PHCL 515-4(702515-4):

pathophysiology and Therapeutics 3

PSYCHIATRIC
DISORDERS

Anxiety
 Introduction
 Anxiety is a normal, protective, psychological response to an unpleasant or
threatening situation.

 Excessive or prolonged anxiety can be disabling, lead to severe distress and cause
much impairment in social functioning.

 The term anxiety disorder includes a variety of conditions that can either exist on
their own or in conjunction with another psychiatric or physical illness.

 Symptoms of anxiety vary, but patients generally present with a combination of

psychological, physical and behavioral symptoms.

 Anxiety disorders are broadly divided into generalized anxiety disorder (GAD), panic
disorder (PD), social anxiety disorder, specific phobias, separation anxiety disorder
and illness anxiety disorder.
 Cont.
 Posttraumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD)
were previously classified under the umbrella of anxiety disorders but are now
considered to be separate illnesses.

 Approximately two-thirds of sufferers of an anxiety disorder will have another

psychiatric illness such as depression, alcohol and substance use disorders .

 Successful treatment of an underlying depression will significantly improve the

symptoms of anxiety.

 Many patients also present with symptoms of more than one anxiety disorder at the
same time, which can further complicate treatment.

 Anxiety disorders are the most commonly reported mental disorders and as a whole
have a lifetime prevalence of approximately 21%

 Prevalence rates across the anxiety spectrum increase from the younger age group
(18–29 years) to older age groups (30–44 and 45–59 years); however, rates are
substantially lower for those older than age 59 years.
 Cont.
 Anxiety is commonly precipitated by stress or adverse life events, but vulnerability to
stress and trait anxiety also appear to be linked to genetic factors.

 Many patients presenting for the first time with anxiety symptoms have a long history
of high anxiety levels going back to childhood.

 Anxiety may also be induced by central stimulant drugs (e.g. amphetamines),

withdrawal from chronic use of central nervous system depressant drugs (e.g,
hypnotics, anxiolytics) and metabolic or endocrine disturbances (e.g.
hyperventilation, hypoglycaemia, thyrotoxicosis).

 Along with the psychological symptoms, biological symptoms may be prominent in

anxiety and include palpitations, chest pain, shortness of breath, dizziness,
dysphagia, gastro-intestinal disturbances, loss of libido, headaches and tremor.

 Panic attacks are experienced as storms of increased autonomic activity combined

with a fear of imminent death or loss of control.

 If panic becomes associated with a specific environment, commonly a crowded place

with no easy escape route, the patient may actively avoid similar situations and
eventually become agoraphobic.
 CLINICAL PRESENTATION
** GENERALIZED ANXIETY DISORDER
 The diagnosis of GAD requires excessive anxiety and worry most days about a

number of matters for at least 6 months.

 Symptoms are at least three of the following:

A. restlessness; easily fatigued; difficulty concentrating; irritability; muscle tension; and
sleep disturbance
B. Significant distress or impairment in functioning is present, and the disturbance is not
caused by a substance or another medical condition.
C. Women are twice as likely as men to have GAD. The illness has a gradual onset at
an average age of 21 years. The course is chronic, with multiple exacerbations and
remissions.
 Cont.
** PANIC DISORDER
A. Recurrent unexpected panic attacks. At least one attack has been followed by at
least one month of : 1) persistent worry about additional panic attacks or 2) change
in behavior related to the attacks.
B. During an attack, there must be at least four physical symptoms in addition to intense
fear or discomfort.
C. Symptoms reach a peak within 10 minutes and usually last no more than 20 or 30
minutes.
D. Up to 70% of patients eventually develop agoraphobia, which is avoidance of specific
situations (eg, being in crowded places or crossing bridges) where they fear a panic
attack might occur. Patients may become homebound.
 Cont.
** SOCIAL ANXIETY DISORDER
A. SAD is a chronic disorder with an intense fear or anxiety about one or more social
situations in which there is scrutiny by others which may result in negative evaluation
and rejection.
B. Exposure to the feared situation(s) almost always provokes fear or anxiety, and the
situations are avoided or endured with intense anxiety.
C. The fear or avoidance lasts for at least 6 months and causes significant impairment
in functioning.
 DIAGNOSIS
 Evaluation of the anxious patient requires a physical and mental status examination;
complete psychiatric diagnostic exam; appropriate laboratory tests; and a medical,
psychiatric, and drug history.

 Anxiety symptoms may be associated with medical illnesses or drug therapy and
they may be present in several major psychiatric illnesses (eg, mood disorders,
schizophrenia, organic mental syndromes, and substance withdrawal).
 Cont.
** GENERALIZED ANXIETY DISORDER

 Goals of Treatment:
1. Reduce severity, duration, and frequency of symptoms and improve functioning.
2. The long-term goal is minimal or no anxiety symptoms, no functional impairment,
prevention of recurrence, and improved quality of life.

 Non-pharmacologic modalities include psychotherapy, short-term counseling, stress

management, cognitive therapy, meditation, supportive therapy, and exercise.

 Patients with GAD should have psychological therapy, alone or in combination with
antianxiety drugs.

 Cognitive behavioral therapy (CBT), though not widely available, is the most effective
psychological therapy.

 Patients should avoid caffeine, stimulants, excessive alcohol, and diet pills.
 Cont.
** PANIC DISORDER
 Goals of Treatment: complete resolution of panic attacks, marked reduction in

anticipatory anxiety, elimination of phobic avoidance, and resumption of normal

activities.

 SSRIs are first-line agents for panic disorder

 Most patients without agoraphobia improve with pharmacotherapy alone, but if

agoraphobia is present, CBT typically is initiated concurrently.

 Patients treated with CBT are less likely to relapse than those treated with
imipramine alone.

 For patients who cannot or will not take medications, CBT alone is indicated.

 Educate patient to avoid caffeine, nicotine, alcohol, drugs of abuse, and stimulants.

 If pharmacotherapy is used, antidepressants, especially the SSRIs, are preferred in

elderly patients and youth.
 Cont.
 The benzodiazepines are second line in these patients because of potential
problems with disinhibition.

 The most common side effect of benzodiazepines is CNS depression. Tolerance

usually develops to this effect. Other side effects are disorientation, psychomotor
impairment, confusion, aggression, excitement, and anterograde amnesia.

 Patients with a history of drug abuse should not receive benzodiazepines.

 Patients with GAD and panic disorder are at high risk for dependence because of
the chronicity of the illnesses.

 Benzodiazepine dependence is defined by appearance of a withdrawal syndrome (ie,

anxiety, insomnia, agitation, muscle tension, irritability, nausea, diaphoresis,
nightmares, depression, hyperreflexia, tinnitus, delusions, hallucinations, and
seizures) upon abrupt discontinuation.
 Cont.
 After benzodiazepines are abruptly discontinued, three events can occur:
1) Rebound symptoms are an immediate but transient return of original symptoms with
an increased intensity compared with baseline

2) Recurrence or relapse is the return of original symptoms at the same intensity as

before treatment

3) Withdrawal is the emergence of new symptoms and a worsening of preexisting

symptoms.

 The onset of withdrawal symptoms is within 24 to 48 hours after discontinuation of

short-elimination half-life benzodiazepines and 3 to 8 days after discontinuation of
long-elimination half-life drugs.

 Usually patients are treated for 12 to 24 months before discontinuation is attempted

over 4 to 6 months.

 Many patients require long-term therapy.

 Single weekly doses of fluoxetine have been used for maintenance.

 Cont.
** SOCIAL ANXIETY DISORDER
 Goals of Treatment: Reduce the physiologic symptoms and phobic avoidance,

increase participation in desired social activities, and improve quality of life.

 Patients with SAD often respond more slowly and less completely than patients with
other anxiety disorders.

 After improvement, at least 1 year of maintenance treatment is recommended. Long-

term treatment may be needed for patients with unresolved symptoms, comorbidity,
an early onset of disease, or a prior history of relapse.

 CBT (exposure therapy, cognitive restructuring, relaxation training, and social skills
training) and pharmacotherapy are considered equally effective in SAD, but CBT can
lead to a greater likelihood of maintaining response after treatment termination.

 Even after response, most patients continue to experience more than minimal
residual symptoms.

 CBT and social skills training are effective in children with SAD.
 Cont.
 SSRIs and serotonin norepinephrine reuptake inhibitors are effective in children 6 to
17 years of age.

 Individuals up to 24 years of age should be closely monitored for increased risk of

suicide.

 Paroxetine, sertraline, extended-release fluvoxamine, and extended-release

venlafaxine are first-line agents.

 With SSRI treatment, the onset of effect is delayed 4 to 8 weeks, and maximum
benefit is often not observed until 12 weeks or longer.

 The TCAs are not effective for SAD. Mixed results have been reported for fluoxetine.

 SSRIs are initiated at doses similar to those used for depression. If there is comorbid
panic disorder, the SSRI dose should be started at one fourth to one half the usual
starting doses of antidepressants.

 The dose should be tapered slowly (monthly) during discontinuation to decrease the
risk of relapse.
 Cont.
 Efficacy with extended-release venlafaxine is well established.

 Reserve benzodiazepines for patients at low risk of substance abuse, those who
require rapid relief, or those who have not responded to other therapies.

 Clonazepam is the most extensively studied benzodiazepine for treatment of

generalized SAD.

 It should be tapered not faster than 0.25 mg every 2 weeks.

 Gabapentin was effective for SAD, with an onset of effect of 2 to 4 weeks.

 Pregabalin was superior to placebo at a dose of 600 mg/day.

 β-Blockers blunt the peripheral autonomic symptoms of arousal (eg, rapid heart rate,
sweating, blushing, and tremor) and are often used to decrease anxiety in
performance-related situations.

 For specific SAD, 10 to 80 mg of propranolol or 25 to 100 mg of atenolol can be

taken 1 hour before the performance.