Anxiety Disorders-

Anti-anxiety Drugs
 Definitions
Anxiety
• Feelings of impending doom not linked to
a specific stimulus in the environment
• Feeling of fear in absence of externalized
threat

Fear
• Feelings in response to a specific stimulus
 Symptoms
Mental Symptoms

Vague sense of irritability & uneasiness

Increasing anxiety

Feeling that something terrible is going to happen

Terror or panic
 Symptoms of Generalized
Anxiety Disorder

• Persistent anxiety for at least 1 month

• Motor tension
• Autonomic hyperactivity
• Apprehension
• Vigilance and scanning
 Symptoms
Physical Symptoms

• Autonomic Nervous System Activation

– Sweating
– Increased heart rate & blood pressure
– Dry mouth
– Upset GI tract
– Cold & clammy hands
 Treatments
Medication Anxiety Disorder
Benzodiazepines All anxiety disorders for symptomatic treatment
Serotonin Antidepressants (low doses) Agoraphobia; Panic disorders
Serotonin Antidepressants (antidepressant doses) PTSD
Serotonin Antidepressants (high doses) OCD
Beta blockers Social phobia
Buspirone (Buspar) GAD
 Anti-anxiety Drugs
Drugs Dose Half-Life Duration
Benzodiazepines 2-3x/day
diazepam (Valium) 1-10 mg 30-60 hours long
lorazepam (Ativan) 2-6 mg 10-20 hours medium
alprazolam (Xanax) .25-.5 mg 12-15 hours medium
chlordiazepoxide (Librium) 10-100 mg 5-15 hours short

Non-Benzodiazepines
buspirone (Buspar) 20-30 mg 2-3 hours short
propanolol (Inderal) 10-80 mg 4 hours short
clomipramine (Anafranil) 150-250 mg 20-40 hours long
fluoxetine (Prozac) 40-80 mg 48-72 hours long
 Hypnotics

Drugs Dose Half-Life Duration

flurazepam (Dalmane) 15-30 mg 50-100 hours long

temazepam (Restoril) 15-30 mg 10-20 hours medium

triazolam (Halcion) .25-1.0 mg 2-5 hours short

zolpidem (Ambien) 5-10 mg 2-3 hours short
 Benzodiazepines
Physiological Effects:

Do not:
• respiratory rate
• heart rate
• impair GI
 Benzodiazepines
Normal
Anti-anxiety
Disinhibition
Sedation
BZP Sleep
General Anesthesia
Coma
Death
 Benzodiazepines
1. Safe - will not kill you
– Diazepam (Valium)

2. Effective in treating symptoms of anxiety

3. Less abuse potential than other sedative-

hypnotics
4. No effect on cardiovascular system
 Medical Uses - Benzodiazepines
Anti-Anxiety Alcohol Withdrawal
– Acute Anxiety – Chloriazepoxide
– Anxiety Disorders (Librium)

Anti-Convulsant Pre-Operative
– Status epilepticus
– Midazolam (Versed)
– Diazepm intravenous
Behavioral Effects- Benzodiazepines

• Takes edge off anxiety

• Mild High, relaxed, disinhibited
• Decreased distractability, increased focus
• Decreased autonomic symptoms
• Muscle relaxation
 Side Effects - Benzodiazepines
• Decreased Performance
• Decreased Memory
• Traveler’s Amnesia (Blackout)
• Abuse Potential?
• Withdrawal - dependence like alcohol
delayed [alprazolam (Xanax)]
 Benzodiazepines
• Dependence is moderate

• Withdrawal syndrome similar to alcohol

– Longer onset
– Longer in duration
– Less intense
 Types of Disorders

Simple Phobia
– Persistent fear of circumscribed stimulus

• Treatment:
– Behavioral Therapy
– Benzodiazepines: Alprazolam
(Xanax)
 Types of Disorders

Social Phobia
– Fear of situations involving possible scrutiny of
others

• Treatment:
– Cognitive Behavioral Therapy
– Monoamine oxidase inhibitor-MAOIs
– Serotonin selective reuptake inhibitor-SSRIs
– Beta blockers – Atenolol (Tenormin)
 Types of Disorders

Agoraphobia
– Avoidance of situations where escape may be
difficult

• Treatment:
– Benzodiazepines
– Antidepressants (low doses)
– Psychotherapy
 Types of Disorders

Panic Disorder
– Discrete periods of intense fear & anxiety that
come out of nowhere

• Treatment:
– Psychotherapy
– Benzodiazepines (symptomatic)
– Antidepressants (low doses)
 Types of Disorders

Generalized Anxiety Disorder (GAD)

– Increased tension, vigilance, autonomic activity,
apprehension

• Treatment:
– Psychotherapy
– SSRIs (low doses)
– Benzodiazepines
– Buspirone (Buspar)
 Types of Disorders

Obsessive Compulsive Disorder (OCD)

– Obsessions & compulsions

• Treatment:
– Cognitive Behavioral therapy
– Behavioral therapy
– SSRIs (high doses)
– Less robust clinical response of SSRIs than SSRIs
for depression
 Types of Disorders

Post Traumatic Stress Disorder (PTSD)

– Experience outside range of normal human
experience
– Flashbacks, psychic numbness, persistent
arousal, nightmares

• Treatment:
– Behavioral therapy
– Benzodiazepines (symptomatic)
– SSRIs
 Mood
Disorders

Antidepressants
 Depression Definitions
• Anhedonia - without pleasure
• Hypomania - symptoms of mania that do not meet
the criteria for a manic episode
• Euthymia - normal mood state
• Dysthmia - decrease in mood that does not meet full
criteria for MDE
• Remission - full response < 1 year out
• Recovery - full response > 1 year out
 Tricyclic Antidepressants
• Drug: amitryptyline (Elavil)
• Side effects: anticholinergic side effects,
decreased libido & sexual performance,
precipitation of mania
• Use and contraindications
– Effective anti-depressant
– More side effects than SSRIs
– Lethal dose 5X therapeutic dose
 Anticholinergic Side Effects TCA
• Dry mouth
• Constipation
• Urinary retention
• Increased heart rate
• Orthostatic hypotension
• Blurring of vision
• Dementia - delirium 300mg/day
• 2,000 mg/day = death
Monoamine Oxidase Inhibitors-
MAOIs
• Drug: phenelzine (Nardil)
• Side effects: anticholinergic like including dry mouth,
constipation, heart arrythmias, but also: insomnia-
stimulant effect and potential hypertensive crises
• Use and contraindications
– Often use to treat “atypical” depression
– Potential lethal side effects that requires dietary
monitoring;
– no tyramine containing foods: aged cheese, red
wine, fava beans
 Serotonin Selective Reuptake Inhibitors-
SSRIs
• Drugs: escitalopram (Lexapro)
fluoxetine (Prozac)
• Side effects: nausea, insomnia or
sedation, decreased sexual function:
decreased libido and orgasm
• Use and contraindications
– Effective antidepressants and anti-anxiety
drugs
– Safe antidepressants
 Serotonin Norepinephrine
Reuptake Inhibitors - SNRIs
• Drug: duloxetine (Cymbalta)
• Side effects: nausea, insomnia or
sedation, dizziness, sexual side effects
like SSRIs
• Use and contraindications
– Effective antidepressant
– Effective anti-anxiety drug
– First line treatment for major depressive
episodes
 Atypical Antidepressants
• Drug: buproprion (Wellbutrin)
• Side effects: anxiety, restlessnes and
weight gain
• Use and contraindications
– Effective anti-depressant
– No sexual side effects
– Seizures in 0.5 percent of subjects at
therapeutic doses
 Time Course of AD Treatment
1. Delay in response of antidepressants: 7-10
days
2. Differential response in symptoms

• First vegetative symptoms

• Second emotional/subjective feelings
 Psychiatrist Jeffrey Schwartz, author of Brain Lock:
Free Yourself from Obsessive-Compulsive Behavior,
offers the following four steps for dealing with OCD
• RELABEL – Recognize that the intrusive obsessive
thoughts and urges are the RESULT OF OCD.
• REATTRIBUTE – Realize that the intensity and
intrusiveness of the thought or urge is CAUSED BY OCD; it
is probably related to a biochemical imbalance in the brain.
• REFOCUS – Work around the OCD thoughts by focusing
your attention on something else, at least for a few
minutes: DO ANOTHER BEHAVIOR.
• REVALUE – Do not take the OCD thought at face value. It Is
not significant in itself.
 DSM-IV: Simple Phobia
A. Marked and persistent fear that is excessive or
unreasonable, cued by the presence or anticipation
of a specific object or situation (e.g., flying, heights,
animals, receiving an injection, seeing blood).
B. Exposure to the phobic stimulus almost invariably
provokes an immediate anxiety response, which may
take the form of a situationally bound or situationally
predisposed Panic Attack. Note: In children, the
anxiety may be expressed by crying, tantrums,
freezing, or clinging.
C. The person recognizes that the fear is excessive or
unreasonable. Note: In children, this feature may be
absent.
 DSM-IV: Social Phobia
A. A marked and persistent fear of one or more
social and performance situations in which the
person is exposed to unfamiliar people or to
possible scrutiny by others. The individual
fears that he or she will act in a way (or show
anxiety symptoms) that will be humiliating or
embarrassing.
B. Exposure to the feared social situation almost
invariably provokes anxiety, which may take the
form of a situationally bound or predisoposed
Panic Attack.
C. The person recognizes that the fear is
excessive or unreasonable.
 DSM-IV: Panic Disorder
A. Both (1) and (2):
1. Recurrent unexpected Panic Attacks
2. At least one of the attacks has been followed by 1
month (or more) of one (or more) of the following:
• persistent concern about having additional attacks
• worry about the implications of the attack or its
consequences
• a significant change in behavior related to the attacks
B. Absence of Agoraphobia
C. The Panic Attacks are not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a
medication) or a general medical condition (e.g.,
hyperthyroidism).
 DSM-IV: Agoraphobia
A. Anxiety about being in places or situations from which escape might be
difficult (or embarrassing) or in which help may not be available in the
event of having an unexpected or situationally predisposed Panic Attack
or panic-like symptoms.

B. The situations are avoided (e.g., travel is restricted) or else are endured
with marked distress or anxiety about having a Panic Attack or panic-
like symptoms, or require the presence of a companion.

C. The anxiety or phobic avoidance is not better accounted for by another

mental disorder.
 DSM-IV: GAD
A. Excessive anxiety and worry (apprehensive expectation),
occurring more days than not for at least 6 months, about a
number of events or activities (such as work or school
performance).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of
the following six symptoms (with at least some symptoms
present for more days than not for the past 6 months).
• restlessness or feeling keyed up or on edge
• being easily fatigued
• difficulty concentrating or mind going blank
• irritability
• muscle tension
• sleep disturbance (difficulty falling or staying asleep, or
restless unsatisfying sleep)
 DSM-IV: OCD
Obsessions as defined by (1), (2), (3), and (4):
1. recurrent and persistent thoughts, impulses,
or images that are experienced, at some time during
the disturbance, as intrusive and inappropriate and that
cause marked anxiety or distress
2. the thoughts, impulses, or images are not
simply excessive worries about real-life problems
3. the person attempts to ignore or suppress
such thoughts, impulses, or images, or to neutralize
them with some other thought or action
4. the person recognizes that the obsessional
thoughts, impulses, or images are a product of his or
her own mind (not imposed from without as in thought
insertion)
 DSM-IV: OCD
Compulsions as defined by (1) and (2):

1. repetitive behaviors (e.g., hand washing, ordering,

checking) or mental acts (e.g., praying, counting, repeating words
silently) that the person feels driven to perform in response to an
obsession, or according to rules that must be applied rigidly
2. the behaviors or mental acts are aimed at preventing or
reducing distress or preventing some dreaded event or situation;
however, these behaviors or mental acts either are not connected
in a realistic way with what they are designed to neutralize or
prevent or are clearly excessive

B. At some point during the course of the disorder, the person has
recognized that the obsessions or compulsions are excessive or
unreasonable. Note: This does not apply to children.
 DSM-IV: PTSD

A. The person has been exposed to a

traumatic event
B. The traumatic event is persistently re-
experienced
C. Persistent avoidance of stimuli associated
with the trauma and numbing of general
responsiveness