Anxiety disorders Posttraumatic stress disorder Social

Panic disorder, posttraumatic stress disorder, social anxiety disorder PO Adults, Elderly. 

Clinicians will readily recognize in Table 3.7 the experiences reported by many of their patients when receiving treatment for depression or other related psychiatric disorders. By looking at the Function affected column, it is possible to understand why some medications (say, SSRIs) are effective in variable degrees in several conditions associated with serotonin dysfunction (depression, OCD, social anxiety disorder, posttraumatic stress disorder, generalized anxiety disorder, panic disorder, and bulimia nervosa). 

Southwick SM, Krystal JH, Bremner JD, Morgan CA, Nicolaou A, Nagy LM, Johnson DR, Heninger GR, Charney DS (1997) Noradrenergic and serotonergic fimction in posttraumatic stress disorder. Arch Gen Psychiatry 54 749-758 Stein MB, Tancer ME, Uhde TW (1992) Heart rate and plasma norepinephrine responsivity to orthostatic challenge in anxiety disorders. Comparison of patients with panic disorder and social phobia and normal control subjects. Arch Gen Psychiatry 49 311-317 Stein MB, Huzel LL, Delaney SM (1993) Lymphocyte b-adrenoceptors in social phobia. Biol Psychiatry 34 45-50... 

Posttraumatic stress disorder (PTSD) is another anxiety disorder that can be characterized by attacks of anxiety or panic, but it is notably different from panic disorder or social phobia in that the initial anxiety or panic attack is in response to a real threat (being raped, for example) and subsequent attacks are usually linked to memories, thoughts, or flashbacks of the original trauma. The lifetime incidence of PTSD is about 1%. Patients have disturbed sleep and frequent sleep complaints. Comorbidities with other psychiatric disorders, especially depression and drug and alcohol abuse, are the rule rather than the exception. The DSM-IV diagnostic criteria are given in Table 9—11. 

GAD, generalized anxiety disorder PD, panic disorder OCD, obsessive-compulsive disorder SAD, social anxiety disorder PTSD, posttraumatic stress disorder. Also indicated as an anticonvulsant. 

Antidepressants tend to provide a more sustained and continuous improvement of the symptoms of attention-deficit/hyperactivity disorder than do the stimulants and do not induce tics or other abnormal movements sometimes associated with stimulants. Indeed, desipramine and nortriptyhne may effectively treat tic disorders, either in association with the use of stimulants or in patients with both attention deficit disorder and Tourette s syndrome. Antidepressants also are leading choices in the treatment of severe anxiety disorders, including panic disorder with agoraphobia, generalized anxiety disorder, social phobia, and obsessive-compulsive disorder, as weU as for the common comorbidity of anxiety in depressive illness. Antidepressants, especially SSRIs, also are employed in the management of posttraumatic stress disorder, which is marked by anxiety, startle, painful recollection of the traumatic events, and disturbed sleep. Initially, anxious patients often tolerate nonsedating antidepressants poorly (Table 17-1), requiring slowly increased doses. Their beneficial actions typically are delayed for several weeks in anxiety disorders, just as they are in major depression. 

Alcohol is one of the most commonly consumed drugs in the world and has been used by humans since the Stone Age. It is anxiolytic for this reason, it has been used not only for relaxation purposes but also by people with anxiety disorders to suppress their symptoms. Between 10% and 20% of agoraphobic patients are alcohol dependent. Thyrer et al. [1986] reported a 36% prevalence of alcoholism among socially phobic patients entering an anxiety disorders clinic, and [according to population studies] 20%-80% of people with posttraumatic stress disorder [PTSD] are dependent on alcohol. Sierles et al. [1983], in their study of Vietnam War veterans with PTSD, found that 64% were alcohol dependent. Since the Epidemiological Catchment Area study estimated the lifetime prevalence of PTSD to be 1% in the United States population, it is clear that self-medication with alcohol for anxiety symptoms will have a major influence on the development of alcohol dependency [Regier et al. 1990]. 

The nosology of anxiety disorders has changed considerably over the past 40 years (141). Such disorders were not mentioned in the original DSM. In DSM-II, problems with anxiety were considered a subset of behavioral disorders and were restricted to overanxious and withdrawing reactions. The DSM-III defined three types of anxiety disorders in children and adolescents overanxious, avoidant, and separation disorder. The DSM-III also acknowledged that children and adolescents could meet adult criteria for simple phobias, panic disorder, posttraumatic stress disorder, and obsessive-compulsive disorder (OCD). In DSM-IV ( 45), generalized anxiety disorder (GAD) and social phobia (or social anxiety disorder with childhood onset) replaced overanxious disorder and avoidant disorder, respectively. 

By the 1990s antidepressants from the serotonin selective reuptake inhibitor (SSRI) class became recognized as preferred first-line treatments for anxiety disorder subtypes, ranging from obsessive-compulsive disorder, to panic disorder, and now to social phobia and posttraumatic stress disorder (Fig. 8—9). Not all antidepressants, however, are afficacious anxiolytics. For example, desipramine and bupropion seem to be of little help in several anxiety disorder subtypes. Documentation of efficacy... 

In this chapter we have given clinical descriptions and have also explored the biological basis and a variety of treatments for numerous anxiety disorder subtypes, including obsessive-compulsive disorder, panic disorder, social phobia, and posttraumatic stress disorder. 

Noradrenergic model. This model suggests that the autonomic nervous system of anxious patients is hypersensitive and overreacts to various stimuli. The locus ceruleus may have a role in regulating anxiety, as it activates norepinephrine release and stimulates the sympathetic and parasympathetic nervous systems. Chronic noradrenergic overactivity down regulates 02-adrenoreceptors in patients with generalized anxiety disorder (GAD) and posttraumatic stress disorder (PTSD). Patients with social anxiety disorder (SAD) appear to have a hyperresponsive adrenocortical response to psychological stress. 

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