Anxiety-Related Disorders

Psychological, physiological, and behavioral state in animals and humans, caused by a perceived threat to well-being or survival (normal!).

Interferes with ability to cope successfully with life challenges

Excessive anxiety and worry lasting > 6 months and difficulty controlling the worry.

0-17

18-24

25-30

>70% reduction in symptoms from baseline

50-70% reduction in symptoms from baseline

24-49% reduction in symptoms from baseline

<25% reduction in symptoms from baseline

Caffeine and caffeine-containing products
Steroids
Bupropion
Stimulants (prescribed or illicit)
Bronchodilators
Thyroid hormone
Ginseng
St. John’s wort

Psychotherapy with or without medication

SSRIs:
paroxetine
escitalopram
citalopram
sertraline

SNRIs:
venlafaxine XR
duloxetine

Pregabalin

Alternative first line agent
Augment (benzo, buspirone, SGA, antihistamine, hydroxyzine)

treatment with antidepressants may take 4-12 weeks for response in GAD
Many patients (~60-70%) will not achieve remission (HAM-A score <7)
Antidepressants may initially worsen anxiety symptoms start low and titrate slowly to max tolerated dose

Reduce dose by 25% per week until 50% of dose is reached then reduce dose by one-eighth every 4-7 days

more than a year

Recurrent unexpected panic attacks with > 1 attack followed by at least one month of > 1 of the following:
Constant concern about having another attack
Being anxious about the implications of the attack or its consequences
Maladaptive behavior changes to avoid having panic attack

Fear or anxiety in > 2 of the following situations:
Public transportation
Open spaces
Enclosed places
Crowds or standing in line
Outside of home alone

psychotherapy
SSRIs:
all equally effective

SNRIs:
venlafaxine XR

alternative first line agent
benzodiazapines for residual anxiety or rapid symptom contol (with no hisotry of substance abuse disorder) (alprazolam, clonazepam)
TCAs

3-4 week response time with antidepressants, up to 6 months for full effect
BZD acute anxiety reduced within hours, but may take 4-6 weeks for full benefit as monotherapy

acute phase
maintinence phase
discontinuation phase

1-3 months, change treatment if no response after 6-8 weeks at max dose

continue for 12 months after treatment response

taper over 4-6 months to avoid relapse if deemed appropriate

Feeling detached from self, body, or time
Feel as if one were an outside observer of one’s mental processes or body

Unreality of surroundings
World seems unreal, dreamlike, distant, or distorted

Trauma focused therapy (exposure based or CBT)

SSRI:
paroxetine
sertraline
fluoxetine

SNRI:
venlafaxine XR

alternative first line agent
mirtazapine

BZD use is not recommended in patients with PTSD

allow 12 weeks at max tolerated dose to assess effectiveness
continue treatment for 12 months after response at full dose, continue longer if symptoms persist, may be lifelong
if discontinuing, taper over more than a month and assess for relapse

Must have obsessions, compulsions, or both
Obsessions and compulsions cause marked distress and are time consuming (>1 hour/day) or significantly interfere with functioning

Persistent and recurrent thoughts, images, or urges felt by the person to be intrusive and unwanted, typically cause anxiety and distress
Person attempts to ignore or suppress the thoughts, images, or urges or tries to neutralize them with a different thought or action

Repetitive behaviors or mental acts person feels driven to perform to relieve an obsession or according to rules that must be applied rigidly
Aimed at preventing or reducing anxiety or preventing a dreaded event or situation
Excessive and not connected in a realistic way with what they are designed to counteract

32-40

24-31

16-23

8-15

0-7

greater than or equal to 25% reduction in symptoms

score of less than or equal to 8

CBT

SSRIs:
fluoxetine
fluvoxamine
paroxetine
sertraline

change to a different SSRI
venlafaxine XR

clomipramine (TCA)
augmentation for patients with a partial response using an antipsychotic (haloperidol, risperidone)

Only 20-30% of patients will have significant improvement with pharmacotherapy, 40-50% have moderate improvement, but 20-40% have no improvement or symptoms worsen
10-12 weeks of treatment to see a reponse
higher doses used

Continue medications for 1-2 years before tapering
High relapse rate: 24-89%
Lifelong therapy recommended after 2-4 severe relapses or 3-4 less severe relapses
if discontinueing, taper by 10-25% every 1-2 months