five
main components outlined in Table 3.
Screen for anxiety and related symptoms
Anxiety and related disorders are generally characterized
by the features of excessive anxiety, fear, worry, and avoid-
ance. While anxiety can be a normal part of everyday life,
anxiety disorders are associated with functional impair-
ment; as part of the key diagnostic criteria for anxiety dis-
orders is the requirement that the symptoms cause
clinically significant distress or impairment in social, occu-
pational, or other important areas of functioning [26].
Asking patients if they are feeling nervous, anxious or
on edge, or whether they have uncontrollable worry, can
be useful to detect anxiety in patients in whom the clini-
cian suspects an anxiety or related disorder [7]. The
DSM-5 suggests the questions shown in Table 4 for the
identification of anxiety-related symptoms; items scored
as mild or greater may warrant further assessment [26].
If anxiety symptoms are endorsed, they should be
explored in more detail by including questions about
the onset of the anxiety symptoms, associations with life
events or trauma, the nature of the anxiety (i.e., worry,
avoidance, or obsession), and the impact they have had
on the patient’s current functioning.
Table 5 presents suggested screening questions for
individual anxiety and related disorders, from various
validated screening tools [27-30], some of which are
freely available online (e.g., http://www.macanxiety.com/
online-anxiety-screening-test).
Conduct differential diagnosis
The differential diagnosis of anxiety and related disor-
ders should consider whether the anxiety is due to
another medical or psychiatric condition, is comorbid
with another medical or psychiatric condition, or is
medication-induced or drug-related [32].
When a patient presents with excessive or uncontrolla-
ble anxiety it is important toidentifyotherpotential
causes of the symptoms, including direct effects of a sub-
stance (e.g., drug abuse or medication) or medical condi-
tion (e.g., hyperthyroidism, cardiopulmonary disorders,
traumatic brain injury), or another mental disorder [26].
However, since comorbid conditions are common, the
presence of some of these other conditions may not pre-
clude the diagnosis of an anxiety or related disorder.
Certain risk factors have been associated with anxiety
and related disorders and should increase the clinician’s
index of suspicion (Table 6) [4,9,33-37]. A family [33] or
personal history of mood or anxiety disorders [34,35] is
an important predictor of anxiety symptoms. In addi-
tion, family history is associated with a more recurrent
course, greater impairment, and greater service use [33].
Apersonalhistoryofstressfullifeeventsisalsoasso-
ciated the development of anxiety and related disorders
[36,37], in particular, childhood abuse [37].
Women generally have higher prevalence rates across
all anxiety and related disorders, compared with men
[4,5,9]. The median of age of onset is very early for some
Table 3 Overview of the management of anxiety and
related disorders
•Screen for anxiety and related symptoms
•Conduct differential diagnosis (consider severity, impairment, and
comorbidity)
•Identify specific anxiety or related disorder
•Psychological and/or pharmacological treatment
•Perform follow-up
Table 4 General screening questions
•During the past two weeks how much have you been bothered by
the following problems?
○Feeling nervous, anxious, frightened, worried, or on edge
○Feeling panic or being frightened
○Avoiding situations that make you anxious
Adapted from reference [26].
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phobias and for separation anxiety disorder (seven to
14 years), but later for GAD, panic disorder, and PTSD
(24-50 years) [1,2].
Loneliness [38], low education [38], and adverse parent-
ing [39], as well as chronic somatic illnesses, such as cardi-
ovascular disease, diabetes, asthma, and obesity may
increase the risk for a lifetime diagnosis of anxiety [34,40].
Comorbid medical and psychiatric disorders Anxiety
and related disorders frequently co-occur with other psy-
chiatric disorders [3]. More than half of patients with an
anxiety disorder have multiple anxiety disorders [3,15],
and almost 30% will have three or more comorbid anxiety
or related disorders [3]. Anxiety is often comorbid with
substance use and mood disorders [3,40]. An estimated
52% of patients with bipolar disorder [43], 60% of patients
with MDD [44], and 47% of those with ADHD [45] will
have a comorbid anxiety or related disorder. Therefore,
anxiety disorders should be considered in these patients.
The high frequency of comorbidity must be consid-
ered when diagnosing anxiety and related disorders
since this can have important implications for diagnosis
and treatment [32]. Anxiety disorders comorbid with
other anxiety or depressive disorders are associated with
poorer treatment outcomes, greater severity and chroni-
city [46-49], more impaired functioning [46], increased
health service use [50], and higher treatment costs [51].
The impact tends to increase with an increasing number
of comorbid conditions [46].
Patients with anxiety disorders have a higher preva-
lence of hypertension and other cardiovascular condi-
tions, gastrointestinal disease, arthritis, thyroid disease,
Table 5 Screening questions for specific anxiety and related disorders
Panic disorder –MACSCREEN [29,30]
•Do you have sudden episodes/spells/attacks of intense fear or discomfort that are unexpected or out of the blue?
If you answered “YES”then continue
•Have you had more than one of these attacks?
•Does the worst part of these attacks usually peak within several minutes?
•Have you ever had one of these attacks and spent the next month or more living in fear of having another attack or worrying about
the consequences of the attack?
SAD (Based on Mini-SPIN [28])
•Does fear of embarrassment cause you to avoid doing things or speaking to people?
•Do you avoid activities in which you are the center of attention?
•Is being embarrassed or looking stupid among your worst fears?
GAD [31]
•During the past 4 weeks, have you been bothered by feeling worried, tense, or anxious most of the time?
•Are you frequently tense, irritable, and having trouble sleeping?
OCD –MACSCREEN [29,30]
Obsessions:
•Are you bothered by repeated and unwanted thoughts of any of the following types:
○Thoughts of hurting someone else
○Sexual thoughts
○Excessive concern about contamination/germs/disease
○Preoccupation with doubts (“what if”questions) or an inability to make decisions
○Mental rituals (e.g., counting, praying, repeating)
○Other unwanted intrusive thoughts
•If you answered “YES”to any of the above…Do you have trouble resisting these thoughts, images, or impulses when they come into
your mind?
Compulsions:
•Do you feel driven to perform certain actions or habits over and over again, or in a certain way, or until it feels just right? Such as:
○Washing, cleaning
○Checking (e.g., doors, locks, appliances)
○Ordering/arranging
○Repeating (e.g., counting, touching, praying)
○Hoarding/collecting/saving
•If you answered “YES”to any of the above…Do you have trouble resisting the urge to do these things?
PTSD –MACSCREEN [29,30]
•Have you experienced or seen a life-threatening or traumatic event such as a rape, accident, someone badly hurt or killed, assault,
natural or man-made disaster, war, or torture?
If you answered “YES”then continue
•Do you re-experience the event in disturbing (upsetting) ways such as dreams, intrusive memories, flashbacks, or physical reactions to
situations that remind you of the event?
Table 6 Common risk factors in patients with anxiety and
related disorders
•Family history of anxiety [33]
•Personal history of anxiety or mood disorder [34,35]
•Childhood stressful life events or trauma [36,37]
•Being female [4,9]
•Chronic medical illness [34,40]
•Behavioral inhibition [41,42]
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respiratory disease, migraine headaches, and allergic con-
ditions compared to those without anxiety disorders
[16,52]. Comorbid anxiety and related disorders have a
significant impact on quality of life (QoL) in patients
with medical conditions [52].
Baseline assessment Baseline assessment should include
a review of systems, prescribed medications, over-the-
counter agents, alcohol use, caffeine intake, and illicit
drug use, in addition to evaluation of the anxiety symp-
toms and functioning [32]. Table 7 lists potential investi-
gations that can be considered based on an individual
patient’s presentation and specific symptoms (e.g., dizzi-
ness or tachycardia). Ideally, a physical examination and
baseline laboratory investigations should be performed
before pharmacotherapy is initiated, with repeat assess-
ments according to best practice guidelines [32]. Patients
with anxiety and related disorders should be monitored
initially every one to two weeks and then every four
weeks for weight changes and adverse effects of medica-
tions, as this is a major factor contributing to disconti-
nuation of medication.
Closer monitoring may be required in children younger
than 10 years of age, older or medically ill patients,
patients on medications associated with metabolic
changes, and those on multiple medications [32].
Identify specific anxiety or related disorder
The fifth edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5) has been finalized by the
American Psychiatric Association (APA) [26]. The new
DSM-5 provides diagnostic criteria for psychiatric disor-
ders based on scientific reviews of the literature, field
trial data, internal evaluations, public comments, and a
final review by APA’s Board of Trustees.
The “anxiety disorders”chapter now includes panic
disorder, agoraphobia, GAD, selective mutism, separation
anxiety disorder, SAD (social phobia), specific phobia,
substance/medication-induced anxiety disorder, as well
as anxiety disorder due to another medical condition or
not elsewhere classified. OCD and PTSD have been
moved to separate chapters on obsessive-compulsive and
related disorders and trauma- and stressor-related disor-
ders, respectively [26].
Table 8 provides a brief summary of the key DSM-5
diagnostic features of the anxiety and related disorders
that are included in these guidelines [26]. While the
DSM-5 is the most up-to-date diagnostic criteria, it is
important to note that the evidence for treatment is
based on studies using DSM-IV criteria (or earlier) for
inclusion of patients. However, most of the diagnostic
criteria have not changed substantially (see Sections 3–9
for more information on diagnosis); the exception being
agoraphobia, which is now designated as a separate
diagnosis.
Specific individual anxiety and related disorders
should be diagnosed with the DSM-5 criteria in the sec-
tions devoted to each anxiety disorder. An accurate
diagnosis is important to help guide treatment.
Psychological and pharmacological treatment
Treatment options for anxiety and related disorders
include psychological and pharmacological treatments. All
patients should receive education about their disorder,
efficacy (including expected time to onset of therapeutic
effects) and tolerability of treatment choices, aggravating
factors, and signs of relapse [32]. Information on self-help
materials such as books or websites may also be helpful.
The choice of psychological or pharmacological treat-
ment depends on factors such as patient preference and
motivation, ability of the patient to engage in the treat-
ment, severity of illness, clinicians’skills and experience,
availability of psychological treatments, patient’sprior
response to treatment, and the presence of comorbid med-
ical or psychiatric disorders [32].
A brief overview of psychological and pharmacological
treatments is provided below, with more specific recom-
mendations in the individual sections for each anxiety
and related disorder.
Overview of psychological treatment Psychological
treatments play an important role in the management of
anxiety and related disorders. Regardless of whether for-
mal psychological treatment is undertaken, patients should
receive education and be encouraged to face their fears.
Meta-analyses have demonstrated the efficacy of psycholo-
gical treatments in group and individual formats in
patients with panic disorder [54-56], specific phobia [57],
SAD [58,59], OCD [60-63], GAD [55,64,65], or PTSD
[66-69], particularly exposure-based and other cognitive
behavioral therapy (CBT) protocols [70,71], as well as
mindfulness-based cognitive therapy (MBCT) [72]. When
choosing psychological treatments for individual patients,
the forms of therapy that have been most thoroughly eval-
uated in the particular anxiety or related disorder should
be used first.
CBT is not a single approach to treatment, but rather
a process that focuses on addressing the factors that
Table 7 Considerations for baseline laboratory
investigations (as needed based on patient’s presenting
symptoms)
Basic lab tests
•Complete blood count •Fasting glucose
•Fasting lipid profile (TC, vLDL, LDL, HDL, TG) •Thyroid-stimulating
hormone
•Electrolytes •Liver enzymes
If warranted
•Urine toxicology for substance use
Adapted from references [32,53]. HDL = high density lipoprotein; LDL = low
density lipoprotein; TC = total cholesterol; TG = triglyceride; vLDL = very low
density lipoprotein.
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