Anxiety Disorders


Anxiety Disorders
Panic disorder • Three attacks in 3-week period with no clear circumscribed stimulus
• Abrupt onset of symptoms, peak within 10 minutes
Clinical signs:
- Great apprehension and fear
- Palpitations, trembling, sweating
- Fear of dying or going crazy
- Hyperventilation, "air hunger"
- Sense of unreality

Treatment: alprazolam, clonazepam, irnipramine
Agoraphobia
(fear of open spaces)
• Also sense of helplessness or humiliation
• Manifest anxiety, panic-like symptoms
• Travel restricted
Specific phobias
(fear of specific object, e.g., spiders, snakes)
• Anxiety when faced with identifiable object
• Phobic object avoided
• Persistent and disabling fear
Social phobia
(fear of feeling or being stupid, shameful)
• Leads to dysfunctional circumspect behavior, e.g., inability to urinate in public washrooms
• May accompany avoidant personality disorder Discrete performance anxiety (stage fright): most common phobia.

Treatment:
  - Paroxetine (SSRI) or atenolol or propranolol (beta blocker)
  - For generalized social anxiety, use phenelzine (MAO inhibitor or paroxetine
Generalized anxiety disorder • Symptoms exhibited more days than not for longer than a 6-month period
- Motor tension (fidgety, jumpy)
- Autonomic hyperactivity (heart pounding, sweating, chest pains), hyperventilation
- Apprehension (fear, worry, rumination), difficulty concentrating
- Vigilance and scanning (impatient. hyperactive, distracted)
- Fatigue and sleep disturbances common, especially insomnia and restlessness

Treatment: benzodiazepines, buspirone
Obsessive-compulsive disorder Obsession: focusing on one thought, usually to avoid another
Compulsion: repetitive action shields person from thoughts, action "fixes" bad thought
• Primary concern of patient is to not lose control . frontal lobe metabolism, activity in the caudate nucleus

Treatment: fluoxetine, fluvoxamine, or other SSRI, clomipramine


 

Panic Disorder

  • Can occur with or without agoraphobia
  • Agoraphobia is now a separate diagnosis in DSM-5
  • Is a discrete, unprovoked psychophysiological event
  • Almost always (90%) comorbid with another illness
  • Female:male ratio is 2:1

Symptoms of Panic Attacks

  • Sudden onset and escalation of extreme anxiety, fear, and apprehension
  • Accompanied by somatic complaints such as feeling dizzy, lightheaded, faint, tremulous, short of breath, and sweating
  • Patients often state, “I am about to die,” or “I am going crazy.”
  • 25% will have nocturnal attacks

Treatment of Panic Disorder

  • Should treat for at least 12 months
  • Psychotherapy helpful if agoraphobia does not respond to drug treatment of actual panic attacks
#1 = CBT
SSRI or SNRI
Paroxetine : 5-10 mg orally (immediate release) once daily initially, increase by 10 mg/day increments every 7 days according to response, maximum 60 mg/day
Sertraline : 25 mg orally once daily initially, increase by 25-50 mg/day increments every 7 days according to response, maximum 200 mg/day
Fluoxetine : 5-10 mg orally (immediate release) once daily initially, increase by 10-20 mg/day increments every 4 weeks according to response, maximum 80 mg/day
Fluvoxamine : 25-50 mg orally (immediate release) once daily initially, increase by 25-50 mg/day every 4-7 days according to response, maximum 300 mg/day
Citalopram : 5-10 mg orally once daily initially, increase by 10-20 mg/day increments every 7 days according to response, maximum 40 mg/day
Escitalopram : 5 mg orally once daily initially, increase by 5-10 mg/day increments every 4 weeks according to response, maximum 20 mg/day
Venlafaxine (Effexor): 37.5 mg orally (extended release) once daily initially, increase by 37.5 to 75 mg/day increments every 7 days according to response, maximum 225 mg/day
 
TCA
Imipramine : 10-25 mg orally once daily initially, increase by 10 mg/day increments every 2-4 days according to response, maximum 300 mg/day
Clomipramine : 12.5 to 25 mg orally once daily initially, increase gradually according to response, maximum 250 mg/day
 
MAOIs
– May be more effective than tricyclics
– 3rd or 4th line due to dietary restrictions and risk of hypertensive crisis
 
Others
• Buspirone (Buspar) is not effective
 

Specific Phobia

  • 11% lifetime prevalence
  • Some phobias common and culturally or family related
  • Little comorbidity
  • Often don’t seek help
  • Treated with cognitive behavioral therapy and graded desensitization

Social Anxiety Disorder

  • Known as Social Phobia in DSM-IV
  • Fear of “performance” situations
    – Speeches and presentations
    – Meeting new people
    – Eating in crowded places
  • May affect 2% of the population

Treatment of Social Anxiety Disorder

  • SSRIs surprisingly effective
  • Phenelzine (MAOI)
  • Buspirone not effective
  • Beta blockers reduce tremors, sweating, etc, but do not help subjective anxiety

Generalized Anxiety Disorder (GAD)

  • Involves excess anxiety and worry for > 6 months
  • Accompanied by at least 3 physical symptoms:
    • Restlessness
    • Fatigue
    • Poor concentration
    • Muscular tension
    • Irritable bowel symptoms
    • Sleep disturbance, etc.
  • Female:Male ratio is 2:1
  • GAD patients say they have been anxious all of their lives and that they “worry about everything
  • Many GAD patients are:
    • Shy, compliant, perfectionist, and are concerned with their own failures and imperfections.
  • Major differential diagnosis:
    • Major depression
    • Frequently comorbid
  • Is chronic; 50% still diagnosed GAD at 5 year follow-up

Treatment of GAD

  • Must individualize treatment
  • SSRIs effective for generalized anxiety
  • Venlafaxine also useful
  • Benzodiazepines useful for immediate relief, or if above meds fail.
  • Beta blockers do not relieve generalized anxiety
  • Buspirone (Buspar) may be effective, especially if used as a 1st agent
    Dose:  Start: 7.5 mg PO bid, then incr. 5 mg/day q2-3 days; Max: 60 mg/day
    – Not a controlled substance, does not prevent ETOH or BZD withdrawal
    – Delayed action, 1-2 weeks
    – Daily bid dosing, not prn