Anxiety Management

PresenterDr. Anusa A MFirst year MD PG

Prepared by Prof. Rooban T,

Oral & Maxillofacial Pathologist

What is anxiety ?

Physical and emotional distress which interfere with normal life.

Physiological Anxiety

I have a presentation I have a tough exam I have an important interview

Should I be anxious ?

“Anxiety is an emotional state, unpleasant in nature, associated with uneasiness, discomfort and concern or fear about some defined or undefined future threat”

Pathological Anxiety

Some degree of anxiety is a part of normal life; but psychotics exhibit pathological anxiety, therefore, treatment is required.

Common Symptoms of Anxiety

EMOTIONAL SYMPTOMS

Irrational & excessive

fear, worry

Irritability

Restlessness

Trouble concentrating

Feeling tense

PHYSICAL SYMPTOMS

Sweating

Tachycardia

Stomach upset

Shortness of breath

Frequent urination or diarrhea

Sleep disturbances (Insomnia)

Fatigue

Types of Anxiety

Primary/Situational

Panic disorder

Generalized anxiety disorder

Obsessive-compulsive disorder

Post traumatic stress disorder

Phobic disorders

Secondary/Non-situational

Medical conditions

Substance abuse

Psychiatric conditions

Psychosocial stress

DSM IV-TR. Washington, DC: American Psychiatric Association. 2000.

Generalized Anxiety Disorder

Excessive anxiety and worry about a number of events for the majority of days over 6 months

Difficulty in controlling the worry

Associated with at least 3 physical and psychological symptoms

Causes significant distress or impairment

Generalized & acute stress disorder

Depressed mood

Anhedonia

Appetite disturbance

Worthlessness

Suicidal ideation

Anxiety

Sleep disturbance

Psychomotor agitation

Concentration difficulty

Irritability

Fatigue

Worry

Muscle tension

Palpitations

Sweating

Dry mouth

Nausea

Overlapping Symptoms of Depression and GAD

DSM-IV-TR. Washington, DC: American Psychiatric Association. 2000.

Fernandez et al. J Clin Psychiatry. 1995;56(suppl 2):20–29.Kirkwood et al. Anxiety disorders. In: DiPiro et al, eds. Pharmacotherapy: A Pathophysiologic Approach. 3rd ed. 1997:1443–1462.

Differential Diagnosis Medications Which Can Cause Anxiety Symptoms

Thyroid supplementationAntidepressants CorticosteroidsOral

contraceptivesStimulants

(caffeine)

BronchodilatorsDecongestantsAbrupt withdrawal

of CNS depressants▪ Alcohol ▪ Barbiturates▪ Benzodiazepines

Differential Diagnosis Medical Conditions with 2dry Anxiety Symptoms

Endocrine disorders Thyroid disease Parathyroid

diseases Hypoglycemia Cushings Disease

Cardio-respiratory disorders Angina Pulmonary

embolism

Neurological Seizure disorder

Substance-related dependence/ withdrawal Nicotine Alcohol Benzodiazepines Opioids

Obsessive-Compulsive Disorder (OCD)

An anxiety disorder in which people cannot prevent themselves from unwanted thoughts or behaviors that seem impossible to stop as washing their hands

Anxiety Disorders: OCD

Obsessive-Compulsive Disorder

Obsessions:

1) recurrent or persistent thoughts, impulses, or images are

experienced as intrusive or inappropriate and cause distress

2) not simply excessive worries about real-life problems

3) person attempts to ignore or suppress thoughts or

neutralize them with another thought or action

4) person recognizes that obsessions are product of his/her

mind, not imposed from without

DSM IV-TR. Washington, DC: American Psychiatric Association. 2000. 15

Obsessive-Compulsive Disorder

Compulsions:1) repetitive behaviors or mental acts

performed in response to an obsession or according to certain rules

2) designed to neutralize or prevent discomfort or some dreaded event or situation

DSM IV-TR. Washington, DC: American Psychiatric Association. 2000. 16

Obsessive-Compulsive Disorder

Obsessions and compulsions:

cause marked distress

time-consuming

Significantly interfere with normal routine,

occupational functioning

Usual social activities or relationships with others

DSM IV-TR. Washington, DC: American Psychiatric Association. 2000. 17

Rasmussen & Eisen (1992a) Zetin & Kramer (1992)

Common obsessions in OCD

Contamination

Pathological doubt

Aggressive impulse

Somatic concerns

Need for symmetry

Sexual impulse

Rasmussen & Eisen (1992a) Zetin & Kramer (1992)

Common Compulsions in OCD

Washing

Checking

Counting

Symmetry and precision

Need to ask or confess

Hoarding

19

OCD Treatments

Behavior Therapy (Exposure and

Response Prevention)

Pharmacotherapy (SSRI)

Combination

20

Behavior Therapy for OCDExposure and Response Prevention

Systematic and intensive treatment

Stimuli for rituals and avoidance identified

and assigned a place in a hierarchy of

anxiety provocation

Intensive exposure to stimuli is done both

with therapist and as homework

Exposure is graded from easiest to most difficult

Rituals omitted or, if not possible, delayed21

Steiner et al. Presented at the American Psychiatric Association Annual Meeting, May, 1995.

Serotonergic antidepressants for OCD Minimum duration of treatment: 10-12 weeks

Therapeutic doses: clomipramine 250 mg/day fluoxetine 60 mg/day fluvoxamine 300 mg/day sertraline 50-200 mg/day paroxetine 60 mg/day

Maintenance therapy prevents relapse

Risk of relapse 2.7 times greater with placebo than

paroxetine

Panic Disorder

An disorder in which people have sudden and intense attacks of anxiety in certain situations.

Anxiety Disorders: Panic Disorder

Panic Disorder Treatment:General Principles

Pharmacotherapy

Cognitive-Behavior Therapy (CBT)

Manual-driven CBT treatment to

normalize “catastrophic thinking”

Exposure to panic symptoms and other

feared situations

Panic Disorder Treatment:General Principles

Pharmacotherapy Selective serotonin reuptake inhibitors first line

due to favorable side effect profile

Other antidepressant classes work also

Venlafaxine (Effexor) is effective

Nefazodone(Serzone) no longer on US market due to liver

toxicity

Benzodiazepines and Beta-blockers useful

adjunctive treatments for residual symptoms

SSRI’s -PRACTICAL USAGE IN PANIC DISORDER

Sertraline• 1st week : 5mg/day for 2-3 days & if no side effects

50mg days 4-7• 2nd week-:75mg/day-days 8-10 & if no side effects

100mg days 11-14 • 3rd week-----------------------125 mg/day----if no response• 4-6 week-----------------------150mg/day ----if no response• 6 weeks & beyond-----------200mg/day & if partial

response consider up to 250-300mg day• With sertraline might need a benzodiazepine (Xanax or

Ativan-0.25-0.5mg bid-tid for breakthrough anxiety)

Paroxetine • 1st week-------------------------10mg/day for 2-4 days & if no side effects 20mg days 4-7• 2-3 weeks-----------------------30mg/day--if no response• 4-6 weeks-----------------------40mg/day-- if no response• 6 weeks & beyond-------------50-60mg/day as needed• With paroxetine less of a need for a benzodiazepine

Escitalopram• 1st week------------------------ -5 mg/day for 2 days then 10mg days 3-7• 2nd week------------------------ 10mg/day--if no response• 3rd thru 5thweek--------------15mg/day ----if no response• 6 weeks & beyond--------------20 mg/day as needed• Though 20mg is PDR recommended maximum, often 25-30 may be given to patients with partial

responses at 20mg and no side effects

SSRI’s -PRACTICAL USAGE IN PANIC DISORDER

Post-traumatic stress disorder

An anxiety disorder that affects people who have experienced a severe emotional trauma, such as rape or dramatic car accident, or even war.

Anxiety disorders: Post Traumatic Stress Disorders

PsychosocialExposure therapyCognitive therapy

Anxiety managementDesensitization

EMDRHypnotherapy

PTSD Treatment Options

PharmacologicSSRIsTCAs

MAOIs Mood stabilizers

Antianxiety agents

EMDR = eye movement desensitization and reprocessing. 31

An intense, uncontrolled fear of a specific situation such as open spaces & heights

Anxiety Disorder: Phobias

Anxiety Disorder: Phobias

Symptoms of social anxiety disorderFeared situations

Social Attending parties,

weddings etc Conversing in a group Speaking on

telephone Interacting with

authority figure (eg teacher or boss)

Making eye contact Ordering food in a

restaurant

Performance Public speaking Eating in public Writing a check Using public toilet Taking a test Trying on clothes in a

store Speaking up at a

meeting

34

Social anxiety disorder

CombinationCBT + pharmacotherapy

MAOIs

Benzodiazepines CBT

SSRIs

Social anxiety disorderTreatment options

35

Social anxiety disorder Treatment goals

Control anxiety and phobic avoidance Reduce associated disability Treat depression / other comorbid

disorders Tolerability over long term Eventual medication-free status

36

Pharmacological management of social anxiety disorder

Consider initial choice of an SSRI Initial dose for 2-4 weeks, then increase if

necessary example sertraline: 100mg/day with increase to

200mg/day Some benefit evident by 2-4 weeks If no response by 6-8 weeks, switch to drug

of another class or augment Consider psychosocial treatments Continue pharmacotherapy for at least 1 year

37

Social Anxiety Disorder: Pharmacological Treatments

Monoamine oxidase inhibitors

(standard/RIMAs)

Benzodiazepines

SSRIs--leading choice as sertraline

and paroxetine are FDA approved for

this disorder38

Treatment of anxiety

Psychotherapy (cognitive behavioral therapy).

Anxiolytics

Classification of anxiolytic drugs:

1. Benzodiazepines ( BDZ ).

2. 5HT1A agonists.

3. 5HT reuptake inhibitors.4. Antidepressants5. Beta adrenergic blockers6. MAO inhibitors 7. Mood Stabilizers (?)

Pathways of action of Anxiolytics

Classifications of Benzodiazepines

- Short acting: (3-5 hours): triazolam

-  Intermediate: (6-24 hours)

Alprazolam

Lorazepam

Oxazepam

Estazolam

Temazepam

Classifications of Benzodiazepines

-  Long acting: ( 24-72 hours) Clonazepam Chlordiazepoxide Diazepam Flurazepam

Mechanism of actions

Pharmacokinetics

are lipid soluble

well absorbed orally,

can be given parenterally

Chlordiazepoxide- Diazepam (IV only NOT IM)

widely distributed.

cross placental barrier (Fetal depression).

excreted in milk (neonatal depression).

Pharmacokinetics

metabolized in the liver to active metabolites (long duration of action- cumulative effect).

Redistribution from CNS to skeletal muscles, adipose tissue) (termination of action).

Pharmacological Actions

Anxiolytic action.

Depression of cognitive & psychomotor

function

Sedative & hypnotic actions

Anterograde amnesia.

Pharmacological Actions

Minimal depressant effects on

Cardiovascular system

Respiratory system

Some have anticonvulsant effect:

clonazepam, diazepam.

Adverse effects

• Ataxia (motor in coordination)

• Cognitive impairment.

• Hangover: (drowsiness, confusion)

• Tolerance & dependence

• Risk of withdrawal symptoms

Rebound Insomnia, anorexia, anxiety,

agitation, tremors and convulsion.

Adverse effects

Toxic effects:

Respiratory Depression

cardiovascular depression in large doses.

Drug interactions

Examples

CNS depressants Alcohol & Antihistaminics of effect of benzodiazepines

Cytochrome P450 (CYT P450) inhibitors

Cimetidine & Erythromycin

t ½ of benzodiazepines

CYT P450 inducers Phenytoin & Rifampicint 1/2 of benzodiazepines

Drug interactions

Dose should be reduced in

o Liver diseaseo Old people.

Precaution Should not used in pregnant women or breast-feeding. People over 65.

5HT1A agonists - Buspirone

acts as agonist at brain 5HT1A receptors

rapidly absorbed orally.

Slow onset of action (delayed effect)

T½ : (2 – 4 hrs).

liver dysfunction its clearance.

Drug Interactions with CYT P450 inducers

and inhibitors.

Buspirone

Only anxiolytic

No hypnotic effect.

Not muscle relaxant.

Not anticonvulsant.

No potentiation of other CNS depressants.

Minimal psychomotor and cognitive dysfunctions.

Does not affect driving skills.

Minimal risk of dependence.

No withdrawal signs.

Uses of buspirone

As anxiolytic in mild anxiety & generalized

anxiety disorders.

Not effective in severe anxiety/panic disorder.

Beta Blockers

Propranolol – atenolol

act by blocking peripheral sympathetic

system.

Reduce somatic symptoms of anxiety.

Decrease BP & slow HR.

Used in social phobia.

are less effective for other forms of anxiety

Tricyclic Antidepressants

Doxepin- imipramine

act by reducing uptake of 5HT & NA.

Used for anxiety associated with depression.

Effective for panic attacks.

Delayed onset of action (weeks).

dry mouth, postural hypotension, sexual

dysfunction, weight gain.

Selective serotonin reuptake inhibitors (SSRIs)

Fluoxetine

acts by blocking uptake of 5HT

Orally

Delayed onset of action (weeks).

Used for panic disorder – OCD depression-

Generalized anxiety disorders - phobia.

Side Effects:

Weight gain, sexual dysfunction, dry mouth

MONOAMINE OXIDASE INHIBITORS

Phenelzine Acts by blocking MAO enzymes. Used for panic attacks and phobia. Require dietary restriction Avoid wine, beer, fermented foods as

old cheese that contain tyramine. Side effects - Dry mouth, constipation,

diarrhea, restlessness, dizziness

Anxiolytics

CLASSES OF ANXIOLYTICS USES

Benzodiazepines Generalized anxiety disorders, OCD, phobia, panic attack

SSRIs(Fluoxetine)

Generalized anxiety disorders, OCD, phobia, panic attack

Tricyclic antidepressants(doxepin, imipramine )

anxiety with depression.panic attacks

5HT1A agonists(Buspirone)

Mild anxietyNot effective in panic attack

Beta blockers (propranolol, atenolol)

Phobia (social Phobia)

MAO inhibitorsPhenelzine

Panic attack, phobia

Conclusion - AnxiolyticsCLASSES OF ANXIOLYTICS

Adverse effects

Benzazepines Ataxia, confusion, dependence, tolerance, withdrawal

symptoms,

SSRIs(Fluoxetine)

weight gain, sexual dysfunction Dry mouth

Tricyclic antidepressants

(doxepin, imipramine )

weight gain, sexual dysfunction, atropine like

actions

5HT1A agonists(Buspirone)

Minimal adverse effects

Beta blockers (propranolol, atenolol)

Hypotension

Thank You