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ANXIETY DISORDERS – II
MANAGEMENT

Dr Vivek Kumar
Professor
 RECAP
 Normal (Fear) vs. Pathological (Anxiety)

 Cognitive, Biological and Behavioral Signs/Symptoms

 Etiology Bio-Psycho-Social model

 Classification according to ICD-10; Agopraphobia

with/without Panic Disorder, Social Phobia, Specific
(Isolated) Phobias and Generalized Anxiety Disorder.

 Differential Diagnosis.
MANAGEMENT.
Phamacologic
Managem Lab.
ent Investigations

Non-
Phamacologic
LABORATORY EXAMINATION
 A targeted work-up is required.

 If possible, tests should be selected to rule in specific

diagnoses.

 Routine Test to consider include

 complete blood count,
 electrolytes,
 glucose fasting/PP/HbA1c,
 kidney function test,
 liver function tests,
 thyroid function tests, and urinalysis.
LABORATORY EXAMINATION (CONT.)
 Occasionally, additional studies may be indicated to rule
out
 pheochromocytoma (e.g., urinary catecholamines),
 seizure disorder (e.g., EEG),
 cardiac arrhythmia (e.g., ECG/Holter monitoring), and
 pulmonary disease (pulse oximetry, arterial blood gases, x-
ray).

 Brain imaging may be useful in ruling out demyelinating

disorder, tumor, stroke, or hydrocephalus.
PHARMACOLOGIC
TREATMENT
 TREATMENT
(CLASSESS OF DRUGS AVAILABLE)
Class Drugs
Tricyclic Antidepressants (TCAs) Amytrptyline, Clomipramine, Imipramine,
Nortryptyline, etc.

Selective Serotonin Reuptake Citalopram, Escitalopram, Fluoxetine, Fluvoxamine,

Inhibitors (SSRIs) Proxetine, Sertraline

Selective Norepinephrine Duloxetine, Atomoxetine, Desvenlafaxine,

Reuptake Inhibitors (SNRIs) Venlafaxine

Benzodiazapines (BZDs) Diazepam, Lorazepam, Clonazepam, Oxazepam,

Chlordiazepoxide

Beta Blockers Propranolol, Atenolol, Metoprolol

Buspiron
Low dose of antipsychotics
 TREATMENT
GENERAL PRINCIPLES (CONT.)
 Mechanisms
 TCAs blocks the
transporter site for
norepinephrine and
serotonin , thus
increasing synaptic
concentrations of
these
neurotransmitters.

 SSRIs – Selective
Serotonin reuptake
inhibition.
 TREATMENT
GENERAL PRINCIPLES (CONT.)
 Mechanisms
 Benzodiazepine
agonists bind a
receptor complex
that contains
benzodiazepine
and GABA
receptors.
 TREATMENT
(DRUGS DOSAGE)
Class Drugs (mg/day)
TCAs Amytrptyline (50-150) Imipramine (2-6)
Clomipramine (100-200) Nortryptyline (75-150)

SSRIs Citalopram (20-40) Fluvoxamine (100-300)

Escitalopram (10-20) Proxetine, (10-20)
Fluoxetine (20-80) Sertraline (50-100)

SNRIs Duloxetine (40-60) Desvenlafaxine (50-100)

Atomoxetine (40-100) Venlafaxine (75-225)

BZDs Diazepam (4-40) Oxazepam, (30-60)

Lorazepam (2-6) Chlordiazepoxide (15-100)
Clonazepam (0.5-2.0)
Beta Blockers Propranolol, (40-400) Metoprolol
Atenolol,

Buspiron (20-30)
 TREATMENT GENERAL PRINCIPLES (CONT.)
 SIDE EFFECTS (TCAs)
TCA
Anticholinergic SEs Dry mouth, Constipation, Blurred vision, Urinary
retention, Delirium. Avoid in Narrow angle glaucoma.

Cardiac Side Effects Tachycardia, QTc prolongation, flat T wave, depressed ST

Autonomic Effects Orthostatic hypotension

Neurologic Side Effects Tremors, Myoclinic twitches, Paresthisia,Peroneal palsy,
ataxia, lowering seizure threshold
Allergic & Hematologic Agranulocytosis, leukocytosis, leukopenia, eosiniphilia

Hepatic Self limiting rise in enzymes, Fulminant acute hepatitis

(0.1 to 1%)
Others Sedation, Weight gain, Sexual problems, SIADH
D2 antagonist activity related
SE (Amoxapine)
 TREATMENT GENERAL PRINCIPLES (CONT.)
 SIDE EFFECTS (SSRIs)
SSRI
Anticholinergic Ses Dry mouth, Constipation, Blurred vision, Urinary retention,
(Paroxetine) Delirium. Avoid in Narrow angle glaucoma.

Autonomic Effects Orthostatic hypotension

Neurologic Side Effects Anxiety, Insomnia/Sedation, Vivid dreams, Bruxism, RLS,
Nocturnal myoclonus, Sweating, Yawning, Emotional Blunting,
EPSEs, lowering seizure threshold
Hematologic Functional Impairment of platelet Aggregation.

Allergic & Endocrinal Hypoprolactinemia

Serotnin Syndrome Agitation, Insomnia, Confusion

Rapid HR and high BP, Dilated pupils, in-coordination or
twitching, rigidity, Diarrhea, Shivering, Goose bumps. Severe -
High fever, Tremor, Seizures, Irregular
heartbeat ,Unconsciousness
Others Weight gain, Sexual problems, SIADH, Serotonin Syndrome,
Sweating
 TREATMENT
GENERAL PRINCIPLES (CONT.)
 SIDE EFFECTS (BZDs)
BZD
Drowsiness/Dizziness
Mild cognitive deficits
Anterograde amnesia
Aggression
Hepatotoxicity
Respiratory depression
Withdrawal seizure
Ataxia
Hallucinosis
Appetite Stimulation
 TREATMENT
GENERAL PRINCIPLES (CONT.)
 DRUG SELECTION
 efficacy and adverse effects

 patient variables.

 No drug is universally effective,

 Decisions about drug selection and use are made on a case-

by-case basis, relying on the individual judgment by the
psychiatrist.
 TREATMENT
GENERAL PRINCIPLES (CONT.)
Concurrent Medical or Psychiatric Disorders
 Initial assessment should elicit information about
coexisting medical disorders.
 In some cases, a medical disorder may be responsible for
the symptoms.
 TREATMENT
GENERAL PRINCIPLES (CONT.)
 Overdose
 Safety in overdose is always a consideration in drug
selection.
 clinicians must recognize that the prescribed medication
can be used in an attempt to commit suicide.
 an attempt should be made to verify that the medication
is not being hoarded for a later overdose attempt.
 TREATMENT of OVERDOSE- General ± Specific
TREATMENT
GENERAL PRINCIPLES (CONT.)
 Duration of Treatment
 A common question from a patient is “How long do I need to
take the medication?”

 The answer depends on multiple variables, including:

the nature of the disorder, the duration of symptoms, the
family history, and the extent to which the patient tolerates
and benefits from the medication.

 Treatment is conceptually broken down into three phases: the

initial therapeutic trial, the continuation, and the maintenance
phase.
 COURSE OF ANXIETY DISORDER
 The course of AD  Remission Recovery

 No Anxiety 
 Response

Severity

Pro isorde

 Symptoms
to d
g re

 Syndrome
ssio
n

  Recurre


Relaps nce
e 
 Treatment  Acute  Continuation Maintena
phases: nce
TREATMENT
GENERAL PRINCIPLES (CONT.)
 Duration of Treatment (cont.)
 Ongoing use of medication, however, does not provide
absolute protection against relapse.

 Continuation therapy provides clinically and statistically

significant protective effects against relapse.

 In addition to early onset, a history of multiple past episodes

and severity and length of a current episode would make
longer, even indefinite, treatment appropriate.
NON PSYCHOPHARMACOLOGICAL
TREATMENT
CONTENT
 Cognitive behavior therapy (CBT)
 Systematic desensitization

 Implosion

 Applied Relaxation

 Respiratory exercise

 Virtual reality therapy

COGNITIVE BEHAVIOR THERAPY
COGNITIVE BEHAVIOR THERAPY
 CBT Techniques
 Identifying Negative Thoughts
 It is important to learn how thoughts, feelings, and situations can contribute to
maladaptive behaviors.
 Generating a list of possible solutions
 Evaluating the strengths and weaknesses of each possible solution
 Choosing a solution to implement (Practicing New Skills)
 It is important to start practicing new skills that can then be put in

to use in real-world situations.

 Goal-Setting: During CBT, a therapist can help with goal-setting
skills by teaching you how to identify your goal, distinguish between
short- and long-term goals, set SMART(specific, measurable,
attainable, relevant, time-based) goals
 Implementing the solution
COGNITIVE BEHAVIOR THERAPY
 The key benefits:
 It allows you to engage in healthier thinking patterns by
becoming aware of the negative and often unrealistic
thoughts that dampen your feelings and moods.
 It is an effective short-term treatment option.
 It has been found effective for a wide variety of
maladaptive behaviors.
 It is often more affordable.
 It has been found to be effective online as well as face-to-
face.
 It can be used for those who don't require psychotropic
medications.
COGNITIVE AND BEHAVIORAL MODEL
FOR PANIC ATTACKS.

Panic Attack
Occurs

Increased Misinterprete
Anxiety d as
Fear Heart Attack

Hypervigilanc
e
Anticipatory
Anxiety
 COGNITIVE AND BEHAVIORAL MODEL
FOR AGORAPHOBIA.

Repeated
Situational
Panic Attacks

Misinterprete
Increased
d as it occurs
Anxiety
in open
Fear
situation.

Agoraphobia Avoiding
Such
Stuations
 COGNITIVE AND BEHAVIORAL MODEL
FOR SOCIAL PHOBIA.

Social
Situation

Misinterprete
Increased d as if:
Anxiety Being judged
Fear Being stupid
Make mistake

Social Phobia Avoiding

Social
Situations
 COGNITIVE AND BEHAVIORAL MODEL
FOR SOCIAL PHOBIA.

Specific
Situation

Increased Misinterprete
Anxiety d as
Fear dangerous

Specific Phobia Avoiding

these
Situations
 SYSTEMATIC DESENSITIZATION
(JOSEPH WOLPE)
 ‌ ystematic desensitization therapy is a type of
S
behavioral therapy used to treat anxiety disorders, post-
traumatic stress disorder (PTSD), phobias, and a fear of
things like snakes or spiders.

 Systematic desensitization therapy has three main steps.

 First,to learn ways to relax your muscles.
 Next, to make a list of your fears and rank them based on
how intense your fears are.
 Last, to start exposing yourself to your fear in stages so you
get more and more comfortable dealing with it.
SYSTEMATIC DESENSITIZATION
 Step 1: Deep muscle relaxation techniques.
 Relaxation techniques are generally these types:
 Autogenic relaxation. You repeat words, phrases, or
suggestions in your mind that create a feeling of
relaxation
 ‌Progressive muscle relaxation. You learn to slowly
tense and relax each muscle group. You normally start
from your toes
 ‌Visualization. You imagine a journey to a peaceful
and calm situation, place, or setting, like a seashore or
a garden.
SYSTEMATIC DESENSITIZATION
 Step 2: Creating a Anxiety hierarchy.
 In the second stage, you create a list where you write out all
your fears and rank them on a scale of 1 to 10.
 First list level-10 fear, which causes you the highest amount
of anxiety that can be imagined. In the last, list level-1 fear,
which causes the least amount of anxiety.
 After this, brainstorm the remaining fears and list them in
order from 2 to 9.
SYSTEMATIC DESENSITIZATION
 Step 3: Working up through the fear scale through
exposure. The process of exposure can be done in two
ways:
 ‌In vitro – the patient imagines being exposed to the object of
fear in the mind's eye.
 ‌In vivo - the patient is actually exposed to the fear.
 A third type of exposure therapy called virtual reality exposure
therapy (VRET) has become popular in recent years. Virtual
Reality (VR) technology mimics real-life situations in a
computer-generated environment. Virtual reality exposure therapy
helps you work through your fears in a safe and controlled place.
 SYSTEMATIC DESENSITIZATION
EXAMPLE: ARACHNOPHOBIA (FEAR OF SPIDERS)
 At the start, the therapist might simply discuss spiders
and then lead the client through a relaxation practice.
 Next, the therapist introduces pictures of spiders, and
again leads the client through a relaxation practice.
 The next step could be watching spiders on video, plus
practicing relaxation.
 With each greater exposure, the therapist is careful not to
overwhelm the client.
IMPLOSION
 Implosive therapy (or “flooding”), in fact, is based on
the opposite rationale—that it is more effective to begin
at the top of the hierarchy rather than the bottom so that
rapid extinction might take place.
 Implosive therapy is a therapy based on the principles of 
classical conditioning. Classical conditioning is a
process that results in the learning of a new behavior that
is achieved through the process of association. Implosive
therapy makes use of this principle in order to eliminate
or replace a behavior, particularly the emotional
responses of fear and anxiety.
RESPIRATORY EXERCISE
 Shallow Breathing Contributes to Anxiety
 When people are anxious, they tend to take rapid, shallow
breaths.

 This type of breathing, called thoracic or chest breathing,

causes an upset in the oxygen and carbon dioxide levels in
the body resulting in increased heart rate, dizziness, muscle
tension, and other physical sensations.

  Blood is not being properly oxygenated and this may signal

a stress response that contributes to anxiety and panic attacks.
RESPIRATORY EXERCISE
 Simple Breathing Exercise
 You can perform this simple breathing exercise as often as
needed. It can be done standing up, sitting, or lying down. If you
find this exercise difficult or believe it's making you anxious or
panicky, stop for now. Try it again in a day or so and build up
the time gradually.
 ​Inhale slowly and deeply through your nose. Keep your
shoulders relaxed. Your abdomen should expand, and your chest
should rise very little.
 Exhale slowly through your mouth. As you blow air out, purse
your lips slightly but keep your jaw relaxed. You may hear a soft
“whooshing” sound as you exhale.
 Repeat this breathing exercise. Do it for several minutes until
you start to feel better.
RESPIRATORY EXERCISE (OTHERS)
 Deep Breathing Exercises for Anxiety
 Alternate-Nostril Breathing

 Belly Breathing abdominal breathing or 

diaphragmatic breathing
 Box Breathing

 4-7-8 Breathing

 Lion’s Breath

 Mindful Breathing

 Pursed-Lip Breathing

 Resonance Breathing
VIRTUAL REALITY THERAPY
FUTURE TRENDS
 Partial GABA agonists (Bretazanil, imidazenil, abecarnil, pagoclone) might not
have the side-effects/ addictive potential of BZDs while retaining the anti-anxiety
potential

 Specific 5HT1A receptor agonists (Gepirone, Sunepiterone) are being developed

with similar efficacy and better tolerability

 NMDA receptor antagonists have some anxiolytic affect in animal models

(Kotflinska and Liljequist, 1998)

 Riluzole (presynaptic glutamate release inhibitor) - found anxiolytic

(Zarate, 2004; Sanacora, 2004)

 Pregabalin (Feltner et al, 2003; Pohl et al, 2005) and Gabapentin (Dooley et al.,
2000) have been shown to be efficacious in the treatment of GAD through
their action on the glutamate receptors.
 THANK YOU
Recap
 Lab. Investigations

 Classifications of Drugs

 Mechanisms of actions, doses and Side Effects of Drugs

 General Principals of Psychopharmacology

 Non-pharmacologic Mx:
 Cognitive behavior therapy (CBT), Systematic
desensitization, Implosion, Applied Relaxation, Respiratory
exercise, Virtual reality therapy.