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Anxiety Disorders

I. Prevalence
Lifetime (%)   12 mos (%)
Any Anxiety Disorder 24.9  17.2
Panic Disorder 3.5  2.3
Agoraphobia  5.3 2.8
Social Phobia 13.3 7.9
Simple Phobia 11.3 8.8
Generalized Anxiety Disorder 5.1 3.1

 

II. DSM-IV Anxiety Disorders

A. Panic Disorder +/- Agoraphobia

B. Agoraphobia without Panic Disorder

C. Social Phobia

D. Generalized Anxiety Disorder

E. Post Traumatic Stress Disorder

F. Acute Stress Disorder

G. Obsessive-Compulsive Disorder

H. Specific Phobia

I. Anxiety Disorder due to a general medical condition

J. Substance Induced Anxiety Disorder

K. Anxiety Disorder anxiety, anxious, panic disorder, post-traumatic stress disorder, phobia, fobia, posttraumatic stress disorder, anxous, axiety, anziety

L. Adjustment Disorder with Anxious Mood

III. Panic Disorder

A. Prevalence: (lifetime)1.5-3.5%; F:M = 3:1

B. Age of onset: late adolescence and mid 30's

C. Criteria:

1) Recurrent, unexpected panic attacks

2) At least one of the attacks followed by >1 month of

a) Persistent concern about additional attacks; or

IV. Agoraphobia

A. Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of an unexpected or situationally predisposed panic attack or panic-like symptoms

B. Situations are avoided or are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or anxiety, anxious, anxous, axiety, anziety

V. Treatment

A. Pharmacotherapy: SSRIs, TCAs, MAOIs, HPBs

B. Cognitive-Behavioral Therapy

VI. Pathogenesis and Course

Genetics: familial transmission

Constitutional Vulnerability: dysregulated CNS

Early Expression: inhibited temperament, childhood anxiety disorders

Environmental Risk Factors: parental psychopathology, abuse

Triggers: antecedent life events, physiological provocations

Course: often chronic

VII. Complications of Panic Disorder

Persistent Anxiety

Phobic Fear/Avoidance

Comorbid Anxiety Disorders

Depression

VI. Social Phobia

A. Prevalence:

- 3-13% (depends on threshold)

- F>M in epidemiologic/community samples

- MF in clinical samples

B. Age of onset: mid-teens; sometimes childhood

C. Criteria:

1) Fear of acting in a way (or showing anxiety symptoms) that will be embarrassing/humiliating in situations of scrutiny by others

2) Situation almost invariably provokes anxiety

3) Person recognizes fear is excessive or unreasonable

4) Situation avoided or endured with intense anxiety

IX. Post-Traumatic Stress Disorder (PTSD)

A. Prevalence

-General population 1%

-Civilians exposed to trauma 3.5-15%

-Wounded Vietnam Vets 20%

B. Age of onset: may occur at any age

C. Criteria

1) Person experienced, witnessed or was confronted with an event that involved actual or threatened death, serious injury or threat to the physical integrity of self or others/and the person's response involved intense fear, helplessness or 

D. Course:

1) Usually begins within 3 months of trauma, although may be delayed

2) Distinguished from Acute Stress Disorder in which symptoms must occur within 4 weeks of trauma and persist for <4 weeks

3) Complete recovery within 3 months for 50% of cases, for many others symptoms may persist for >1 year

E. Treatment

1) Psychotherapy (eg, abreaction, survivor guilt, anger, helplessness)

X. Generalized Anxiety Disorder (GAD)

A. Prevalence:

- Community sample: 5%

- F >M (2:1)

B. Age of onset:

- Childhood or adolescence (often)

- After 20 (sometimes)

C. Criteria:

1) Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities

2) Person finds it difficult to control the 

D. Course: Chronic, but fluctuating, worsened with stress

E. Treatment

1) Psychotherapy

2) Cognitive/Behavioral Therapy

3) Pharmacotherapy: BZD, SSRI, TCA, Buspirone

XI. Specific Phobia

A. Prevalence:

-Lifetime: 10-11%, depending on threshold - phobias are common but rarely significantly impairing/distressing -Sex ratio varies by type:

B. Age of Onset: Varies by type

-Animal: childhood

-Natural environment (childhood)

-Heights: childhood, sometimes early adulthood)

C. Criteria:

1) Persistent, excessive, unreasonable fear of object or situation

2) Exposure to situation almost invariably provokes anxiety, including panic

3) Person recognizes fear is excessive or unreasonable

D. Specify subtype:

-Animal

-Natural environment (eg, heights, storms, water)

-Blood injection

-Situation (eg, airplanes, elevators, enclosed places)

-Other (eg, avoidance of situations that may lead to choking or contracting an illness)

E. Predisposing factors: familial pattern, traumatic events (eg, being attacked by animal), unexpected panic attacks in the to be feared situation), observing others undergoing trauma or exhibiting fear, information transmission (eg, repeated warnings from parents, media attention).

F. Feared objects may be things/situations that may represent a real threat or did at some point during evolution.

G. Course: Only 20% of phobias persisting into adulthood remit

H. Treatment

1) Behavioral Therapy (eg, exposure)

2) Pharmacotherapy (acute): BZD (eg, flying)

XII. Standard Pharmacopoeia for 

XII. Pharmacopoeia for Anxiety Disorders

Antidepressants

Serotonin Specific Reuptake Inhibitors (SSRIs) Atypical Antidepressants

Tricyclic Antidepressants (TCAs)

Monoamine Oxidase Inhibitors (MAOIs)

Benzodiazepines

High-Potency Benzodiazepines

Low-Potency Benzodiazepines

Other Agents

Azaspirones 

Beta blockers 

Anticonvulsants

Antidepressants

A. Serotonin Selective Reuptake Inhibitors

Fluoxetine (Prozac), 20-80 mg/d

-Initiate with 5-10 mg/d

Sertraline (Zoloft), 50-200 mg/d



Drug Half-Life (hr) Dose Equivalent  (Mg)  Onset  Significant Metabolites  Typical Route of Administration
Midazolam (Versed) 1-12 2.0 Fast  No  IV, IM
Oxazepam (Serax) 5-15 15  Slow  No po
Lorazepam (Ativan) 10-20 1.0 Intermed  No  IV, IM, po
*Alprazolam (Xanax) 12-15 0.5 Intermed-fast No  po
 Chlordiazepoxide (Librium) 5-30 10  Intermed  Yes  po, IV
*Clonazepam (Klonopin)  15-50 0.25 Intermed  No po
Diazepam (Valium) 20-100 5.0 Fast  Yes  po, IV
Flurazepam (Dalmane) 40  5.0 Fast  Yes  po
Clorazepate (Tranxene) 30-200 7.5 Fast  Yes  po

* Commonly used to treat panic disorder

 

Benzodiazepines

Benzodiazepine-GABA receptor

Drug selection based on pharmacokinetic properties

a) For acute dosing:

- onset: rate of absorption

IX. Cognitive-Behavioral Therapy

Distress and impairment mediated by cognitive responses to somatic symptoms and by avoidance

Exposure: In-vivo vs. Interoceptive

Components of therapy

-Correction of cognitive misperceptions -breathing retraining -muscle relaxation

Duration of benefits reported higher after discontinuation of behavioral treatment

Combined pharmacological and behavioral treatment for refractory symptoms and