Anxious patients anxiety disorders

Avoidant Personality Disorder (APD) and Social Anxiety Disorder. These illnesses share the tendency toward social withdrawal and isolation with the Cluster A disorders. There is, however, a critical difference that can help make the distinction. The patient with social anxiety disorder is greatly troubled by the fact that (s)he may have so few friends or feel uncomfortable around them. (S)he would, in general, much prefer to feel more at ease in a social setting. This differs from the Cluster A personality disorders. The patient with SPD is indifferent to the fact that (s)he has few friends in fact, (s)he prefers to not have any. The patient with STPD is in a somewhat more intermediate position, feeling very anxious around others and perhaps preferring to have more friends, but also finds it easy to withdraw into a life of isolated fantasy. 

Obsessive-Compulsive Personality Disorder (OCPD). Despite the similarity in name, OCD and OCPD are not closely related. Therefore, the medications used to treat OCD are not necessarily helpful for OCPD. As a result, we also cannot offer any specific medication recommendations for the treatment of OCPD. The overall anxious nature of the illness and the likelihood that such patients have comorbid depression or anxiety disorders may, however, guide medication selection. 

At present, SSRIs are the most commonly prescribed first-line agents in the treatment of both MDD and anxiety disorders. Their popularity comes from their ease of use, tolerability, and safety in overdose. The starting dose of the SSRIs is usually the same as the therapeutic dose for most patients, and so titration may not be required. In addition, most SSRIs are now generically available and inexpensive. Other agents, including the SNRIs, bupropion, and mirtazapine, are also reasonable first-line agents for the treatment of MDD. Bupropion, mirtazapine, and nefazodone are the antidepressants with the least association with sexual side effects and are often prescribed for this reason. However, bupropion is not thought to be effective in the treatment of the anxiety disorders and may be poorly tolerated in anxious patients. The... 

The DSM-IV classifies anxiety disorders in children into four categories, namely social anxiety, over-anxious disorder, phobias and separation anxiety. Only separation anxiety, a fear of losing a loved one or a close attachment, has been reasonably well studied from the point of view of drug treatment. School phobia is perhaps the most severe form of separation anxiety and there are several trials to show that imipramine, in daily doses of up to 5mg/kg, is effective. Many patients require drug treatment for at least 6 to 8 weeks before an optimal response is achieved. Frequently, children remain symptom free after a 3M month course of treatment. In addition to the usual anticholinergic effects of imipramine, it should be noted that children are often susceptible to withdrawal symptoms such as nausea and gastrointestinal spasm. This may be reduced if the drug is slowly withdrawn over a 2-week period. 

Panic attacks are the common symptom for many of the anxiety disorders. A panic attack is a brief and intense experience of fear or distress accompanied by some of the symptoms listed in Table 4.4 (DSM-IV-TR requires four or more symptoms for this diagnosis but acknowledges that patients can be severely anxious with fewer than four different symptoms). A panic attack—or even several panic attacks—is not by itself a disorder. Many people have a panic attack at some point in their lives. However, about 4% of individuals develop recurrent panic attacks, and 3.5% actually meet DSM-IV-TR criteria for panic 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. 

Anxiety symptoms are an inherent part of the initial clinical presentation of several diseases, thus complicating the distinction between anxiety disorders and medical disorders. If the anxiety symptoms are secondary to a medical illness, they usually will subside as the medical situation stabilizes. However, the knowledge that one has a physical illness (e.g., cancer and diabetes) can trigger anxious feelings and further complicate therapy. Persistent anxiety subsequent to a physical illness requires further assessment for an anxiety disorder. Symptoms of anxiety frequently present in medical disorders include palpitations, tachycardia, chest pain or tightness, shortness of breath, and hyperventilation. Medical disorders most closely associated with anxiety are listed in Table 69-1. " About 50% of patients with GAD have irritable bowel syndrome. ... 

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. 

Psychogenic dysfunction occurs if a patient does not respond to psychic arousal. It occurs in up to 30% of all cases of ED. Common causes include performance anxiety, strained relationships, lack of sexual arousability, and overt psychiatric disorders such as depression and schizophrenia.5 It is postulated that the anxious or nervous man will have excessive stimulation of the sympathetic system, leading to smooth muscle contraction of arterioles and vascular spaces within erectile tissue.6 O Many patients may initially have organic dysfunction, but develop a psychogenic component as they try to cope with their inability to achieve an erection. It has been estimated that up to 80% of ED cases have an organic cause, with many having a psychogenic component as well.1... 

In contrast to panic disorder, the somewhat more subtle and persistent symptoms of GAD do not always command immediate attention. Although patients with GAD may present with a primary complaint of anxiety, they are more likely to complain of a physical ailment or another psychiatric condition or symptoms, for example, depression or insomnia. As such, many patients with GAD will seek treatment from a primary care physician long before recognizing the need for mental health care despite readily acknowledging that they have been anxious virtually all of their lives. 

The so-called anxious disorders of Cluster C include avoidant personality disorder (APD), dependent personality disorder (DPD), and obsessive-compulsive personality disorder (OCPD). Like the Cluster A disorders, these personality disorders are typically unobtrusive and may escape clinical detection for many years. Over time, patients adapt their life styles to these illnesses by decreasing their social contacts in an effort to minimize anxiety. In so doing, they further decrease the likelihood of encountering mental health professionals. 

Unlike the disorders we have discussed so far, in GAD anxiety is not focused on a specific event, situation, or object. People with GAD worry and feel anxious about many aspects of their lives, snch as the demands of their work or school, finances, the safety of loved ones, and even the minor challenges of everyday life (e.g., getting the car repaired or being on time to an appointment). Of course, from time to time, we all have problems we worry about, but in GAD the worry is far ont of proportion to the actual likelihood of danger or risk and so persistent that patients cannot control their worries, which, along with the associated symptoms (e.g., tension, anxiety), interfere with their lives. This pervasive anxiety also results in various physical symptoms resdessness, easy fatigability, difficulty in concentrating, irritability, mnscle tension, and sleep problems. 

The day after stopping fluoxetine 60 mg daily, a 41-year-old man was started taking 75 mg and later 100 mg of bupropion three times daily. After 10 days he became edgy and anxious and after 12 days he developed myoclonus. After 14 days he became severely agitated and psychotic, with delirium and hallucinations. His behaviour returned to normal 6 days after the bupropion was stopped. Another patient taking lithium carbonate for bipolar disorder developed anxiety, panic and eventually mania a little over a week after stopping fluoxetine and starting bupropion. ... 

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