If the patient is clearly abstinent from their substances now, in accordance with the criteria set forth in the Help section of the last question, a thorough review of the differential diagnosis of the anxiety symptoms should be done, ruling out or treating any medical causes (such as thyroid dysfunction, occurring in perhaps 6.5% of patients with panic disorder and 10.4% of patients with generalized anxiety disorder¹). Also, investigate the possible ongoing use of anxiety-producing substances such as caffeine,² and the presence of other addictions such as nicotine.³ This process should be repeated, throughout the algorithm, after each sequential treatment trial if the response is still unsatisfactory. At each decision point, the physician should also always consider the possibility of an undetected substance abuse relapse. The hidden relapse could be manifested as an aggravation of anxiety symptoms.
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