Download Extra Anxiety Reading File

Anxiety with
Fear, Avoidance and Worry
Excessive anxiety about specific situations, with:
 Fear,
Avoidance, Worry, Anxious anticipation
Phobias
 Agoraphobia,
specific phobias, social phobia
Anxiety
with obsessions or compulsions

If there is recurrent and persistent thoughts
(obsessions) and / or ritualistic behaviour (i.e.
compulsive behaviour repeated over and over)
Obsessive
Compulsive Disorder
Simply Anxious

If none of the above, then simply
Anxiety
Algorithm: Anxiety
Re-experience
traumatic events
Fear, avoidance:
Phobias
Anxiety
General medical
condition
Anxiety
Substance
Induced
Other mental
disorders
Recurrent anxiety
attacks:
Panic attacks
Obsessions,
compulsions
OCD
E.g.: adjustment
disorder
< 4 weeks
Acute Stress
Disorder
> 4 weeks
PTSD
Pharmacologic Treatment of GAD



SSRIs: Zoloft, Citalopram, Paroxetine are effective
TCAs:
 Imipramine effective in panic and GAD (150 mg GAD)
 Trazodone 50 mg qam can help
Start low, go slow

Buspirone: best in mild anxiety
B-blockers: effective for peripheral manifestations

Venlafaxine: shows good effect


Benzodiazepines:

Double-edged sword

Tolerance can become a problem

Withdrawal symptoms related to time on drug

 Use early if necessary until antidepressants kick in
Treatment of Panic Disorder

SSRI and TCAs and BZDs

Efficacy 50-80%, 6-8 weeks

Treat for a year to 18 months then trial taper

Whether depression is comorbid or not : ATD > BZD

BZD effective and early onset – good for early coverage

Agoraphobia will often require psychotherapy
Treatment of Social Anxiety Disorder

Psychotherapy:



Cognitive behavioral therapy (w. exposure, role playing)
Community groups (exposure)
 Toastmasters (English)
Pharmacologic often less effective
SSRIs (Fluvoxamine, Paroxetine, Sertraline, Citalopram)
 B-blockers (for specific performance anxiety)
 TCAs can be helpful
 MAOIs (phenelzine)
 RIMA (moclobemide)
 BDZ (clonazepam, alprazolam)

Treatment of OCD





Cognitive-Behavioral Therapy
Clomipramine (TCA) is the gold standard of pharmacologic
treatment (50mg panic; 150mg depression; 400mg OCD)
SSRIs almost as effective as clomipramine
Refractory cases can be treated with addition of a serotonergic
agent:
 L-Tryptophan
 MAOI
 Lithium
 Buspirone
Or add a dopaminergic agent:
 Risperidone 0.5- 3 mg
Post-Traumatic Stress Disorder

Literature states up to 25% of those experiencing trauma


Symptoms “often begin immediately after the event”



~30% of all Vietnam war veterans
Watch for the 1-month criterion
Can be delayed for many years, however
Core symptoms

Re-experience traumatic event


Avoidance of reminders of trauma


Vivid and distressing
People, situations, circumstances, memories
Other symptoms



Hypervigilance
Exaggerated startle responses
Difficulty concentrating
Recognizing PTSD

Screening for PTSD using debriefing must not be routine

For high-risk populations only


Screen using a short questionnaire 1 month after disaster
Note people who have symptoms


If mild and < 4 weeks, simply use watchful waiting
Follow up these people in 1 month