ANXIETY DISORDER

embarrassed or humiliated in a
social or performance situation.

Anxiety

A normal, protective, psychological

response to an unpleasant or
threatening situation.

Mild to moderate

Excessive and prolonged

Symptoms of Anxiety
Symptoms common to all anxiety disorder:
Fear or worry
Sleep disturbances
Concentration problems
Dry mouth
Sweating

D. SPECIFIC PHOBIA

Marked and persistent fear that is

excessive or unrealistic, precipitated
by the presence of a specific object
or situation.

E.g. flying or spiders

E. POST-TRAUMATIC STRESS DISORDER

(PTSD)

Can occur after an exposure to a

traumatic event

The person responds with intense

fear, helplessness or horror.

Sufferers can re-experience

flashbacks

Occurs within 6 months of traumatic

event

Palpitations
GI discomfort
Restlessness
SOB
Avoidance behavior

F. OBSESSIVE-COMPULSIVE DISORDER
(OCD)

Persistent thoughts, impulses or

images (obsessions) that are
intrusive and cause distress.

Person attempts to get rid of these

obsessions by completing repetitive
time-consuming purposeful
behaviors or actions.

E.g. contamination fear ( repetitive

washing or cleaning)

Types of anxiety disorder

A. GENERALIZED ANXIETY DISORDER
(GAD)

Persistent (free floating), excessive

and inappropriate anxiety for at least
6 months.

The anxiety is not restricted to a

specific situation

worry about everything, worry

about worry

PATHOPHYSIOLOGY

Anxiety occurs when there is a

disturbance of the arousal systems
in the brain.

Arousal is maintained by at least 3

interconnected systems:

B. PANIC DISORDER

With or without agoraphobia

Recurrent, unexplained surges of

severe anxiety (panic attack)

Agoraphobia - fear in places or

situations from which escape might
be difficult.

C. SOCIAL PHOBIA

Social anxiety disorder

A marked, persistent, and

unreasonable fear of being observed,

a. General arousal system

b. Emotional arousal system
c. Endocrine/ Autonomic arousal
system
ETIOLOGY AND CLINICAL
MANIFESTATION
Anxiety is commonly precipitated by stress.
May also be induced by:

1. Central stimulant drugs ( caffeine,

amphetamines)
2. Withdrawal from chronic use of CNS
depressant drugs ( alcohol,
hypnotics, anxiolytics)
3. Metabolic disturbances
( hyperventilation. hypoglycemia,
thyrotoxicosis)
Clinical manifestations

b. Eye movement desensitization and

reprocessing (EMDR)

sometimes recommended in PTSD

Moving a finger continuously in front

of the patients eye or hand tapping.

c. Exposure and response prevention

(ERP)

a CBT for OCD

Repeatedly facing the fears,

beginning with the easiest situations
and progressing until all fears have
been faced.

Psychological symptoms
apprehension
fear
Somatic symptoms
Palpitations
chest pain

SOB

d. Self-help- Alternative technique

recommended for GAD and panic disorder.
PHARMACOTHERAPY
BENZODIAZEPINES

commonly prescribed

have sedative/ hypnotic, anxiolytic,

amnesic, muscular relaxant and
anticonvulsant actions

Over dependence and tolerance

restrict use to short-term use only.

dizziness

dysphagia

GI disturbances

loss of libido

Head ache

tremor

Pharmacokinetics:
well absorbed
rapidly penetrate the brain

TREATMENT

T 1/2 = 8-35 h

PYSCHOTHERAPY

undergo hepatic metabolism

Psychological therapies / talking

therapy

First-line treatment in all anxiety

disorder

The treatment of mental and

emotional disorders through the use
of psychological techniques as
psychoanalysis, group therapy, or
behavioral therapy.

a. Cognitive behavioral therapy (CBT)

A type of psychotherapeutic
treatment that helps patients
understands the thoughts and
feelings that influence behaviors.

60-90 minutes every week for 8-16

weeks therapy.

MOA:

Benzodiazepines bind to GABA

receptor facilitating GABA-mediated
chloride ion channel opening
resulting in membrane
hyperpolarization.

increased risk of falls and fractures

addiction and tolerance

Withdrawal

abrupt withdrawal is dangerous

can induce acute anxiety, psychosis

or convulsions

gradual withdrawal with

psychological treatment is required

Drug interactions

GABA ACTIVITY
More GABA activity

sedation
amnesia
ataxia

Reduced GABA activity

arousal
anxiety
restlessness

Role in treating anxiety:

Useful at the start of SSRI treatment

in OCD and as hypnotics in PTSD.
use for no longer than 2-4 weeks

alcohol, TCAs, antihistamines ,

opioids

sedation, collapse and severe

respiratory depression.

Pregnancy and lactation:

CI

associated with oral cleft

enter breast milk

may cause sedation, lethargy,

weight loss in infant

ANTIDEPRESSANTS

provide long term treatment

for those who have not responded to

psychological therapies

First-line treatment w or w/o CBT in

patients with OCD

Initial worsening of symptoms occur

upon use

require high therapeutic doses to

improve response

Choice of Benzodiazepine

Lorazepam and alprazolam widely used but needed to be taken

several times a day.
Diazepam- rapid onset of action and
slow elimination ensures a steady
blood concentration.
Clonazepam- long acting, more
potent than diazepam, but difficult to
withdraw and only indicated for
epilepsy

Adverse Effects:

drowsiness

light-headedness

confusion

ataxia

amnesia

increase in aggression

a. Selective Serotonin Reuptake

inhibitors (SSRIs)

First drug options in GAD, panic

disorder, social phobia, PTSD and
OCD

Initial worsening of symptoms occur

begin with half dose

b. Tricyclic antidepressants (TCAs)

Clomipramine, imipramine and

amitriptyline are efficacious

2nd line treatment if SSRI fail

AEs: anticholinergic effects,

hypotension and weight gain

cardiac toxicity (overdose)

c. Monoamine Oxidase Inhibitors

(MAOIs)

Rarely used

Phenelzine and meclobamide are

used for social phobia when SSRI fail

Phenelzine is 3rd line treatment in

PTSD

d. OTHER ANTIDEPRESSANTS
Selective norepinephrine reuptake
inhibitor (SNRI)
Venlafaxine

Licensed for use in GAD and social

phobia (dose: 75mg/day)

Increase BP ( higher dose)

CI in patients with a very high risk of

cardiac ventricular arrhythmia or
uncontrolled HTN

Duloxetine

For GAD
Can increase BP

Mirtazapine

a2-adrenoreceptor antagonist

For PTSD

Lower incidence of nausea, vomiting,

and sexual dysfunction than SSRI

can cause weight gain and sedation

OTHER MEDICATIONS OCCASIONALLY

USED IN ANXIETY
Hydroxyzine

sedating antihistamine, for short

term treatment of anxiety

Use in GAD if sedation is required

Not used in panic disorders

Antipsychotics
1st gen (Typical)

associated with movement disorder

such as akathisia and tardive
dyskinesia

Rarely used in anxiety

2nd gen (Atypical)

Risperidone and Quetiapine in

combination with an SSRI in OCD

Olanzapine- used in PTSD and

social phobia

OTHER MEDICATIONS OCCASIONALLY USED IN ANXIETY

Pregabalin

for GAD
Causes dizziness, somnolence and nausea

Propranolol and Oxprenolol

For anxiety symptoms such as palpitations, tremor, sweating, and shortness of breath.
OVERVIEW OF THE RECOMMENDED DRUG TREATMENTS IN ANXIETY
GAD

Intermediate
management
/ short-term
treatment

Benzodiazepin
es
(2-4 weeks
only)
Hydroxyzine

PANIC
DISORDER

SOCIAL
PHOBIA

Benzodiazepines
not
recommended

Benzodiazepi
nes
(2-4 weeks
only)

OCD
Benzodiazepine
s (to counter
worsening of
symptoms with
SSRI)

PTSD
Hypnotics
(insomnia)

First-line

Pharmacother
apy

Other drug
treatments

SSRI
Escitalopram
Paroxetine
Sertraline

SSRI
Citalopram
Escitalopram
Paroxetine

SSRI
Escitalopram
Paroxetine

Buspirone
Duloxetine
Imipramine
Pregabalin
Venlafaxine

Clomipramine
Imipramine
Mirtazapine
Meclobamide
Venlafaxine

Meclobamide
Phenelzine
Venlafaxine

SSRI
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
Clomipramine
Augmentation
with quetiapine
or risperidone

SSRI
Paroxetine
Sertraline

Amitriptyline
Augmentation
with olazapine
or risperidone
Imipraprime
Mirtazapine
Phenelzine
Venlafaxine