Download Anxiety. Drug treatments

Pharmaceutical guidelines of
patients with pathology of CNS
organs.
Symptomatic treatment of
ASTHENIA AND ANXIETY
Asthenia
• Asthenia: Weakness. Lack of energy and
strength. Loss of strength. The word
asthenia is not much used in medicine
today, although it is a prominent part of
myasthenia, a loss of muscle strength, as in
myasthenia gravis.
Asthenia
• It is a frequent cause of consult, almost 30% in
ambulatory settings. The chronic fatigue
represents up to 10% of these cases, and the 0.20.7% belongs to the chronic fatigue syndrome.
• It is very important to differentiate asthenia from
weakness, dizziness or dyspnoea, since patients
may confuse them. The factor time in asthenia is
very useful for its characterization, it was defined
to the prolonged fatigue when it lasts for more
than a month and chronic when the duration is
greater than 6 months.
• The depression is the commonest fatigue cause,
representing approximately half of the cases.
Asthenia
• General asthenia occurs in many chronic wasting diseases
anemia and cancer,
is probably most marked in diseases of the adrenal gland.
Asthenia may be limited to certain organs or systems of
organs, as in asthenopia, characterized by ready
fatiguability.
Asthenia is also a side effect of Ritonavir (Protease Inhibitor
used in HIV treatment) and fentanyl patches (an opioid
used to treat pain).
The condition is also commonly seen in patients suffering
from chronic fatigue syndrome, sleep disorders or chronic
disorders of the heart, lungs or kidneys.
Differentiating between psychogenic asthenia and true
asthenia with muscular weakness is often difficult, and in
time apparent psychogenic asthenia accompanying many
chronic disorders is seen to progress into a primary
weakness.
Chronic fatigue syndrome (CFS)
‘functional’ syndrome
• uncertain classification as neurasthenia in the
psychiatric classification and myalgic
encephalomyelitis (ME) under neurological
diseases.
• It occurs most commonly in women between the
ages of 20 and 50 years.
• The cardinal symptom is chronic fatigue made
worse by minimal exertion. The fatigue is usually
both physical and mental, associated most
commonly with poor concentration, impaired
registration of memory, alteration in sleep pattern
(either insomnia or hypersomnia), and muscular
pain.
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• Mood disorders are present in a large minority of patients,
and can cause problems in diagnosis because of the large
overlap in symptoms.These mood disorders may be
secondary, independent (co-morbid), or primary (with a
misdiagnosis of CFS).
• The most effective treatment of the asthenia is to solve the
underlying cause, although up to 20% of the patients
remain without diagnosis. The diagnosis of the chronic
fatigue syndrome is of exclusion and the criteria of the
international consensus of year 1994 are due to use. The
high frequency of the symptom entails an enormous social
and economic cost and it is for that reason so important for
physicians to have a correct manage of this symptom.
Treatment of asthenic syndrome
• includes a variety of approaches: psychotherapy,
lifestyle changes, the ordering of work and leisure
modes of wakefulness and sleep, regular meals,
eliminating the causes of emotional stress,
physical therapy, spa treatment.
• In some cases, such events can bring tangible
benefits and rights to withdraw from the state of
fatigue. However, for obvious reasons, these
recommendations are not always feasible. On the
other hand, in some cases, these measures are
insufficient, and the doctor had to resort to
medication.
Asthenic syndromes treatment
• Asthenic syndromes with symptoms of a
"simple" fatigue (feeling tired, increased
sensitivity to external stimuli and
pathological bodily sensations) are
preferred tranquilizers narrow spectrum of
action - oxazepam, medazepam, tofizapam,
trioxazine in combination with stimulants
and nootropics
Nootropic drugs with stimulant
properties:
• deanol aceglumat,
• salbutiamin
• Ladasten (adamantylbromphenilamin)
Anxiety
• Anxiety is a feeling of constant,
inappropriate or excessive worry, fear,
apprehension, tension or inner restlessness,
seen in anxiety and depressive disorders as
well as drug withdrawal.
ANXIETY DISORDERS
• are classified according to whether the
anxiety is persistent (general anxiety) or
episodic, with the episodic conditions
classified according to whether the episodes
are regularly triggered by a cue (phobia) or
not (panic disorder).
General anxiety disorder
• This occurs in 4–6% of the population and is more
common in women. Symptoms are persistent and
often chronic.
• General anxiety disorder (GAD) and its related
panic disorder are differential diagnoses for
functional somatic syndromes, owing to the many
physical symptoms that are caused by these
conditions.
Anxiety disorder caused by
physical diseases
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Thyrotoxicosis
Hypoglycaemia (transient)
Phaeochromocytoma
Complex partial seizures (transient)
Alcohol withdrawal
Physical and psychological
symptoms of anxiety
Physical symptoms
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Gastrointestinal
Dry mouth
Difficulty in swallowing
Epigastric discomfort
Aerophagy (swallowing air)
‘Diarrhoea’ (usually frequency)
Respiratory
Feeling of chest constriction
Difficulty in inhaling
Overbreathing
Choking
Cardiovascular
Palpitations
Awareness of missed beats
Chest pain
Physical and psychological
symptoms of anxiety
Physical symptoms
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Genitourinary
Increased frequency
Failure of erection
Lack of libido
Nervous system
Fatigue
Blurred vision
Dizziness
Sensitivity to noise and/or light
Headache
Sleep disturbance
Trembling
Physical and psychological
symptoms of anxiety
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Psychological symptoms
Apprehension and fear
Irritability
Difficulty in concentrating
Distractibility
Restlessness
Depersonalization
Derealization
Panic disorder
• Panic disorder is diagnosed when the patient has repeated
sudden attacks of overwhelming anxiety, accompanied by
severe physical symptoms, usually related to both
hyperventilation and sympathetic nervous system activity
(palpitations, tremor, restlessness and sweating).
• The lifetime prevalence is 5%. Patients with panic disorder
often have catastrophic illness beliefs during the panic
attack, such as convictions that they are about to die from a
stroke or heart attack.
• The fear of a stroke is related to dizziness and headache.
• Fear of a heart attack accompanies chest pain (atypical
chest pain).
• The occasional patient with long-standing attacks may
deny feeling anxious and simply report the physical
symptoms.
Aetiology
• General anxiety and panic disorders occur four or
more times as commonly in first-degree relatives
of affected patients, suggesting a genetic
influence.
• Sympathetic nervous system overactivity,
increased muscle tension and hyperventilation are
the common pathophysiological mechanisms.
Anxiety is the emotional response to the threat of
a loss, whereas depression is the response to the
loss itself.
Phobic (anxiety) disorders
• Phobias are common conditions in which intense
fear is triggered by a stimulus, or group of stimuli,
that are predictable and normally cause no
particular concern to others (e.g. agoraphobia,
claustrophobia, social phobia).
• This leads to avoidance of the stimulus. The
patient knows that the fear is irrational, but cannot
control it. The prevalence of all phobias is 8%,
with many patients having more than one.
• Many phobias of ‘medical’ stimuli exist (e.g. of
doctors, dentists, hospitals, vomit, blood and
injections) which affect the patient’s ability to
receive adequate healthcare.
Phobic (anxiety) disorders
(cont’d)
• Women have twice the prevalence of most phobias
than men.
• Agoraphobia - common phobia (4% prevalence)
presents as a fear of being away from home, with
avoidance of travelling, walking down a road and
supermarkets being common cues. This can be a
very disabling condition, since the patient can be
too unwell to ever leave home, particularly by
themselves. It is often associated with
claustrophobia, a fear of enclosed spaces.
Phobic (anxiety) disorders
(cont’d)
• Social phobia - the fear and avoidance of social situations:
crowds, strangers, parties and meetings. Public speaking
would be the sufferer’s worst nightmare. It is suffered by
2% of the population.
• Simple phobias - The commonest is the phobia of spiders
(arachnophobia), particularly in women. The prevalence of
simple phobias is 7% in the general population.
• Other common phobias include insects, moths, bats, dogs,
snakes, heights, thunderstorms and the dark.
• Children are particularly phobic about the dark, ghosts and
burglars, but the large majority grow out of these fears.
Treatment of anxiety disorders
• Psychological treatments
■ Relaxation techniques can be effective in mild/moderate
anxiety. Relaxation can be achieved in many ways,
including complementary techniques such as meditation
and yoga. Conventional relaxation training involves
slowing down the rate of breathing, muscle relaxation
and mental imagery.
■ Anxiety management training involves two stages. In the
first stage, verbal cues and mental imagery are used to
arouse anxiety to demonstrate the link with symptoms.
In the second stage, the patient is trained to reduce this
anxiety by relaxation, distraction and reassuring
self-statements.
Treatment of anxiety
disorders(cont’d)
• Behaviour therapies are treatments that are
intended to change behaviour and thus symptoms.
The most common and successful behaviour
therapy (with 80% success in some phobias) is
graded exposure, otherwise known as systematic
desensitization. First, the patient rates the phobia
into a hierarchy or ‘ladder’ of worsening fears
(e.g. in agoraphobia: walking to the front door
with a coat on; walking out into the garden;
walking to the end of the road). Second, the
patient practises exposure to the least fearful
stimulus until no fear is felt. The patient then
moves ‘up the ladder’ of fears until they are cured.
Treatment of anxiety
disorders(cont’d)
■ Cognitive behaviour therapy (CBT) is the
treatment of choice for panic disorder and
general anxiety disorder because the
therapist and patient need to identify the
mental cues (thoughts and memories) that
may subtly provoke exacerbations of
anxiety or panic attacks.
Drug treatments
• Initial ‘drug’ treatment should involve advice to
gradually cease taking anxiogenic recreational
drugs such as caffeine and alcohol (which can
cause a rebound anxiety and withdrawal).
• Prescribed drugs used in the treatment of anxiety
can be divided into two groups:
- those that act primarily on the central nervous
system,
- those that block peripheral autonomic receptors.
Benzodiazepines
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are centrally acting anxiolytic drugs
They bind to specific receptors that stimulate release of the
inhibitory transmitter γ-aminobutyric acid (GABA)
Diazepam (5 mg twice daily, up to 10 mg three times daily
in severe cases), alprazolam (250–500 μg three times
daily) and chlordiazepoxide have relatively long half-lives
(20–40 hours) and are used as anti-anxiety drugs in the
short term.
Side-effects include sedation and memory problems, and
patients should be advised not to drive while on treatment.
They can cause dependence and tolerance within 4–6
weeks, particularly in dependent personalities.
The withdrawal syndrome can occur after just 3 weeks of
continuous use and is particularly severe when high doses
have been given for a longer time.
Withdrawal syndrome with
benzodiazepines
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Insomnia
Anxiety
Tremulousness
Muscle twitchings
Perceptual distortions
Hallucinations (which may be visual)
Hypersensitivities (light, sound, touch)
Convulsions
Benzodiazepines
• If a benzodiazepine drug is prescribed for
anxiety, it should be given in as low a dose
as possible, preferably on an ‘as necessary’
basis, and for not more than 2–4 weeks. A
withdrawal programme from chronic use
includes changing the drug to the longacting diazepam, followed by a very gradual
reduction in dosage.
Anxiety. Drug treatments
SELECTIVE SEROTONIN REUPTAKE
INHIBITORS
• Most SSRIs (e.g. fluoxetine, paroxetine, sertraline,
escitalopram, citalopram) are useful symptomatic
treatments for general anxiety and panic disorders,
as well as some phobias (social phobia).
Imipramine and clomipramine are alternative
symptomatic treatments for panic disorder and
GAD. Treatment response is often delayed several
weeks; a trial of treatment should last 3 months.
Anxiety. Drug treatments
TRICYCLIC/POLYCYCLIC
ANTIDEPRESSANTS
(block norepinephrine, and serotonin
uptake into the neuron)
• Imipramine and clomipramine are
alternative symptomatic treatments for
panic disorder and GAD. Treatment
response is often delayed several weeks; a
trial of treatment should last 3 months.
Anxiety. Drug treatments
• Many of the symptoms of anxiety are due to
an increased or sustained release of
epinephrine (adrenaline) and norepinephrine
(noradrenaline) from the adrenal medulla
and sympathetic nerves. Thus, betablockers
such as propranolol (20–40 mg two or three
times daily) are effective in reducing
peripheral symptoms such as palpitations,
tremor and tachycardia, but do not help
central symptoms such as anxiety.