PSYC 179 Lecture 15 - Anxiety Disorders- Anti Anxiety Drugs

8/7/2019 PSYC 179 Lecture 15 - Anxiety Disorders- Anti Anxiety Drugs

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DefinitionsAnxiety

Feelings of impending doom not linked to

a specific stimulus in the environment

Feeling of fear in absence of externalized

threat

Fear

Feelings in response to a specific stimulus


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SymptomsMental Symptoms

Vague sense of irritability & uneasiness

Feeling that something terrible is going to happen

Terror or panic

Increasinganxiety


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SymptomsPhysical Symptoms

Autonomic Nervous System Activation

Sweating

Increased heart rate & blood pressure Dry mouth

Upset GI tract

Cold & clammy hands


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Treatments

Medication Anxiety Disorder

Benzodiazepines All anxiety disorders for symptomatic treatment

Serotonin Antidepressants (low doses) Agoraphobia; Panic disorders

Serotonin Antidepressants (antidepressant doses) PTSD

Serotonin Antidepressants (high doses) OCD

Beta blockers Social phobia

Buspirone (Buspar) GAD


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Anti-anxiety Drugs

Drugs Dose Half-Life Duration

Benzodiazepines 2-3x/day

diazepam (Valium) 1-10 mg 30-60 hours long

lorazepam (Ativan) 2-6 mg 10-20 hours medium

alprazolam (Xanax).25-.5 mg 12-15 hours medium

chlordiazepoxide (Librium) 10-100 mg 5-15 hours short

Non-Benzodiazepines

buspirone (Buspar)20-30 mg 2-3 hours short

propanolol (Inderal) 10-80 mg 4 hours short

clomipramine (Anafranil) 150-250 mg 20-40 hours long

fluoxetine (Prozac) 40-80 mg 48-72 hours long


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Hypnotics

Drugs Dose Half-Life Duration

flurazepam (Dalmane) 15-30 mg 50-100 hours long

temazepam (Restoril) 15-30 mg 10-20 hours medium

triazolam (Halcion) .25-1.0 mg 2-5 hours short

zolpidem (Ambien) 5-10 mg 2-3 hours short


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Benzodiazepines

Physiological Effects:

Do not:

respiratory rate heart rate

impair GI


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Benzodiazepines

NormalAnti-anxiety

Disinhibition

SedationSleep

General Anesthesia

Coma

Death

BZP


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Benzodiazepines

1. Safe - will not kill you Diazepam (Valium)

2. Effective in treating symptoms of anxiety

3. Less abuse potential than other sedative-

hypnotics4. No effect on cardiovascular system


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Medical Uses - Benzodiazepines

Anti-Anxiety Acute Anxiety Anxiety Disorders

Anti-Convulsant Status epilepticus

Diazepm intravenous

Alcohol Withdrawal Chloriazepoxide

(Librium)

Pre-Operative

Midazolam (Versed)


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Behavioral Effects- Benzodiazepines

Takes edge off anxiety Mild High, relaxed, disinhibited

Decreased distractability, increased focus

Decreased autonomic symptoms Muscle relaxation


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Side Effects - Benzodiazepines

Decreased Performance Decreased Memory

Travelers Amnesia (Blackout)

Abuse Potential? Withdrawal - dependence like alcohol

delayed [alprazolam (Xanax)]


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Benzodiazepines

Dependence is moderate

Withdrawal syndrome similar to alcohol

Longer onset Longer in duration

Less intense


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Types of Disorders

Simple Phobia

Persistent fear of circumscribed stimulus

Treatment:

Behavioral Therapy

Benzodiazepines: Alprazolam

(Xanax)


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Types of Disorders

Social Phobia Fear of situations involving possible scrutiny of

others

Treatment: Cognitive Behavioral Therapy

Monoamine oxidase inhibitor-MAOIs Serotonin selective reuptake inhibitor-SSRIs

Beta blockers Atenolol (Tenormin)


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Types of Disorders

Agoraphobia Avoidance of situations where escape may be

difficult

Treatment: Benzodiazepines

Antidepressants (low doses) Psychotherapy


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Types of Disorders

Panic Disorder Discrete periods of intense fear & anxiety that

come out of nowhere

Treatment: Psychotherapy

Benzodiazepines (symptomatic) Antidepressants (low doses)


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Types of Disorders

Generalized Anxiety Disorder (GAD) Increased tension, vigilance, autonomic activity,

apprehension

Treatment:

Psychotherapy

SSRIs (low doses)

Benzodiazepines

Buspirone (Buspar)


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Types of Disorders

Obsessive Compulsive Disorder (OCD) Obsessions & compulsions

Treatment: Cognitive Behavioral therapy

Behavioral therapy

SSRIs (high doses) Less robust clinical response of SSRIs than SSRIs

for depression


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Types of Disorders

Post Traumatic Stress Disorder (PTSD) Experience outside range of normal human

experience

Flashbacks, psychic numbness, persistentarousal, nightmares

Treatment: Behavioral therapy

Benzodiazepines (symptomatic)

SSRIs


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Mood

Disorders

Antidepressants


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Depression Definitions

Anhedonia - without pleasure

Hypomania - symptoms of mania that do not meet

the criteria for a manic episode

Euthymia - normal mood state

Dysthmia - decrease in mood that does not meet full

criteria for MDE

Remission - full response < 1 year out Recovery - full response > 1 year out


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Tricyclic Antidepressants

Drug: amitryptyline (Elavil)

Side effects: anticholinergic side

effects, decreased libido & sexualperformance, precipitation of mania

Use and contraindications

Effective anti-depressant

More side effects than SSRIs

Lethal dose 5X therapeutic dose


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Anticholinergic Side Effects TCA

Dry mouth

Constipation

Urinary retention

Increased heart rate

Orthostatic hypotension Blurring of vision

Dementia - delirium 300mg/day

2,000 mg/day = death


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Monoamine Oxidase Inhibitors-

MAOIs Drug: phenelzine (Nardil)

Side effects: anticholinergic like including dry mouth,constipation, heart arrythmias, but also: insomnia-stimulant effect and potential hypertensive crises

Use and contraindications Often use to treat atypical depression

Potential lethal side effects that requires dietarymonitoring;

no tyramine containing foods: aged cheese, redwine, fava beans


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Serotonin Selective Reuptake Inhibitors-

SSRIs

Drugs: escitalopram (Lexapro)fluoxetine (Prozac)

Side effects: nausea, insomnia or

sedation, decreased sexual function:decreased libido and orgasm


Effective antidepressants and anti-anxietydrugs

Safe antidepressants


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Serotonin Norepinephrine

Reuptake Inhibitors - SNRIs

Drug: duloxetine (Cymbalta)

Side effects: nausea, insomnia or

sedation, dizziness, sexual side effectslike SSRIs


Effective antidepressant

Effective anti-anxiety drug

First line treatment for major depressive

episodes


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Atypical Antidepressants

Drug: buproprion (Wellbutrin)

Side effects: anxiety, restlessnes and

weight gain Use and contraindications

Effective anti-depressant

No sexual side effects Seizures in 0.5 percent of subjects at

therapeutic doses


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Time Course of AD Treatment

1. Delay in response of antidepressants: 7-10days

2. Differential response in symptoms

First vegetative symptoms

Second emotional/subjective feelings


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Psychiatrist Jeffrey Schwartz, author ofBrain Lock:

Free Yourself from Obsessive-Compulsive Behavior,

offers the following four steps for dealing with OCD

RELABEL Recognize that the intrusive obsessive

thoughts and urges are the RESULT OF OCD.

REATTRIBUTE Realize that the intensity and

intrusiveness of the thought or urge is CAUSED BY OCD; itis probably related to a biochemical imbalance in the brain.

REFOCUS Work around the OCD thoughts by focusing

your attention on something else, at least for a few

minutes: DO ANOTHER BEHAVIOR.

REVALUE Do not take the OCD thought at face value. It Isnot significant in itself.


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DSM-IV: Simple PhobiaA. Marked and persistent fear that is excessive or

unreasonable, cued by the presence or anticipationof a specific object or situation (e.g., flying, heights,animals, receiving an injection, seeing blood).

B. Exposure to the phobic stimulus almost invariably

provokes an immediate anxiety response, which maytake the form of a situationally bound or situationallypredisposed Panic Attack. Note: In children, theanxiety may be expressed by crying, tantrums,

freezing, or clinging.C. The person recognizes that the fear is excessive or

unreasonable. Note: In children, this feature may beabsent.


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DSM-IV: Social PhobiaA. A marked and persistent fear of one or more

social and performance situations in which theperson is exposed to unfamiliar people or topossible scrutiny by others. The individualfears that he or she will act in a way (or show

anxiety symptoms) that will be humiliating orembarrassing.

B. Exposure to the feared social situation almostinvariably provokes anxiety, which may take theform of a situationally bound or predisoposedPanic Attack.

C. The person recognizes that the fear is

excessive or unreasonable.


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DSM-IV: Panic Disorder

A. Both (1) and (2):

1. Recurrent unexpected Panic Attacks

2. At least one of the attacks has been followed by 1month (or more) of one (or more) of the following:

persistent concern about having additional attacks

worry about the implications of the attack or itsconsequences

a significant change in behavior related to the attacks

B. Absence of AgoraphobiaC. The Panic Attacks are not due to the direct physiologicaleffects of a substance (e.g., a drug of abuse, amedication) or a general medical condition (e.g.,hyperthyroidism).


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DSM-IV: AgoraphobiaA. Anxiety about being in places or situations from which escape might be

difficult (or embarrassing) or in which help may not be available in the

event of having an unexpected or situationally predisposed Panic Attack

or panic-like symptoms.

B. The situations are avoided (e.g., travel is restricted) or else are endured

with marked distress or anxiety about having a Panic Attack or panic-like symptoms, or require the presence of a companion.

C. The anxiety or phobic avoidance is not better accounted for by another

mental disorder.


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DSM-IV: GADA. Excessive anxiety and worry (apprehensive expectation),

occurring more days than not for at least 6 months, about anumber of events or activities (such as work or schoolperformance).

B. The person finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of

the following six symptoms (with at least some symptomspresent for more days than not for the past 6 months).

restlessness or feeling keyed up or on edge

being easily fatigued

difficulty concentrating or mind going blank irritability

muscle tension

sleep disturbance (difficulty falling or staying asleep, or

restless unsatisfying sleep)


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DSM-IV: OCDObsessions as defined by (1), (2), (3), and (4):

1. recurrent and persistent thoughts, impulses,or images that are experienced, at some time duringthe disturbance, as intrusive and inappropriate and thatcause marked anxiety or distress

2. the thoughts, impulses, or images are notsimply excessive worries about real-life problems

3. the person attempts to ignore or suppresssuch thoughts, impulses, or images, or to neutralizethem with some other thought or action

4. the person recognizes that the obsessionalthoughts, impulses, or images are a product of his orher own mind (not imposed from without as in thoughtinsertion)


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DSM-IV: OCDCompulsions as defined by (1) and (2):

1. repetitive behaviors (e.g., hand washing, ordering,checking) or mental acts (e.g., praying, counting, repeating wordssilently) that the person feels driven to perform in response to anobsession, or according to rules that must be applied rigidly

2. the behaviors or mental acts are aimed at preventing orreducing distress or preventing some dreaded event or situation;however, these behaviors or mental acts either are not connectedin a realistic way with what they are designed to neutralize orprevent or are clearly excessive

B. At some point during the course of the disorder, the person hasrecognized that the obsessions or compulsions are excessive orunreasonable. Note: This does not apply to children.


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DSM-IV: PTSD

A. The person has been exposed to a

traumatic event

B. The traumatic event is persistently re-

experienced

C. Persistent avoidance of stimuli associated

with the trauma and numbing of general

responsiveness

PSYC 179 Lecture 15 - Anxiety Disorders- Anti Anxiety Drugs

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