Anxiety disorders history

Benzodiazepines have a low risk for abuse in anxiety disorder patients without a history of alcohol or other substance abuse. Among the benzodiazepines there may be a spectrum of abuse liability, with drugs that serve as prodrugs for desmethyldiazepam (e.g., clorazepate), slow-onset agents (e.g., oxazepam), and partial agonists (e.g., abecarnil) having the least potential for abuse. However, there is no currently marketed benzodiazepine or related drug that is free of potential for abuse. 

Mueller TI, Goldenberg IM, Gordon AL, et al Benzodiazepine use in anxiety disordered patients with and without a history of alcoholism. J Clin Psychiatry 57 83-89, 1996... 

Posternak MA, Mueller TI Assessing the risks and benefits of benzodiazepines for anxiety disorders in patients with a history of substance abuse or dependence. Am J Addict 10 48-68, 2001... 

Anxiety disorders rarely exist alone. More than 90% of individuals with an anxiety disorder have a lifetime history of one... 

It is considered a second-line agent for GAD because of inconsistent reports of efficacy, delayed onset of effect, and lack of efficacy for comorbid depressive and anxiety disorders (e.g., panic disorder or SAD). It is the agent of choice in patients who fail other anxiolytic therapies or in patients with a history of alcohol or substance abuse. It is not useful for situations requiring rapid antianxiety effects or as-needed therapy. 

There are, however, subgroups of young adults who may not mature out of drug problems as easily as others. Those who seem to have problems maturing out usually have other problems that preceded the onset of drug use. For instance, researchers have found that young adults who have a history of Conduct Disorder or who have other psychiatric disorders (such as schizophrenia, Bipolar Disorder, depression, Anxiety Disorder, or a major personality disorder) mature out of drug problems at much lower rates than those who do not have these additional problems. 

The risk factors for dysthymia include a family history of depression and the coexistence of a personality disorder. In addition, dysthymic patients often have major depression, anxiety disorders, or substance abuse disorders as well. 

As noted earlier, prior to the advent of DSM-IIl in 1980, the anxiety disorders were collectively subsumed under some variation of the single diagnostic entity, anxiety neurosis. Consequently, the history of pharmacological treatment for the discrete anxiety syndromes is relatively brief, only approximately 20 years. Prior to 1980, we can only speak in a general manner as to how well medicines relieved anxiety in the broad sense of the term. Consequently, weTl present the more extensive history of pharmacological treatment for anxiety in this broader sense before launching into a more detailed discussion of the treatment of the individual anxiety disorders. 

The etiology of social anxiety remains unclear however, evidence suggests that developmental and genetic factors may predispose some individuals to social anxiety disorder. Adults with social anxiety disorder are more likely to report a history of childhood shyness and separation anxiety, limited social interaction during adolescence, and having had parents who placed great emphasis on the importance of the opinion of others. 

Individual characteristics can determine how a person reacts to a trauma and thereby contribute to the risk for developing PTSD. These include neurosis, limited social support, a family history of an anxiety disorder, and a personal history of previous significant stressors, particularly childhood sexual or physical abuse. 

Psychiatric medications do not currently play a prominent role in the treatment of cocaine-dependent patients (see Table 6.4). Although researchers have labored to find medications to treat cocaine addiction, there have not been any notable breakthroughs. As with other substance use disorders, the presence of a psychiatric disorder for which medication is indicated (i.e., depression, anxiety disorders, bipolar affective disorder, or schizophrenia) should prompt appropriate treatment. Similar to the presence of alcohol intoxication, deferring a diagnosis for a day or two in a new patient with no past history is often the more prudent course. 

Many patients with anxiety disorders experience an increased susceptibihty to psychosocial stress. Behavioral sensitization may account for these cHnical phenomena, hi the laboratory model of sensitization, single or repeated exposure to physical stimuU or pharmacological agents sensitizes an animal to subsequent stressors (reviewed in Charney et al. 1993). For example, in animals with a history of prior stress, there is a potentiated release of NE in the hippocampus with subsequent exposure to stressors (Nisenbaum et al. 1991). Similar findings were observed in medial prefrontal cortex (Finlay and Abercrombie 1991). The hypothesis that sensitization is underlying neural mechanism contributing to the course of anxiety disorders is supported by clinical studies demonstrating that repeated exposure to traumatic stress is an important risk factor for the development of anxiety disorders, particularly PTSD (Table 1). 

Angst J (1998) Panic disorder history and epidemiology. Eur Psychiatry 13(Suppl 2) 51-55 Angst J, Dobler-Mikola A (1985) The Zurich Study. V. Anxiety and phobia in young adults. Eur Arch Psychiatry Neurol Sci 235 171-178... 

No satisfactory randomised controlled trials have been published demonstrating the efficacy of carbamazepine in anxiety disorders, although it has a history of use as an anxiolytic in panic disorder and PTSD. It has an unfavourable side-effect profile (nausea, dizziness, ataxia) and multiple drug interactions due to induction of liver enzymes. 

This group includes compounds with actions on a range of neurotransmitter systems. Their antidepressant efficacy is mediated by reuptake inhibition of serotonin and noradrenaline, although side-effects such as sedation may also be useful. Their use in anxiety disorders is supported by a long history of clinical experience and a reasonable evidence base from controlled trials. Studies support the use of clomipramine (a potent serotonin reuptake inhibitor) in panic disorder and OCD (Lecrubier et al. 1997 Clomipramine Collaborative Study Group 1991), of imipramine in panic disorder and GAD (Cross-National Collaborative Panic Study 1992 Rickels et al. 1993), and of amitriptyline in PTSD (Davidson et al. 1993a). No controlled studies support the use of TCAs in social anxiety disorder. 

PTSD is highly comorbid with depression (Kessler et al. 1995) and substance use disorders, and is associated with a previous exposure to trauma and a previous history of anxiety disorders. PTSD probably carries the highest risk of suicide among the anxiety disorders (Davidson et al. 1991). Without effective treatment the disorder generally runs a chronic, unremitting course. 

Despite the history of robust BZ anxiolytic impact in adults, controlled studies, open studies, and case reports of BZs for pediatric anxiety have not been impressive. Concerns about BZ-related adverse events, such as behavioral disihnhibition, have since slowed interest in controlled studies of BZs for treatment of pediatric anxiety disorders. Three small placebo-controlled studies of BZs for pediatric anxiety disorders have been published and none demonstrated... 

Children with PTSD may be more likely to have comorbid conditions because traumatic insults occur in developmentally sensitive periods. Early life trauma is particularly toxic in its effects on development. Adults with severe sexual abuse histories exhibit high rates of debilitating disorders such as depression, anxiety disorders, alcoholism, substance abuse, and personality disorders (Herman and Van der Kolk, 1987 Putnam and Trickett, 1993). 

Although anxiety disorders were officially recognized by the American Psychological Association (APA) in 1980, reports of the occurrence of anxiety disorders can be found throughout recorded history. Such prominent figures as Isaac Newton, Emily Dickinson, Abraham Lincoln, and Sigmund Freud all suffered symptoms that would now be classified as an anxiety disorder. 

As the first drugs became available for treatment of mood and anxiety disorders, drugs for mental health became a big business in the United States. In fact, since the 1960s, the history of anxiety and fear disorders has become dominated by research into the drugs used to treat these disorders. 

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