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Anxiety Disorders and Anxiolytic Drugs April 13, 2010 and April 14, 2010 1.

General info on anxiety a. Definition: normal, healthy human emotion which provides important information and energy b. Disorder: anxiety causes impairment and/or significant suffering i. Consequences: 1. Avoidance (people, places, things) 2. Costly to patient (suffering, often silent), society, and physicians ii. Diagnosis: 1. For anxious patient, be sure to consider anxiety disorder associated to a general medical condition OR substance abuse anxiety disorder iii. Treatment: 1. Psychotherapy + meds > meds alone in effectiveness a. Meds: when stopped, anxiety usually returns 2. Discourage avoidance and encourage action! 3. feel the fear and do it anyway 4. *Good diagnosis leads to good treatment! When you see an anxious patient, always consider: a. Anxiety Disorder secondary to a General Medical Condition i. E.g. hyperthyroidism, tachyarrhythmias, hypoxia, CHF, hypoglycemia, etc b. Substance Induced Anxiety Disorder i. During use/intoxication (PSP) ii. During withdrawal (alcohol, sedative-hypnotics, cocaine, theophylline, albuterol, caffeine) iii. Legal and illegal drugs 2. Anxiety Disorders and Therapy

Social Anxiety Disorder (SAD) Benzodiazepines Buspirone SSRIs Venlafaxine X X

Post-Traumatic Stress Disorder (PTSD)

General Anxiety Disorder (GAD) X X

Panic Disorder (PD) X

ObsessiveCompulsive Disorder (OCD)

X X

X X

Anxiety Disorder Type


Social Anxiety Disorder (SAD)

Definition
Also known as Social Phobia = excessive fear of social or performing situations Two types: Generalized Performance

Clinical Presentation
Patient avoids social situations For performance: HR, BP, tremor, sweating

Treatment
*Psychotherapies offer the most effective tx! Drug therapy indicated only when sxs = social dysfunction BZDs for brief PRN for anticipatory anxiety SSRIs for long-term tx Performance anxiety: propranolol (beta-blocker) will tx HR/BP/tremor, but not sweating! Dont use BZDsthey cause cognitive impairment!!

Traumatic Stress Disorders

Occur after a traumatic (life-threatening) experience Acute Stress Disorder: 230 days PTSD: >30 days after trauma

Re-experiencing Avoidance (of people, place, or talking about the trauma) Hyperarousal/hypervigilance Numbing Avoidance

PTSD: SSRIs are first-line tx (paroxetine, sertraline, fluoxetine) can also tx major depression, which is often a comorbidity of PTSD Acute stress: propranolol PTSD: clonidine Psychotherapy is more effective! Psychotherapy + meds > meds alone!

Generalized Anxiety

Occurs when anxiety

Disorder (GAD)

causes impairment and/or significant suffering

Cognitive Behavioral Therapy Pharm: BZDs: effective in 50-70% of patients avoid in elderly or pts w/ hx of substance abuse LOT drugs (lorazepam, oxazepam, temazepam): for pts w/ liver issues Short half-life (triazolam, oxazepam): no accumulation, frequent daily dosing, severe w/d sxs Intermediate half-life (lorazepam, temazepam, alprazolam): no accumulation, w/d sxs Long half-life (clonazepam, diazepam, chlordiazepoxide): accumulation, less severe w/d sxs, once daily dosing *Taper patient off BZD SLOWLY! Side effects: sedation, ataxia, cognitive impairment, paradoxical disinhibition, anterograde amnesia Buspirone: equal efficacy to BZDs works best in BZD-nave patients very slow onset of effect, and max effect 4-6 weeks no sedation, muscle relaxant, or anticonvulsant properties no abuse, tolerance, dependence, w/d, cognitive impairment potential = good for pts w/ hx of drug abuse and elderly! Not PRN med SSRIs: good for long-term GAD tx KAVA: anxiolytic, muscle relaxant, no effect on cognition Antihistamines: sedating use PRN rather than continuous dosing

Panic Disorder (PD)

Recurrent, unexpected panic attacks 50-80% develop agoraphobia Panic attack = dramatic episode of anxiety **In PD, attacks are UNEXPECTED/out of the

Panic attack: discreet period of intense fear; sxs develop abruptly and reach a peak w/in 10 min palpitations, tachycardia sweating trembling/shaking SOB

Very effectively tx w/ medsmust be CONTINUOUS DOSING work by preventing the NEXT panic attack, not current High-dose BZDs: fast onset of action alprazolam

blue (in other disorders, attacks are expected, cued, or situation-based)

chest pain/discomfort Nausea; GI distress Dizziness, unsteady, lightheaded fear of dying; losing control Parasthesias Extreme: one wont leave home

clonazepam SSRIs: take 4-weeks for initial response, >10 weeks for max effect fluoxetine paroxetine setraline Psychotherapy

Agoraphobia

Anxiety about being in places or situations in which leaving would be hard/embarrassing, or help might not be available Obsessions: recurrent thoughts Compulsions: repetitive actions

ObsessiveCompulsive Disorder (OCD)

contamination, need for symmetry checking, counting, washing, symmetry/precision, hoarding, rituals

LEAST RESPONSIVE TO DRUGS PSYCHOTHERAPY HAS GREATEST RESPONSE Only effective meds: SSRIs, venlafaxine, clomipramine (TCA)