Anxiety disorders spectrum

Indeed, 5-HT is also a substrate for the 5-HT transporter, itself an important player in the treatment of depression, and more recently for the whole range of anxiety disorders spectrum (GAD, OCD, social and other phobias, panic and post-traumatic stress disorders). It is the target for SSRIs (selective serotonin reuptake inhibitors) such as fluoxetine, paroxetine, fluvoxamine, and citalopram or the more recent dual reuptake inhibitors (for 5-HT and noradrenaline, also known as SNRIs) such as venlafaxine. Currently, there are efforts to develop triple uptake inhibitors (5-HT, NE, and DA). Further combinations are possible, e.g. SB-649915, a combined 5-HTia, 5-HT1b, 5-HT1d inhibitor/selective serotonin reuptake inhibitor (SSRI), is investigated for the treatment of major depressive disorder. 

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. 

Allgulander C, Bandelow B, Hollander E, et al. WCA recommendations for the long-term treatment of generalized anxiety disorder. CNS Spectrum 2003 8(8 Suppl 1) 53—61. 

When is medication indicated in the treatment of psychiatric illness There is no short answer to this question. At one end of the continuum, patients with schizophrenia and other psychotic disorders, bipolar disorder, and severe major depressive disorder should always be considered candidates for pharmacotherapy, and neglecting to use medication, or at least discuss the use of medication with these patients, fails to adhere to the current standard of mental health care. Less severe depressive disorders, many anxiety disorders, and binge eating disorders can respond to psychotherapy and/or pharmacotherapy, and different therapies can target distinct symptom complexes in these situations. Finally, at the opposite end of the spectrum, adjustment disorders, specific phobias, or grief reactions should generally be treated with psychotherapy alone. 

Taken together, the efficacy of antidepressants covers the spectrum of anxiety disorders, although there are important differences between drugs in the group (Table 3). Several new antidepressants have been marketed since the SS-RIs venlafaxine and mirtazapine are discussed later (Sects. 3.2.1.2 and 3.2.1.4) nefazodone, a serotonin reuptake inhibitor and postsynaptic 5-HT2 blocker showed promise in early studies but was recently withdrawn by its manufacturers reboxetine, a noradrenaline reuptake inhibitor (NARI) showed benefits in panic disorder in one published study (Versiani et al. 2002) and further evidence of its anxiolytic efficacy is awaited. 

Although social attachment and impairment of social behaviors are evident in a wide range of psychopathology, including childhood trauma, personality disorders, and anxiety disorders, an extensive review of this subject is beyond the scope of this chapter. The focus of this section will thus be primarily limited to the neurobiology of affiliation as it relates to autism spectrum disorders. 

Accurate diagnosis is important for optimization of treatment response. It is apparent that especially the serotonin reuptake inhibitors [SRIs] are effective in a broad spectrum of affective and anxiety disorders. It is arguable that alternative diagnostic approaches should be considered and tested. Some of the arguments for reexamining our current system and some tentative solutions are reviewed by Van Praag in Chapter 4. 

As other indications are sought for the SSRls, it is clear that their action extends beyond depression, dysthymia, and the anxiety disorders, and the broad spectrum of therapeutic action of these antidepressants becomes apparent. For example, based on the evidence from placebo-controlled studies [A. Wood 1993], fluoxetine has been licensed in Europe for the treatment of bulimia, and several SSRls are reported to be effective in the treatment of premenstrual syndrome. 

Randrup A, Munkvad 1, Fog R, et al Mania, depression and brain dopamine, in Current Developments in Psychopharmacology, Vol 2. Edited by Essmann WB, ValzeUi L. New York, Spectrum Publications, 1975, pp 206-248 Rapee RM Psychological factors influencing the affective response to biological challenge procedures in panic disorder. J Anxiety Disord 9 59-74, 1995 Rapee RM, Medoro L Pear of physical sensations and trait anxiety as mediators of the response to hyperventilation in nonclinical subjects. J Abnorm Psychol 103 693-699, 1994... 

SSRIs have an unusually broad spectrum of action. They are efficacious in the treatment not only of depression but also of many other psychiatric disorders, including many anxiety disorders. This broad spectrum of efficacy is advantageous when treating patients who have more than one disorder. For example, only SSRIs and clomipramine have been shown in randomized controlled trials to be effective in patients with OCD. 

FIGURE 8-1. Anxiety and depression can be combined in a wide variety of syndromes. Generalized anxiety disorder (GAD) can overlap with major depressive disorder (MDD) to form mixed anxiety depression (MAD). Subsyndromal anxiety overlapping with subsyndromal depression to form subsyn-dromal mixed anxiety depression, sometimes also called anxious dysthymia. Major depressive disorder can also overlap with subsyndromal symptoms of anxiety to create anxious depression GAD can also overlap with symptoms of depression such as dysthymia to create GAD with depressive features. Thus, a spectrum of symptoms and disorders is possible, ranging from pure anxiety without depression, to various mixtures of each in varying intensities, to pure depression without anxiety. 

Dosing varies considerably among individual patients but is definitely at the lower end of the dosing spectrum for patients with chronic neuropathic pain or anxiety disorders (i.e., 2-12 mg either as a split dose or all at night)... 

Cassano, G. B., Pini, S., Saettoni, M., Dell Osso, L. (1999). Multiple anxiety disorder comorbidity in patients with mood spectrum disorders with psychotic features. American Journal of Psychiatry, 156, 474-476. 

Upon assessment it was evident to the social worker that Ron s symptoms were consistent with individuals who suffer from a type of anxiety disorder known as obsessive-compulsive disorder (OCD). The person who suffers from obsessive-compulsive disorder frequently has reoccurring obsessions (thoughts that interfere with action) and compulsions (behaviors that help ease current anxiety levels) that are related to the traumatic event. In OCD, the fourth most common psychiatric disorder in the United States, there appears to be a wide spectrum of symptoms (Cohen Steketee, 1998). These symptoms can range from mild to severe, yet if left untreated can impair an individual s previous level of functioning at work, school, or at home (De Silva Rachman, 1998). 

Gordon JB. (1998). SSRIs and St. John s Wort possible toxicity Am Fam Physician. 57(5) 950-51. Gorman JM. (1996-97). Comorbid depression and anxiety spectrum disorders. Depression Anxiety. 4(4) 160-68. 

There are a number of useful standardized scales to monitor severity and treatment outcomes, (reviewed by Conners [1998] and Barkley [1998]) Because of the overlap with other disorders, an ADHD-specific scale is strongly recommended (such as the Conners, SNAP, Dupaul scales) in which symptom items are based on the DSM criteria and do not include items of other disorders (such as anxiety or mood) or nonspecific functional items. Some ADHD scales provide separate ratings of oppositionality or aggression (SNAP, Conners). It may be helpful to monitor symptoms from non-ADHD conditions as well as functional deficits, and thus a broad-spectrum scale may also be employed but should not be used as the primary measure of ADHD severity or anti-ADHD treatment. Normed rating scales provide comparative information on severity based on age and gender however, such tests are not diagnostic and are not a substitute for the clinical interview. 

The core features of social phobia center on the intense, irrational fear of scrutiny of others and the anticipation of humiliation (Table 25-2). Individuals with this disorder avoid or endure with marked distress the phobic situations. They realize that their fear is unreasonable or excessive. The disorder has been divided into subtypes. Individuals who have anxiety in well-circumscribed situations (e.g., public speaking) have been designated as having a performance subtype those who experience anxiety in a broader spectrum of interpersonal social situations are designated as having a generalized subtype of social phobia. As social phobia has become better character-... 

White SW, Oswald D, Ollendick T, ScahiU L (2009) Anxiety in children and adolescents with autism spectrum disorders. Clin Psychol Rev 29 216-229. 

The besylate salt of mesoridazine 43 is a commercially available antipsychotic medication that is used for treating schizophrenia and mania as well as major depression, anxiety, or severe behavior disorders in children. Mesoridazine 43 has four enantiomers, but the commercial samples are sold as only one diastereomeric pair. The methyl sulfoxide peak of 43 in the H NMR spectrum in the presence of 39 exhibits a peak for each of the four enantiomers. The areas of the sulfoxide resonances were used to compare the diastereomeric ratio of freshly prepared samples of 43 with commercial samples for changes in the ratio of the different isomers. ... 

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