Anxiety Spectrum Disorders
Introduction
Anxiety is an emotional state that is part of the general condition.
- It can be useful in focusing attention during times of perceived threats (internal or external), stimulating appropriate and adaptive responses and ultimately improving function.
- If the anxiety becomes prolonged, excessive or out of proportion to the stimulus, it can become maladaptive and impair function.
Anxiety disorders can occur in isolation, be co-morbid with other psychiatric disorders (particularly depression), be a consequence of physical illness such as thyrotoxicosis or be drug-induced (e.g. by caffeine).
- Co-morbidity with other psychiatric disorders is very common.
- These disorders tend to be chronic, and treatment is often partially successful.
- People with anxiety disorders may be especially prone to adverse effects. High initial doses of SSRIs in particular may be poorly tolerated, for example.
Psychological Approaches
Psychological therapies are the foundational first-line treatment for anxiety spectrum disorders. Examples include
- Cognitive behavioural therapy in generalized anxiety disorder and panic disorder
- Exposure therapy in OCD and social phobia.
Some studies suggest that optimal outcome is achieved by combining psychological and drug therapies, but negative studies also exist.
- Initial drug therapy may be required to help the patient become more receptive to psychological input.
Benzodiazepines
Benzodiazepines provide rapid symptomatic relief from acute anxiety states.
- Nearly all guidelines and consensus statements recommend that this group of drugs should be used only to treat anxiety that is severe, disabling, or subjecting the individual to extreme distress.
- Because of their potential to cause physical dependence and withdrawal symptoms, these drugs should be used at the lowest effective dose for the shortest period of time (maximum 4 weeks), while longer-term treatment strategies are put in place.
In the UK, NICE recommends that benzodiazepines should not be used to treat panic disorder.
- In other countries, alprazolam is widely used for this indication.
SSRIs
When treating generalised anxiety disorder (GAD), panic disorder, post -traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), an SSRI should be used as first-line treatment.
- An early network meta-analysis suggested that fluoxetine is the most effective SSRI in GAD and sertraline the best tolerated. More recent analyses suggest that bupropion or agomelatine is the most effective drug in GAD. Neither analysis found clear effects over placebo for lorazepam or vortioxetine.
- Nonetheless, the selection of a specific SRI is based on side-effect profile, drug-drug interactions, treatment history and patient preference.
- Typically, SSRI are started at the lowest initial dose and slowly titrated up to avoid initial insomnia, agitation or other early side effects.
- All patients treated with SSRIs should be monitored for development of akathisia, increased anxiety and the emergence of suicidal ideation.
SSRIs should not be stopped abruptly, as patients with anxiety spectrum disorders are particularly sensitive to discontinuation symptoms.
- The dose should be reduced as slowly as tolerated over several months.
NOTE: In generalized anxiety disorder, SNRIs (e.g. venlafaxine and duloxetine) and pregabalin are second and third choices, respectively.
Complementary Treatment
Aerobic exercise, mindfulness-based stress reduction, and yoga have been shown to be effective augmenting treatments for patients with GAD.
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