Anticholinergics anxiety with

The tricyclic antidepressants (TCAs), such as imipramine, can alleviate symptoms of ADHD. Like bupropion, TCAs likely will improve symptoms associated with comorbid anxiety and depression. The mechanism of action of TCAs is in blocking norepinephrine transporters, thus increasing norepinephrine concentrations in the synapse the increase in norepinephrine is believed to alleviate the symptoms of ADHD. TCAs have been demonstrated to be an effective non-stimulant option for ADHD but less effective than stimulants. However, their use in ADHD has declined owing to case reports of sudden death and anticholinergic side effects6,13 (Table 39-3). Further, TCAs may lower seizure threshold and increase the risk of car-diotoxicity, (e.g., arrythmias). Patients starting on TCAs should have a baseline and routine electrocardiograms. 

Anticholinergic side effects include dry mouth, blurred vision, constipation, and urinary retention. More serious reactions include forgetfulness, sedation, depression, and anxiety. Patients with preexisting cognitive deficits and the elderly are at greater risk for central anticholinergic side effects. 

During the maintenance phase, treatment can be fine-tnned. If persistent side effects (especially EPS) are a problem, then the antipsychotic can be gradnally switched or conntermeasures snch as anticholinergic therapy can be taken. In addition, maintenance therapy is also an appropriate time to address the less dramatic bnt nonetheless tronblesome symptoms snch as a mood distnrbance. Antidepressants are often used to treat depressed mood in patients with schizophrenia. Likewise, benzodiazepines are commonly nsed with an antipsychotic to treat persistent yet subsyndromal anxiety in schizophrenia patients. 

Hydroxyzine hydrochloride Atarax, Vistarit) is the antihistamine with the greatest use in the treatment of anxiety. It is often used to reduce the anxiety that is associated with anesthesia and surgery. It also produces sedation, dries mucous membranes (via an anticholinergic mechanism), and has antiemetic activity. A more extensive discussion of the pharmacology of the Hj-receptor antagonists is found in Chapter 38. 

The most common side effects associated with aripiprazole include headache, nausea, dyspepsia, agitation, anxiety, insomnia, somnolence, and akathisia. Dose-related adverse events include somnolence and akathisia. Early clinical experience indicates that akathisia may be avoided by starting the medication at doses lower than 10 mg and increasing the dose slowly. Aripiprazole is not associated with significant sedation, anticholinergic side effects, weight gain, or cardiovascular side effects (Petrie et al. 1997). 

A 45-year-old woman with a family history of essential tremor developed severe and persistent parkinsonism after taking kava extract for anxiety for 10 days. Her symptoms improved with anticholinergic drugs. 

A sedative-hypnotic is administered the night before surgery to assist with sleep. An hour before the surgery, premedications are administered to sedate and decrease anxiety. Premedications are an anticholinergic (atropine) to decrease secretions and either a narcotic analgesic or benzodiazepine. 

Kava is an Australasian shrubby pepper (Piper methysticum). Amidst much ceremony, its crushed roots are made into an intoxicating beverage by the aboriginal people of the Molucca Islands and the Northern coast of Australia. In the west, kava is usually recommended for anxiety it appears to have sedative and extrapyramidal effects, in common with some anticholinergic and antidopaminer-gic drugs. Its sedative effects are synergistic when administered with benzodiazepines, barbiturates... 

Most experts agree that the SSRIs are better tolerated than clomipramine. The SSRIs are less likely to cause cardiovascular, sedative, anticholinergic, and weight gain side effects. Clomipramine is less likely than the SSRIs to cause insomnia, akathisia, nausea, and diarrhea. Side effects may be more severe when larger doses are used and with faster dose escalation. Tolerance to adverse effects often develops over 6 to 8 weeks of treatment, and tolerance is more fikely to develop to nausea, diarrhea, sedation, diminished libido and/or orgasm, anxiety, restlessness, insomnia, and anticholinergic side effects than to akathisia. ... 

---