Anxiety treatment for Wellington — SSRI dosing done right, CBT that works.

RECO Integrated Psychiatry sees Wellington adults 28 miles east in Delray Beach — a 38-minute drive that keeps specialist psychiatry accessible without the disruption of a residential program. Anxiety care here means disorder-specific diagnosis with GAD-7, PDSS, LSAS, and Y-BOCS; SSRI dosing at the upper end of the therapeutic range with slow initial titration to avoid activation; and CBT referrals matched to the diagnosis — ERP for OCD, interoceptive exposure for panic disorder, in-vivo exposure for social anxiety. Benzodiazepines are used narrowly, with a documented indication and taper plan, not as open-ended maintenance.

Wellington sits 28 miles inland from RECO Integrated Psychiatry’s Delray Beach office — a 38-minute drive up Southern Boulevard or Florida’s Turnpike that keeps specialist psychiatric care realistic without asking clients to step out of their working lives. Adults from Olympia, Versailles, Aero Club, Palm Beach Polo, and Wellington View typically pair outpatient medication management with local CBT rather than uproot the week for a residential program. What follows is how RECO evaluates and treats anxiety disorders — generalized anxiety disorder, panic disorder, social anxiety disorder, and obsessive-compulsive disorder — in an outpatient setting built around specialist-level pharmacology and disorder-matched therapy referrals.

The disorder distinctions that change treatment

GAD, panic disorder, social anxiety disorder, and OCD are frequently collapsed into “anxiety” in casual conversation and in many primary care visits. Clinically they are different diagnoses that respond to different therapy protocols and, in most cases, to different medication dosing. Intake at RECO uses the GAD-7 for generalized anxiety, the PDSS for panic disorder, the LSAS for social anxiety, and the Y-BOCS for OCD, and the note names the DSM-5-TR primary diagnosis rather than defaulting to “anxiety NOS.”

The distinction matters because treatment sequencing follows the diagnosis. A client with a GAD-7 of 18 and a Y-BOCS of 24 gets a different first-line plan than a client with panic disorder, agoraphobic avoidance, and secondary depression. OCD is treated with ERP as the first-line psychotherapy; panic disorder is treated with interoceptive exposure and cognitive restructuring; social anxiety is treated with in-vivo exposure and social skills work. Generic supportive counseling is not equivalent and does not carry the same effect sizes.

Comorbidity is the rule rather than the exception. Panic disorder frequently rides with major depressive disorder; OCD often carries a tic disorder or subclinical hoarding; social anxiety and alcohol use disorder cluster together in ways that shape prescribing. RECO sequences comorbid conditions by severity and functional impact, and documents the sequencing rationale so the treatment plan is legible to the client, the therapist, and the primary care physician.

SSRI dosing for anxiety versus depression

Effective SSRI dosing for anxiety disorders typically sits at the upper end of the depression range. Sertraline for GAD or OCD often requires 150-200 mg. Escitalopram target is 20 mg. Paroxetine 40-60 mg. Fluoxetine for OCD frequently pushes to 60-80 mg. Underdosing is one of the most common reasons a client arrives on their third medication trial having never had an adequate trial of the first.

Anxious clients are usually started at half the standard starting dose because SSRI activation on initiation — the transient increase in autonomic arousal, insomnia, and jitteriness that can occur in the first two weeks — can worsen anxiety before it improves. Sertraline 25 mg for the first week, escitalopram 5 mg, fluoxetine 10 mg. Titration is slower than in depression, and the target window is higher. Clients are told what activation feels like in advance so they do not stop the medication in week one thinking it is making them worse.

Time-to-response is longer for anxiety than for depression: 8 to 12 weeks at a therapeutic dose before declaring nonresponse, not 4 to 6. For OCD the trial length is 10 to 12 weeks at maximum tolerated dose before switching or augmenting. Serial GAD-7, PDSS, LSAS, or Y-BOCS scores at each follow-up quantify response and drive the decision to hold, increase, or switch.

Augmentation and second-line options

SSRI partial responders in GAD are augmented with buspirone at 20-60 mg per day, usually divided. Buspirone has no dependence liability, no cognitive blunting, and no withdrawal syndrome — a favorable profile for chronic anxiety. Venlafaxine XR is a reasonable SNRI switch when an adequate SSRI trial has failed, particularly in GAD with prominent somatic symptoms.

Panic disorder partial responders generally benefit more from the addition of CBT with interoceptive exposure than from medication augmentation. Interoceptive exposure means deliberately provoking the physical sensations of panic — controlled hyperventilation, spinning, breath-holding — so the catastrophic cognitive interpretations extinguish. The evidence base is strong and the effects durable; medication alone tends to relapse when the SSRI is discontinued if this work has not been done.

OCD partial responders are augmented with low-dose aripiprazole (2.5-10 mg) or risperidone. The evidence for antipsychotic augmentation in OCD is stronger than for switching between SSRIs or moving to an SNRI. Beta-blockers such as propranolol 10-40 mg have a defined role in situational performance anxiety — not maintenance. Hydroxyzine 25-50 mg and gabapentin 300-900 mg per day cover PRN needs without the benzodiazepine risk profile.

Benzodiazepines — when we do and don’t prescribe

Benzodiazepines have a defined role in short-term crisis management and in a narrow chronic indication — panic disorder refractory to adequate SSRI trials and to CBT with interoceptive exposure. Outside those two situations, they are rarely a good long-term answer for anxiety, and the clinical literature has grown less permissive about them over the past two decades.

The primary clinical objection is mechanistic: benzodiazepines blunt extinction learning. Exposure-based CBT depends on the client tolerating the physical sensations of anxiety long enough to learn they are survivable and self-limiting. A dose of alprazolam or lorazepam before an exposure erases the learning that the therapy is trying to build. The medication and the therapy are working against each other.

For clients with any active or prior substance use history, RECO’s default is not to prescribe. When benzodiazepines are prescribed, the note documents the specific indication, the total daily dose, a taper timeline, and the non-benzodiazepine alternatives — buspirone, hydroxyzine, gabapentin, propranolol — that will fill the same PRN or maintenance need as the taper proceeds. Open-ended maintenance without a taper plan is not the standard of care here.

What to expect at the first visit

The initial evaluation runs 60 minutes with a psychiatrist or psychiatric nurse practitioner. GAD-7, PHQ-9, and the disorder-specific scale — PDSS, LSAS, or Y-BOCS — are completed before or during the visit to establish baseline severity and support the named DSM-5-TR diagnosis. The clinician takes a full medical and medication history, including prior SSRI or SNRI trials with the reasons for discontinuation, substance use history screened with CAGE-AID, and a family psychiatric history.

Labs relevant to differential diagnosis are ordered or reviewed — TSH to rule out hyperthyroidism masquerading as GAD, CBC, CMP, and a urine drug screen where clinically indicated. The visit ends with a written treatment plan: primary diagnosis, medication or medication change with dose and titration schedule, CBT referral to a specific evidence-based provider (ERP for OCD, panic-focused CBT for panic disorder, in-vivo exposure for social anxiety), and a follow-up interval — typically two weeks during titration and every four to six weeks once stable.

Insurance and admissions from Wellington

RECO Integrated Psychiatry is in-network with Florida Blue, Aetna, Cigna, UnitedHealthcare, Humana, and BCBS. Verification takes about one business day, and a written benefits summary — copay, deductible remaining, prior authorization requirements for TMS or Spravato — is provided before the first visit. TMS and Spravato prior authorizations typically require documented failure of at least two adequate antidepressant trials at therapeutic dose and duration.

The Delray Beach office is 28 miles east of Wellington, roughly 38 minutes by car. Telepsychiatry is available for medication management follow-ups once the initial in-person evaluation is complete, which limits the drive to the intake visit and the periodic in-person reviews. To start, call the admissions line or complete the online intake; a clinician reviews the intake and schedules an evaluation, typically within 5 to 10 business days.

Serving residents of: Olympia, Versailles, Aero Club, Palm Beach Polo, Wellington View.