Anxiety: anticipatory

The acute phase of panic disorder treatment lasts about 12 weeks and should result in marked reduction in panic attacks, ideally total elimination, and minimal anticipatory anxiety and social anxiety avoidance. Treatment should be continued to prevent relapse for an additional 12 to 18 months before attempting discontinuation. 

The main objectives of treatment are to reduce the severity and frequency of panic attacks, reduce anticipatory anxiety and agoraphobic behavior, and minimize symptoms of depression or other comorbid disorders.48 The long-term goal is to achieve and sustain remission. 

Treatment options include medication, psychotherapy (e.g., CBT preferred), or a combination of both. In some cases, pharmacotherapy will follow psychotherapy treatments when full response is not realized. Patients with panic symptoms without agoraphobia may respond to pharmacotherapy alone. Agoraphobic symptoms generally take longer to respond than panic symptoms. The acute phase of PD treatment lasts about 12 weeks and should result in marked reduction in panic attacks, ideally total elimination, and minimal anticipatory anxiety and phobic avoidance. Treatment should be continued to prevent relapse for an additional 12 to 18 months before attempting discontinuation. 6 49 Patients who relapse following discontinuation of medication should have therapy resumed.49... 

Antidepressants have a delayed onset of antipanic effect, typically 4 weeks, with optimal response at 6 to 12 weeks. Reduction of anticipatory anxiety and phobic avoidance generally follows improvement in panic symptoms. PD patients are more likely to experience stimulant-like side effects than patients with depression, and they should be initiated on lower doses (Table 37-6) of antidepressant than those that are used for depression or other... 

Venlafaxine was approved by the FDA recently for the treatment of PD. Venlafaxine in doses of 75 to 225 mg/day reduced panic and anticipatory anxiety in short-term controlled trials. The most common side effects include anorexia, dry mouth, constipation, somnolence, tremor, abnormal ejaculation, and sweating.52... 

Evaluate patients for symptom improvement frequently (e.g., weekly) during the first 4 weeks of therapy. The goal is to alleviate panic attacks and reduce anticipatory anxiety and phobic avoidance with resumption of normal activities. Alter the therapy of patients who do not achieve a significant reduction in panic symptoms after 6 to 8 weeks of an adequate dose of antidepressant or 3 weeks of a benzodiazepine. Regularly evaluate patients for adverse effects, and educate them about appropriate expectations of drug therapy. 

HT model. GAD symptoms may reflect excessive 5-HT transmission or overactivity of the stimulatory 5-HT pathways. Patients with SAD have greater prolactin response to buspirone challenge, indicating an enhanced central serotonergic response. The role of 5-HT in panic disorder is unclear, but it may have a role in development of anticipatory anxiety. Preliminary data suggest that the 5-HT and 5-HT2 antagonist meta-chlorophenylpiperazine causes increased anxiety in PTSD patients. 

The goals of therapy of panic disorder include a complete resolution of panic attacks, marked reduction in anticipatory anxiety and phobic fears,... 

Imipramine blocks panic attacks within 4 weeks, but maximal improvement, including reduced anticipatory anxiety and antiphobic response, requires 8 to 12 weeks. 

Chua P, Krams M, Toni I, Passingham R, Dolan R (1999) A functional anatomy of anticipatory anxiety. Neuroimage 9 563-571... 

Acute Phase Treatment. The short-term objective when treating panic disorder is to optimize symptom relief. This primarily consists of reducing the severity and frequency of panic attacks but also includes the anticipatory anxiety and secondary... 

Anxiolytics. The use of anxiety-reducing medications has not been systematically assessed in the treatment of AN. Nevertheless, many clinicians anecdotally report that the use of short-acting benzodiazepine such as lorazepam (Ativan) prior to mealtime diminishes anticipatory anxiety and thereby facilitates refeeding. 

In some cases, anxiolytics serve a transitional purpose. For example, for a patient with acute-onset panic disorder, severe anticipatory anxiety, and a family history of depression, administration of an antidepressant medication that also has antipanic effects may be the optimal treatment, but this will not help the patient for several weeks, during which time there is a risk of progression to agoraphobia. For this patient, starting antidepressant therapy and also attempting to obtain acute symptom relief with a benzodiazepine may be helpful. After 4 weeks, the benzodiazepine dose should be slowly tapered so that the patient s condition is controlled with the antidepressant alone. 

Lecci, A., Borsini, F., Voltera, G., Meh, A. Pharmacological validation of a novel model of anticipatory anxiety in mice. Psychopharmacology 101, 255-261, 1990. 

Affective symptoms including terror, heightened arousal, marked anticipatory anxiety, and feelings of despair and failure... 

Patients may complain of headaches, muscle aches, and nausea associated with an individual treatment. Many also report anticipatory anxiety or fearfulness before receiving a treatment. This may require management with anxiolytics, but type and dose must be chosen carefully to avoid increasing the seizure threshold, thus undermining the adequacy of therapy. 

Secondary anticipatory anxiety that they will have another episode in certain places... 

In 1962, Klein and Fink (88) reported that imipramine blocked panic attacks but had only a minor effect on phobic avoidance or anticipatory anxiety. This clinical observation has been validated by approximately 15 double-blind studies, and TCAs have since been studied for their antipanic efficacy. Although many TCAs are effective antipanic agents, they differ in safety and efficacy, a fact that mandates fitting the drug to the individual patient based on the known advantages and potential adverse effects of each TCA (Table 13-4). 

PD and its related symptoms can be quite disabling. The recognition that specific drug therapies can effectively block the panic episodes has brought new found hope for thousands of patients. Optimal outcome, however, often requires the addition of various behavioral techniques to manage all related components of the disorder (e.g., panic attack, anticipatory anxiety, phobic avoidance). 

Diagnosis Spontaneous Panic Attacks Situational Panic Attacks Anticipatory Anxiety Symptoms of Autonomic Arousal Phobic Avoidance... 

The postulated mechanisms of action of SRT are twofold, physiological and psychological. First, SRT produces a mild sleep deprivation, which increases the homeostatic drive to sleep. In addition, sleep anticipatory anxiety is a common feature among insomnia sufferers. Indeed, there is often a great deal of apprehension about bedtime, about the fear of not being able to fall asleep, and... 

In the group-housed mice, the last mice to be tested show an increase in body temperature (compared with the first mice) due to anticipatory anxiety. Therefore, animals should be tested individually, with at least 10 mice in each experimental group (21). 

Panic disorder is one of the most prevalent psychiatric disorders in industrialized countries. It is often associated with agoraphobia and has an estimated prevalence of between 1% and 6%. The use of imipramine in the treatment of anxiety by Klein and Fink, and the discovery by William Sargant that monoamine oxidase inhibitors (MAOIs) were effective in the treatment of "atypical depression" over 30 years ago led to the investigation of the efficacy of such treatments in patients with panic disorder. Since that time, such drugs have been shown to attenuate the symptoms of panic in addition to those of phobic avoidance and anticipatory anxiety. As both the... 

Wolf DL, Desjardins PJ, Black PM, Francom SR, Mohanlal RW, Fleishaker JC. Anticipatory anxiety in moderately to highly-anxious oral surgery patients as a screening model... 

Lu K, Gray MA, Oliver C, Liley DT, Harrison BJ, Bartholomeusz CF, Phan KL, Nathan PJ. The acute effects of L-theanine in comparison with alprazolam on anticipatory anxiety in humans. Hum Psychopharmacol 2004 19 457-65. 

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