Anxiety Disorders: Diagnosis and Treatment

Key Concepts

• Anxiety disorders rank among the most common psychiatric illnesses, yet they are frequently underdiagnosed and undertreated.
• Achieving remission with minimal anxiety symptoms and no functional impairment is the long-term objective in treating generalized anxiety disorder (GAD).
• Antidepressants represent the first-line treatment option for managing GAD.
• When using antidepressants for GAD, be aware that the antianxiety benefits typically manifest after a lag period of 2 to 4 weeks or even longer.
• When assessing the effectiveness of antidepressants for panic disorder, allow at least 8-12 weeks to achieve a comprehensive therapeutic response.
• The optimal duration of panic therapy remains undefined, but a 12- to 24-month pharmacotherapy course is advised before attempting a gradual medication discontinuation over 4 to 6 months.
• Social anxiety disorder (SAD) is a chronic condition necessitating extended therapy, after significant improvement, a maintenance medication period of 6-12 months is advised before considering ending treatment.
• For SAD, selective serotonin reuptake inhibitors or venlafaxine are established as first-line pharmacotherapy.
• An adequate antidepressant trial for SAD should last a minimum of 8 weeks, with maximal benefit potentially observed after 12 weeks.
• Improvement in SAD should focus on three key domains: symptoms, functionality, and overall well-being.

Patient Care Process

• The main steps in the patient care process include:
  • Collect: Gather patient information (age, sex, history, medications)
  • Assess: Determine diagnosis, comorbidities, and treatment readiness
  • Plan: Select pharmacotherapy and monitoring parameters
  • Implement: Educate the patient on the treatment plan
  • Follow-up: Evaluate outcomes and adherence

Anxiety Introduction

• Anxiety is an emotional state driven by a person's perception of real or perceived threats to their security; it can be adaptive and transient
• If anxiety escalates it can produce uncomfortable and debilitating psychological effects (worry or feeling of threat) and physiologic arousal (tachycardia, shortness breath), sometimes causing irrational fears
• Anxiety disorders rank among the most frequent psychiatric disorders encountered in clinical practice, and are often underdiagnosed and undertreated
• Healthcare professionals often mistake anxiety disorders for physical illnesses, and less than one-third of patients receive appropriate treatment
• It is essential for clinicians to differentiate between short-term symptoms of anxiety and anxiety disorders for treatment
• Situational anxiety is a normal response to a stressor, lasting around 2 to 3 weeks, and treated with short term anxiolytic agents like benzodiazepines, prolonged therapy however is not recommended

Epidemiology

• Anxiety disorders are the most common psychiatric disorders as approximately 34% of the population are affected by an anxiety disorder during their lifetime
• 1-year prevalence rate for anxiety disorders was 21.3% in persons aged 18 years old or older
• Specific phobias were the most common anxiety disorder, with a 12-month prevalence of 10.1%
• The 1-year prevalence of generalized anxiety disorder (GAD) was 2.9%, panic disorder was 3.1%, and social anxiety disorder (SAD) was 8.0%

Medical & Psychiatric Comorbidity, & Substance-Induced Anxiety

• Anxiety disorders include medical, psychiatric illnesses, medications, or substances. They may be linked to vulnerability (ex: genetic predisposition/early childhood adversity) & stress (ex: occupational/traumatic experience)
• Anxiety symptoms can exist within medical illnesses & are linked to chronic medical illness, low levels of physical health-related quality of life, as well as physical disability
• Anxiety can be a feature of major psychiatric illnesses, common in patients with mood disorders, schizophrenia, dementia, & SUDs, so it's important to diagnose & treat all comorbid conditions
• Medications & substances are a frequent cause of anxiety symptoms, anxiety can occur during the use of CNS-stimulants in a dose-dependent manner
• Anxiety often occurs in children and adults taking CNS depressants

Neurochemical Theories

• The autonomic nervous system of anxiety disorder patients can be hypersensitive creating symptoms of peripheral autonomic hyperactivity
• The locus ceruleus (LC) is an alarm center activating NE as well as stimulating sympathetic/parasympathetic NSs which result in Chronic central noradrenergic over activity, downregulating adrenoreceptors in GAD patients
• Serotonin function is dysregulated in anxiety, where it is primarily an inhibitory neurotransmitter used by neurons originating in the raphe nuclei of the brain stem
• Greater 5-HT function could facilitate avoidance behavior & reduced 5-HT may increase aggression. SSRIs increase 5-HT levels by blocking the SERT & are efficacious in blocking panic/anxiety symptoms
• Functional neuroimaging studies confirm the roles of the amygdala, anterior cingulate cortex (ACC), ventromedial prefrontal cortex, & insula in anxiety
• Those with panic disorders have abnormalities of midbrain structures, including the PAG and have brain abnormalities in the insula. SAD shows greater activity in the amygdala & insula

Clinical Presentation

• The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies anxiety disorders into categories including GAD, panic disorder, agoraphobia, SAD, specific phobia, and separation anxiety disorder

Generalized Anxiety Disorder (GAD)

• The diagnostic criteria for GAD require persistent symptoms for most days for at least 6 months. The essential feature of GAD is unrealistic or excessive anxiety and worry about a number of events or activities
• The anxiety or apprehensive expectation is accompanied by at least three psychological or physical symptoms. Anxiety and worry are not confined to features of another psychiatric illness (eg, having a panic attack, being embarrassed in public)

Panic Disorder

• Panic disorder begins as a series of unexpected (spontaneous) panic attacks involving an abrupt surge of intense fear or intense discomfort
• The unexpected panic attacks are followed by at least 1 month of persistent concern about having another panic attack, worry about the possible consequences of the panic attack, or a significant maladaptive change in behavior related to the attacks
• During an attack, patients describe at least four psychological and physical symptoms
• Up to 50% of patients develop agoraphobia secondary to the panic attacks and have a high lifetime risk for suicide attempts compared with the general population

Social Anxiety Disorder (SAD)

• Characterized by fear of scrutiny; exposure to scrutiny provokes panic
• Main physical indicator is blushing, out of proportion; lasts 6+ months
• Mean age of onset is mid teens with slightly higher rates among females
• Sufferers often avoid professional help due to fear of consultation

Treatment - Generalized Anxiety Disorder

• The main goals for therapy:
  • Reduce severity and duration of anxiety
• Improve overall functioning
• Goal: Remission with minimal/no symptoms, no functional impairment, and increased QOL
• Prevention of recurrence is a long-term consideration

Non-Pharmacologic Therapy

• Modalities include psycho-education, short-term counseling, stress management, psychotherapy, mindfulness-based therapy, or exercise
• People with anxiety should not have: caffeine, nicotine, diet pills, and excessive alcohol
• Cognitive Behavioral Therapy (CBT) can be done by: - Self-monitoring - Cognitive restructuring - Relaxation Training - Rehearsal of Coping Skills
• Combining medication and psychotherapy over time is lacking

Pharmacologic Therapy

• Benzodiazepines are most effective and common first-line medication to rapidly reduce acute anxiety.
• Considerations of pharmacokinetics and properties will assist in selection
• Antidepressants are the treatment of choice for long-term use
• Buspirone is only effective in the absence of depressive symptoms

Antidepressant Therapy

• They are first-line for the management of GAD
• The antianxiety response is delayed by 2 to 4 weeks or longer
• Effective in acute and long-term management of GAD, as the drugs modulate neurotransmitters & stress-adapting pathways to reduce somatic anxiety and distress
• General SSRIs & SNRIs are well-tolerated

Benzodiazepine Therapy

• Effective as they possess anxiolytic properties
• Act on GABA, specifically subunits a1, a2, & a3 in combination with the b subunit and the y2
  • Reduce neuronal excitability
  • Anxiolytic effect is mediated at the a2 site
• When d osed appropriately, all agents have similar anxiolytic & sedative-hypnotic activity
• Can cause unwanted side effects
  • CNS Depression, like drowsiness and ataxia
  • Disorientation/Depression
• Risk for misuse, so they can be dangerous, triggering physical dependence & a predictable abstinence syndrome, after abrupt discontinuation - A slow 25% dosage reduction taper is recommended

Treatment - Social Anxiety Disorder

• Goal:
  • Reduce anxiety symptoms (fast HR), social anxiety, phobic avoidance
• After the acute phase, goal is to enhance therapeutic benefits and improve quality of life
  • Even small reductions in avoidance and discomfort are valued
• Long-Term Goal:
  • Remission with end of core symptoms & no functional impairment or concurrent depressive symptoms

Antidepressant

• SSRIs and Venlafaxine are for patients with depression but are safe even in SUD
  • Main drugs of this class: paroxetine, sertraline, fluvoxamine extended-release, and venlafaxine extended release - SSRIs are effective
    • May cause diarrhea, sex. dysfunction; consider with patients

General Approach

• Therapeutic options for Panic Disorder include pharmacologic agents, psychotherapy, or both
  • Those without agoraphobic avoidance (an anxiety disorder where one fears places and situations that might cause feelings of panic, entrapment, helplessness, or embarrassment) will improve on medications, for those that have it, Cognitive Behavioral therapy helps
• CBT & Pharmacotherapy helps those that have failed other types
• Teach the patient:
• About the medication delay
  • That it's not dangerous even when it worsens the condition/symptoms