How is an anxiety disorder different from everyday anxiety or stress?

Anxiety as an emotion is normal — it is the alarm system that helps you prepare for a difficult meeting or react to genuine threat. An anxiety disorder is when that system runs persistently, out of proportion to the trigger, and starts costing function. The threshold for generalised anxiety disorder is excessive worry across multiple areas of life, more days than not, for at least six months, with three or more of restlessness, fatigue, concentration difficulty, irritability, muscle tension, or sleep disturbance. Panic disorder is recurrent unexpected panic attacks — abrupt surges of intense fear peaking within minutes — plus persistent concern or behaviour change about further attacks. Social anxiety disorder, specific phobias, agoraphobia, OCD and PTSD have their own criteria but the common thread is impairment that is disproportionate to the situation and persistent across time.

What's the role of CBT in anxiety, and how do I get it in Australia?

Cognitive behavioural therapy is first-line for every anxiety disorder under the [RANZCP 2018 guideline](https://journals.sagepub.com/doi/10.1177/0004867418799453). The protocols differ by disorder — worry exposure and cognitive restructuring for GAD, interoceptive exposure for panic, graded in-vivo exposure for agoraphobia and phobic disorders, exposure and response prevention for OCD, trauma-focused approaches for PTSD — but the overall package is structured, time-limited, and matches medication for short-term effect with better long-term durability. Australian access is via a Mental Health Treatment Plan from your GP, which generates up to 10 Medicare-rebated psychology sessions per calendar year, or via primary-tier online programs (This Way Up, MindSpot, MoodGYM). For under-25s, headspace offers in-centre and online support. The waitlist-and-gap-fee reality is real, particularly in metropolitan areas; online programs are an immediate option while waiting.

Are SSRIs addictive, and how long will I be on one?

SSRIs are not addictive in the substance-use sense — there is no craving, no dose escalation for the same effect, and no compulsive use pattern. They can produce a discontinuation syndrome on abrupt cessation (dizziness, flu-like symptoms, electric-shock sensations, mood disturbance), which is why they are tapered rather than stopped suddenly. The expected duration of treatment for anxiety disorders is longer than for depression: at least 12 months at the effective dose after symptoms remit, and longer if anxiety is chronic, severe, or recurrent. A common counselling point is that anxiety can transiently worsen in the first one to two weeks on an SSRI before the benefit emerges — this is recognised, expected, and usually a reason to persist with close monitoring, not to stop.

Aren't benzodiazepines the fast option — and why do GPs hesitate?

Benzodiazepines (diazepam, oxazepam, temazepam, lorazepam) do work quickly for acute anxiety and panic. The hesitation is grounded in the harms that emerge with regular use: tolerance within weeks, physical and psychological dependence, falls and fractures in older adults, cognitive impairment, motor-vehicle accident risk, paradoxical disinhibition, and dangerous interactions with opioids and alcohol. [Choosing Wisely Australia](https://www.choosingwisely.org.au) recommends against routine long-term use of benzodiazepines for anxiety. Alprazolam has carried Schedule 8 status since 2014 because of its particularly high dependence and overdose risk. The narrow appropriate role is short-course use, generally two to four weeks, as a bridge while CBT or an SSRI takes effect, with a planned taper. Pregabalin is an alternative in refractory generalised anxiety disorder per AU specialty practice, but is also SafeScript-monitored and carries misuse risk.

What does an integrative GP add to the mainstream anxiety approach?

The mainstream pillars — CBT, SSRI when indicated, suicide-risk safety planning, exclusion of medical mimics — are non-negotiable. Where integrative practice adds value is in systematic attention to the modifiable inputs that often get a brief mention and are then dropped: structured exercise prescription (the Cochrane evidence supports an effect size comparable to medication for mild-to-moderate anxiety), caffeine reduction (a recognised trigger for panic in sensitive individuals), alcohol moderation, sleep architecture and treating obstructive sleep apnoea where present, mindfulness-based stress reduction or MBCT, Mediterranean dietary pattern, and screening for thyroid disease, anaemia, and vitamin deficiencies that mimic or worsen anxiety. It also means honest engagement with patient preferences around medication, and being transparent about the limits of evidence for over-the-counter supplements marketed for anxiety.

Anxiety disorders

Anxiety disorders: CBT first, SSRIs when severity warrants — the AU GP pathway

By Dr HB Lo, FACRRM Reviewed 19 May 2026 11 min read

Anxiety disorders are common and treatable — around 1 in 7 Australians experience one in any 12-month period.

Generalised anxiety disorder, panic disorder, social anxiety, phobic disorders, and OCD share a core management pattern. GAD-7 grades severity (10+ moderate, 15+ severe).

Cognitive behavioural therapy is first-line. SSRIs (sertraline, escitalopram) are added when severity warrants or therapy alone is insufficient. Short-course benzodiazepines have a narrow role; long-term use is not recommended. Exercise, sleep, caffeine reduction, and alcohol moderation each carry independent benefit.

Crisis: Lifeline 13 11 14, Beyond Blue 1300 22 4636.

What an anxiety disorder actually is

Everyday anxiety is the threat-response system doing its job. An anxiety disorder is what happens when it runs persistently, out of proportion to the trigger, and costs function. The line is not feeling anxious — it is the duration, the disproportion, and the impairment.

Anxiety disorders are the most common mental disorders in Australia — approximately 1 in 7 adults (around 14%) in any 12-month period, per the ABS National Study of Mental Health and Wellbeing. Women are affected roughly twice as often as men; onset is typically adolescence or young adulthood. About half also experience depression, and around a quarter have a coexisting substance-use issue.

The screening tool referenced throughout is GAD-7 — a seven-item questionnaire scored 0 to 21 (5–9 mild, 10–14 moderate, 15+ severe). It quantifies what you are already describing and lets your GP track change over time.

A. Core clinical — the AU general practice framework

A first anxiety assessment in Australian general practice, aligned with the RANZCP 2018 anxiety guideline, RACGP mental health resources, and eTG Psychotropic, covers several domains in sequence.

Which anxiety disorder. The DSM-5 chapter contains several distinct conditions sharing the core feature of excessive fear or anxiety:

Generalised anxiety disorder (GAD) — excessive uncontrollable worry across multiple domains, more days than not, for at least 6 months, with three or more of restlessness, fatigue, concentration difficulty, irritability, muscle tension, or sleep disturbance.
Panic disorder — recurrent unexpected panic attacks (abrupt surge of intense fear peaking within minutes with four or more physical or cognitive symptoms) plus persistent concern or behaviour change.
Social anxiety disorder (SAD) — fear of social or performance situations involving scrutiny.
Specific phobia — discrete fear of an object or situation.
Agoraphobia — avoidance of situations from which escape is difficult.
OCD (separate DSM-5 chapter, managed similarly in general practice) — obsessions plus compulsions; assessed with Y-BOCS.
PTSD (separate chapter) — trauma exposure with intrusion, avoidance and hyperarousal; trauma-focused therapies preferred.

Structured symptom assessment. GAD-7 for generalised anxiety severity, Panic and Agoraphobia Scale, Social Phobia Inventory (SPIN), Y-BOCS for OCD, K10 for general distress (≥22 high distress), DASS-21 for combined depression-anxiety-stress.

Organic mimics — the rule-outs that matter. Several physical conditions produce identical symptoms and need to be excluded rather than labelled as anxiety:

Hyperthyroidism — low TSH, elevated T4; tremor, weight loss, palpitations.
Anaemia — fatigue and breathlessness mimic GAD; full blood count, iron studies, B12, folate.
Cardiac causes of palpitations and chest pain — arrhythmia, acute coronary syndrome; ECG and selective troponin in any patient with new “panic” plus chest symptoms.
Pulmonary embolism — the classic missed mimic of panic in a high-risk patient.
Phaeochromocytoma — episodic palpitations, sweating and headache; urinary metanephrines if suspected.
Hypoglycaemia in diabetic patients on insulin or sulfonylurea.
Substance- and medication-induced anxiety — caffeine, stimulants, decongestants, beta-agonists, corticosteroids, and SSRI initiation jitteriness. Withdrawal states (alcohol, benzodiazepine, opioid) routinely present as anxiety.

Bloods that matter (per RACGP mental health resources and eTG Psychotropic): full blood count, urea-electrolytes-creatinine, liver function, calcium, glucose, TSH, vitamin B12 and folate, vitamin D, HbA1c. ECG where chest pain or palpitations feature, or before starting a QT-prolonging agent.

Bipolar screen. Before any antidepressant is prescribed, the GP needs to ask about past episodes of elevated mood, decreased need for sleep, racing thoughts or grandiosity. Starting an SSRI in someone with undiagnosed bipolar disorder can precipitate a manic switch.

Suicidality assessment. Anxiety disorders elevate suicide risk, particularly with comorbid depression or substance use. A structured conversation — ideation, plan, intent, preparation, access to means, prior attempts, family history, protective factors — and safety planning are documented in any moderate-to-severe presentation.

B. Psychotherapy first — CBT, IPT, and AU access

The RANZCP 2018 anxiety guideline is explicit: cognitive behavioural therapy is first-line for every anxiety disorder, with the largest evidence base of any single intervention. The protocols differ by condition:

GAD CBT — worry exposure, problem-solving, cognitive restructuring of intolerance-of-uncertainty beliefs, relaxation — including slow guided breathing as a simple self-help adjunct.
Panic CBT — interoceptive exposure, cognitive restructuring of catastrophic interpretations, panic-cycle education.
Agoraphobia and specific phobia — graded in-vivo exposure.
Social anxiety disorder — exposure plus behavioural experiments and cognitive restructuring.
OCD — exposure and response prevention (ERP), often delivered by specialist-trained psychologists.
PTSD — trauma-focused CBT, EMDR, or prolonged exposure.

Interpersonal therapy (IPT), acceptance and commitment therapy (ACT), and mindfulness-based cognitive therapy (MBCT) are reasonable alternatives or adjuncts with their own trial support.

AU access pathways

The Better Access initiative is the main mechanism through which Australians access Medicare-rebated psychological therapy. Your GP completes a Mental Health Treatment Plan (MHTP) — MBS items 2700, 2701, 2715, or 2717 — generating a referral for up to 6 individual psychology sessions, then a GP review (MBS 2712), and up to 4 further sessions if clinically indicated — total 10 individual sessions per calendar year, plus up to 10 group sessions separately.

Provider types: clinical psychologists (higher rebate), registered psychologists, accredited mental health social workers, accredited mental health occupational therapists. Not every psychologist is trained in disorder-specific protocols (particularly ERP for OCD and trauma-focused therapies for PTSD) — ask specifically.

The cost-gap reality. Medicare rebates cover only part of the fee — a clinical psychologist’s standard fee is commonly $250–$280 against a rebate of around $141 (or $96 for a registered psychologist), leaving a gap of $100+ in metropolitan areas. Waitlists of 2–6 months are common. Workarounds:

This Way Up — Australian-developed online CBT programs for GAD, panic, social anxiety, OCD, PTSD and depression; some courses free.
MindSpot Clinic — free, government-funded, clinician-supported CBT for adults.
MoodGYM — free interactive CBT modules.
headspace — free or low-cost support for 12–25 year olds.
Beyond Blue — telephone and webchat support, 1300 22 4636.
University psychology clinics — provisional psychologists supervised by senior staff; substantially reduced fees.
Aboriginal Medical Services and Social and Emotional Wellbeing programs — culturally safe pathways.

Naming the waitlist and gap-fee reality is part of honest pathway planning.

C. Medication — when and what

For moderate-to-severe anxiety, or when CBT alone is insufficient or inaccessible, pharmacotherapy is added. Per RANZCP 2018, eTG Psychotropic and the Australian Medicines Handbook:

First-line: SSRIs

Sertraline and escitalopram are the usual first choices in Australian practice — strong tolerability profile, minimal cytochrome P450 interactions (sertraline particularly), broad indications across GAD, panic, social anxiety disorder and OCD.

Sertraline — start 25 mg daily (half the depression starting dose), range 50–200 mg.
Escitalopram — start 5 mg, range 10–20 mg. QT prolongation at doses above 20 mg.
Fluoxetine 20–80 mg — long half-life; preferred SSRI in adolescents; OCD often needs the upper range.
Citalopram 20–40 mg — QT prolongation at higher doses; maximum 20 mg in over-65s.
Paroxetine 20–60 mg — significant discontinuation syndrome; generally avoided in elderly and first-trimester pregnancy.

Second-line and adjuncts

Venlafaxine XR (SNRI) start 37.5 mg, range 75–225 mg — first-line alternative for GAD, panic and SAD; significant discontinuation syndrome; BP monitoring at higher doses.
Duloxetine (SNRI) 30–120 mg — PBS Authority Required for GAD; useful with comorbid neuropathic pain.
Pregabalin 75–600 mg/day in divided doses — Authority Required for refractory GAD; effective and rapid in onset; misuse/dependency risk; SafeScript-monitored.
Buspirone 5–10 mg TDS — non-sedating; modest efficacy in GAD; not effective for panic.
Mirtazapine 15–45 mg at night — useful where insomnia, anorexia or weight loss dominate.

Important counselling points for SSRIs in anxiety

Start low, go slow. Half the depression starting dose. Initial jitteriness in the first one to two weeks is recognised and a reason to persist with monitoring — not to stop.
Full effect at 6–12 weeks — often longer than for depression. OCD may take longer and need higher doses.
Continuation ≥12 months at the effective dose after remission is standard; longer in chronic, severe or recurrent presentations.
Suicidality monitoring in the first 2–4 weeks, particularly in under-25s (FDA black-box period). Untreated anxiety carries its own risk.
Sexual dysfunction affects 30–50% of users; a switch (mirtazapine, vortioxetine) is reasonable when persistent.
Discontinuation syndrome — flu-like symptoms, dizziness, electric-shock sensations. Most marked with paroxetine, venlafaxine, desvenlafaxine. Tapering over 4–8 weeks is standard; fluoxetine self-tapers.

Benzodiazepines — short course only

Benzodiazepines work quickly, but harms with regular use are well-described: tolerance within weeks, dependence, falls and fractures in older adults, cognitive impairment, motor-vehicle accident risk, paradoxical disinhibition, and respiratory depression with opioids or alcohol.

Choosing Wisely Australia recommends against routine long-term use for anxiety. The narrow appropriate role is short-course use (generally two to four weeks) as a bridge while CBT or an SSRI takes effect, with a planned taper. Alprazolam has been Schedule 8 since 2014 owing to high dependence and overdose risk. SafeScript monitoring should be checked before any benzodiazepine prescription. Long-term users are tapered slowly (typically ≥10% dose reduction every 2–4 weeks), often after conversion to diazepam.

Beta-blockers for performance anxiety

Propranolol 10–40 mg taken before a specific performance situation (public speaking, music performance, exam) reduces palpitations and tremor without affecting the cognitive component. Useful for situational performance anxiety; not appropriate as a treatment for generalised anxiety, panic disorder or social anxiety disorder more broadly.

D. Lifestyle inputs that have independent benefit

Lifestyle is not a substitute for psychotherapy and medication when those are indicated — but the data is strong enough that it belongs in the prescription rather than as an afterthought.

Exercise. The Cochrane 2013 review on exercise for anxiety disorders and subsequent meta-analyses support an effect size comparable to medication in mild-to-moderate anxiety. The pragmatic prescription is 150 minutes per week of moderate aerobic activity plus two sessions of resistance training, scaled to current capacity.

Sleep. Sleep disturbance is bidirectional with anxiety. Treating coexisting insomnia with CBT-I and identifying obstructive sleep apnoea (loud snoring, witnessed apnoeas, daytime sleepiness, hypertension) belong in the plan.

Caffeine reduction. Caffeine is a recognised trigger for panic in sensitive individuals. Trial elimination — including tea, soft drinks, energy drinks, and dark chocolate — is a low-cost intervention with high yield in caffeine-responsive patients.

Alcohol moderation. Alcohol is short-term anxiolytic and longer-term anxiogenic — it disrupts sleep and is frequently used as self-medication that worsens the underlying problem. Reduction to within NHMRC alcohol guidelines (no more than 10 standard drinks per week, no more than 4 on any one day) is part of the treatment plan.

Mindfulness. Mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) carry modest-to-moderate evidence in anxiety, particularly for relapse prevention. AU-developed free options include Smiling Mind.

Nutrition. A Mediterranean-pattern diet (vegetables, legumes, fruit, whole grains, nuts, olive oil, fish, moderate dairy, limited ultra-processed foods) carries modest mental-health benefit generalised across mood and anxiety.

Supplements where evidence exists. Omega-3 EPA-predominant supplementation (1–2 g/day) and vitamin D replacement where deficient have small-to-modest signals. Lavender oil (Silexan 80 mg/day) has some RCT evidence in GAD but is not first-line. Kava is TGA-restricted owing to hepatotoxicity. St John’s wort is contraindicated with SSRIs because of serotonin syndrome risk.

E. Special populations

Perinatal. Anxiety is the most common perinatal mental-health condition, often co-occurring with depression, and is screened with the Edinburgh Postnatal Depression Scale (EPDS). Sertraline is the preferred SSRI in pregnancy and breastfeeding — extensive safety data and low transfer into breastmilk. Paroxetine is generally avoided in the first trimester. Benzodiazepines are avoided in the first trimester and in late pregnancy. Specialist medication information is available via MotherSafe (NSW) and equivalent state services. PANDA supports parents through perinatal anxiety and depression.

Adolescents. CBT is first-line; SSRI (fluoxetine, sertraline) is second-line with close monitoring for treatment-emergent suicidality in the first 2–4 weeks. headspace is the AU specialty consumer pathway for under-25s.

Older adults. Anxiety in later life is often misdiagnosed as depression — and the converse is true. Start SSRIs at lower doses; check sodium at 1–2 weeks (SIADH risk); avoid tricyclic antidepressants and benzodiazepines (fall risk, cognitive impairment); avoid paroxetine. Treatable contributors are common — thyroid disease, B12 deficiency, hearing loss, social isolation, polypharmacy.

Cardiac comorbidity. Anxiety and cardiovascular disease frequently coexist and amplify each other. ECG is appropriate before starting QT-prolonging agents and in any patient with new chest-pain or palpitation symptoms.

Aboriginal and Torres Strait Islander Australians. Higher distress and suicide rates reflecting intergenerational trauma and access barriers. Culturally safe pathways include Aboriginal Medical Services, 13YARN (13 92 76), Social and Emotional Wellbeing programs and Aboriginal Mental Health Workers. The MBS ATSI Health Assessment (item 715) includes mental-health screening.

When to escalate

Same-day or emergency department: active suicidal ideation with plan, intent or preparation; recent suicide attempt; severe panic with cardiac, pulmonary or other medical mimics not yet excluded; severe agitation; postpartum severe anxiety or psychosis; acute alcohol or benzodiazepine withdrawal in a dependent user.

Routine psychiatric referral: failure of an adequate trial of CBT plus at least one SSRI or SNRI at therapeutic dose for 6–12 weeks; OCD requiring specialist ERP; complex PTSD or coexisting eating disorder, personality disorder or severe substance use disorder; suspected bipolar disorder; severe perinatal anxiety; severe adolescent anxiety not responding to first-line care.

What this article is and is not

This is general health information drawn from current Australian guidelines — the RANZCP 2018 anxiety disorders clinical practice guideline, RACGP mental health resources, Therapeutic Guidelines (eTG) Psychotropic, AMH, NPS MedicineWise, Choosing Wisely Australia, Beyond Blue and Black Dog Institute — and the major anxiety trials referenced above. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about specific treatment are made with your own general practitioner and treating clinicians.

Anxiety disorders are common and treatable.

For Australian consumer-friendly sources: Beyond Blue, Black Dog Institute, HealthDirect — Anxiety, HealthDirect — Panic disorder, Better Health Channel, Head to Health, Smiling Mind.

For acute mental-health crisis: Lifeline 13 11 14, Beyond Blue 1300 22 4636, Suicide Call Back Service 1300 659 467, 13YARN 13 92 76.

Sources cited

Frequently asked questions

How is an anxiety disorder different from everyday anxiety or stress?

Anxiety as an emotion is normal — it is the alarm system that helps you prepare for a difficult meeting or react to genuine threat. An anxiety disorder is when that system runs persistently, out of proportion to the trigger, and starts costing function. The threshold for generalised anxiety disorder is excessive worry across multiple areas of life, more days than not, for at least six months, with three or more of restlessness, fatigue, concentration difficulty, irritability, muscle tension, or sleep disturbance. Panic disorder is recurrent unexpected panic attacks — abrupt surges of intense fear peaking within minutes — plus persistent concern or behaviour change about further attacks. Social anxiety disorder, specific phobias, agoraphobia, OCD and PTSD have their own criteria but the common thread is impairment that is disproportionate to the situation and persistent across time.
What's the role of CBT in anxiety, and how do I get it in Australia?

Cognitive behavioural therapy is first-line for every anxiety disorder under the [RANZCP 2018 guideline](https://journals.sagepub.com/doi/10.1177/0004867418799453). The protocols differ by disorder — worry exposure and cognitive restructuring for GAD, interoceptive exposure for panic, graded in-vivo exposure for agoraphobia and phobic disorders, exposure and response prevention for OCD, trauma-focused approaches for PTSD — but the overall package is structured, time-limited, and matches medication for short-term effect with better long-term durability. Australian access is via a Mental Health Treatment Plan from your GP, which generates up to 10 Medicare-rebated psychology sessions per calendar year, or via primary-tier online programs (This Way Up, MindSpot, MoodGYM). For under-25s, headspace offers in-centre and online support. The waitlist-and-gap-fee reality is real, particularly in metropolitan areas; online programs are an immediate option while waiting.
Are SSRIs addictive, and how long will I be on one?

SSRIs are not addictive in the substance-use sense — there is no craving, no dose escalation for the same effect, and no compulsive use pattern. They can produce a discontinuation syndrome on abrupt cessation (dizziness, flu-like symptoms, electric-shock sensations, mood disturbance), which is why they are tapered rather than stopped suddenly. The expected duration of treatment for anxiety disorders is longer than for depression: at least 12 months at the effective dose after symptoms remit, and longer if anxiety is chronic, severe, or recurrent. A common counselling point is that anxiety can transiently worsen in the first one to two weeks on an SSRI before the benefit emerges — this is recognised, expected, and usually a reason to persist with close monitoring, not to stop.
Aren't benzodiazepines the fast option — and why do GPs hesitate?

Benzodiazepines (diazepam, oxazepam, temazepam, lorazepam) do work quickly for acute anxiety and panic. The hesitation is grounded in the harms that emerge with regular use: tolerance within weeks, physical and psychological dependence, falls and fractures in older adults, cognitive impairment, motor-vehicle accident risk, paradoxical disinhibition, and dangerous interactions with opioids and alcohol. [Choosing Wisely Australia](https://www.choosingwisely.org.au) recommends against routine long-term use of benzodiazepines for anxiety. Alprazolam has carried Schedule 8 status since 2014 because of its particularly high dependence and overdose risk. The narrow appropriate role is short-course use, generally two to four weeks, as a bridge while CBT or an SSRI takes effect, with a planned taper. Pregabalin is an alternative in refractory generalised anxiety disorder per AU specialty practice, but is also SafeScript-monitored and carries misuse risk.
What does an integrative GP add to the mainstream anxiety approach?

The mainstream pillars — CBT, SSRI when indicated, suicide-risk safety planning, exclusion of medical mimics — are non-negotiable. Where integrative practice adds value is in systematic attention to the modifiable inputs that often get a brief mention and are then dropped: structured exercise prescription (the Cochrane evidence supports an effect size comparable to medication for mild-to-moderate anxiety), caffeine reduction (a recognised trigger for panic in sensitive individuals), alcohol moderation, sleep architecture and treating obstructive sleep apnoea where present, mindfulness-based stress reduction or MBCT, Mediterranean dietary pattern, and screening for thyroid disease, anaemia, and vitamin deficiencies that mimic or worsen anxiety. It also means honest engagement with patient preferences around medication, and being transparent about the limits of evidence for over-the-counter supplements marketed for anxiety.

Source quality

Sources grouped by evidence tier. AU primary tier first; international where AU is silent or lagging; named-author reconstruction where guidelines have not yet caught up. How tiers work.