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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