Anxiety syndromes

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. 

Other Antidepressants. Antidepressant refinements for the next 30 years primarily consisted of the development of new TCAs. However, in 1988, a novel antidepressant class, the selective serotonin reuptake inhibitors (SSRIs), was introduced in the United States. The chief innovation of the SSRIs was that they afforded the comparable effectiveness of the TCAs with fewer side effects and minimal toxicity. The debut of the SSRIs coincided with the reworking of the nosology of the anxiety disorders in DSM-III and DSM-IV. As a result, the SSRIs have been studied extensively in each of the respective anxiety disorders and in many cases have obtained FDA approval for the treatment of one or more of these anxiety syndromes. The SSRIs currently available in the United States include citalopram (Celexa), escitalo-pram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft). 

Miscellaneous. In recent years, other medication classes have been tested in the treatment of specihc anxiety syndromes. For example, atypical antipsychotics have been used as adjunctive treatments for OCD and GAD, and mood stabilizers have been used to treat PTSD. These syndrome-specific regimens will be discussed in the following sections. 

One drawback to MAOI therapy is that the therapeutic benefit typically does not begin until after the third week of treatment at the earliest. This is, of course, generally true of all antidepressants that are used to treat panic disorder and other anxiety syndromes. Of greater concern are the potentially dangerous food and drug interactions of the MAOIs (cf. Chapter 3), which have relegated the use of MAOIs for those panic disorder patients who do not respond to other treatments. 

The full complement of anxiety syndromes including panic, generalized anxiety, obsessive-compulsiveness, and post-traumatic stress disorder can arise in the after-math of TBI. In fact, anxiety may be the most common neuropsychiatric complication of TBI. Anxiety appears to be most likely to arise when the injury occurs to the right side of the brain. The treatment alternatives for post-TBl anxiety parallel those used when treating anxiety disorders and include serotonin-boosting antidepressants, buspirone (Buspar), and the benzodiazepines (see Table 12.1). 

Severe anxiety syndromes, agitation, or anxiety associated with depression -15 to 30 mg 3 or 4 times/day. 

Klein DF (1964) Delineation of two drug responsive anxiety syndromes. Psychopharma-cologia 5 397-408... 

Khan A, Khan S, Kolts R, Brown WA (2003) Suicide rates in clinical trials of SSRls, other antidepressants, and placebo analysis of FDA reports. Am J Psychiatry 160 790-792 Klein DF (1964) Delineation of two drug-responsive anxiety syndromes. Psychopharma-cologia 5 397-408... 

Fawcett J, Kravitz HM Anxiety syndromes and their relationship to depressive illness. J Chn Psychiatry 44 8-11, 1988... 

Klaiber EL, Broverman DM, Vogel W, et al Estrogen therapy for persistant depression in women. Arch Gen Psychiatry 36 550-554, 1979 Klawans HL, Weiner WJ, Nausieda PA The effect of lithium on an animal model of tardive dyskinesia. Prog Neuropsychopharmacol 1 53-60, 1976 Klein DP Delineation of two drug-responsive anxiety syndromes. Psychopharmaco-logia 5 397-408, 1964... 

Another alternative is buspirone, a non-benzodiazepine anxiolytic that seems to be free of untoward effects on cognitive performance (Ninan et ul., 1998). As indicated in Chapter 1, the anxiolytic effect of this compound ma take a few weeks to occur (and is often rather weak), meaning that buspirone is better suited for long-term treatment of anxiety syndromes than for immediate anxiolvsis. 

In the course of the treatment of schizophrenia, depressive and various anxiety syndromes, it has been found repeatedly that psychopharmaceuticals and psychotherapies are likely to modify different types of symptoms and... 

The prototypes of modem psychopharmaceuticals were discovered between 1952 and 1958. Since that time the effective treatment of schizophrenic psychoses, depressions, anxiety syndromes and other mental disorders has become possible and a new, multidisciplinary science biological psychiatry has developed. Clinical psychiatry has changed dramatically in the past 50 years fewer patients are hospitalized long term, psychiatric care and treatment have largely shifted to outpatient departments and private practices, and new models of combined pharmacological and non-drug-based prophylactic and therapeutic interventions have been developed. 

Blazer D, Hughes D, George U. Stressful life events and the onset of generalized anxiety syndrome. Am J Psychiatry 1987 144 1178-1183. 

Anxiety is a common complaint that invariably complicates addictive illnesses. Estimates of co-morbid anxiety and alcohol disorders range from 20% to 50%, with men more likely to self-medicate anxiety than women (453, 454 and 455). Some investigators have also found increased rates of alcoholism in family members of patients with anxiety disorders (456, 457). Patients with alcohol or drug dependence show a tendency for development of panic disorder earlier, and it has been suggested that repeated alcohol withdrawal may be the trigger for panic attacks in susceptible individuals ( 458, 459). Finally, BZDs, the primary pharmacological treatment for these disorders, are themselves addictive and sometimes associated with anxiety syndromes, especially on their discontinuation ( 460). 

FIGURE 8—4. Subsyndromal anxiety can also be a harbinger of an episode of a full generalized anxiety disorder (GAD). Such patients may have an intermittent clinical course, which waxes and wanes over time between subsyndromal anxiety and GAD. Decompensating to full GAD with recovery only to a state of subsyndromal anxiety over time can also be called the double anxiety syndrome. 

Since the etiology and treatment of these anxiety syndromes vary significantly, each is discussed separately below, with greater detail provided for the disorders that are felt to be more strongly biologically based. 

Lehmann and coworkers (1989) conducted a three-center, double blind placebo-controlled trial of ( )-kavain (Neuronika ). Of the 56 patients included in the study, four dropped out within the first two weeks of treatment due to reasons unrelated to the study. Of the 52 remaining patients, 21 had a panic syndrome, 17 had generalized anxiety syndrome, 10 disturbance of adaptability, and 4 phobic disturbances. No details were provided in terms of gender. The average age of the total sample was about 40 years. None of the patients were on psychotropic medication for any of the conditions. 

Anxiety can be a reaction to major life events, such as moving house, changing jobs or bereavement. As such, it is a normal, but short-lived response to a potentially threatening event. Anxiety becomes a medical problem when it is excessive, long lasting or inappropriate and incapacitating. Then it can be called anxiety neurosis , or an anxiety syndrome. 

According to the DSM-IV, anxiety syndromes are obsessive-compulsive disorder, panic attacks for no apparent reason, phobias and post-traumatic stress disorder. Anxiety can be associated with depression or psychosis. 

Symptoms like these are familiar to most people and do not constitute an anxiety syndrome providing they are mild, short-lived and for a reason. In such cases, drug therapy is not usually necessary. 

Despite their efficacy in a variety of pathologic anxiety syndromes, the benzodiazepines are not perfect anxiolytics. Such a hypothetical agent would selectively ameliorate anxiety without inducing other behavioral effects. Future efforts to enhance the efficacy of benzodiazepine anxiolytics may depend on a greater understanding of the heterogeneity of the GABAa receptor—for example, which specific clinical actions (anxiolytic, muscle relaxation, sleep facilitation) reside with which specific subunit composition. 

Cognitive behavioural therapy for other work-related anxiety syndromes... 

Cross-situational anxiety differs from the situation-specific anxiety described in the previous chapter, in that it involves multiple anxieties and worries that affect performance across a wide range of work and non-work-related situations and tasks. Examples of cross-situational anxiety include disorders such as uncued panic attacks, agoraphobia, generalized social phobia and generalized anxiety disorder (American Psychiatric Association [APA] 2000). The treatment of panic attacks and phobias was discussed in the previous chapter. This chapter thus focuses on the formulation and treatment of generalized anxiety disorder (GAD). GAD warrants specific attention since it requires quite a different CBT treatment approach from the other forms of anxiety already mentioned. Two other anxiety syndromes which have been found to be particularly prevalent among health workers, namely post-traumatic stress disorder (PTSD) and health anxiety, are also discussed in this chapter. 

There are two other work-related anxiety syndromes which have been found to be particularly prevalent among health workers. These are post-traumatic stress disorder and health anxiety. The rest of this chapter looks at the cognitive behavioural treatment of these two anxiety syndromes. 

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