Generalized Anxiety Disorder, Panic Disorder, and Social Anxiety Disorder

Generalized Anxiety Disorder, Panic Disorder,
        and Social Anxiety Disorder

   Anxiety is a normal response to stress or fear.
   Anxiety symptoms generally are short-lived and
   do not necessarily impair function.
   Anxiety that become excessive, causes irrational
   thinking or behavior and impairs a person’s
   functioning is considered an anxiety disorder.

•   Clinical presentation:
•   Restlessness
•   Easily fatigued
•   Poor concentration
•   Irritability
•   Muscle tension
•   Insomnia or unsatisfying sleeping

Treatment of Generalized Anxiety Disorder

• Non-pharmacologic Therapy
• Psychoeducation
• Ecercise
• Stress management
• Psychotherapy
Psychoeducation includes instructing patient to avoid
  stimulating agents such as caffeine, decongestants, diet
  pills, and excessive alcohol use
Cognitive behavioral therapy helps patients to recognize
  and alter patterns of distorted thinking and
  dysfunctional behavior

• Pharmacological Therapy
• The drugs of choice are the antidepressants
• Benzodiazepines remain the most effective and commonly
  used treatment for short term management of anxiety
  where immediate relief of symptoms is desired
• Buspirone (partial 5-HT agonist) and pregabalin
  (presynaptic modulator of excessive excitatory
  neurotransmitter e.g. glutamate release) are alternative
  agents for patients with generalized anxiety disorder
  without depression
• Patients with generalized anxiety disorder must be treated
  to remission of symptoms ( usually from 3 to 18 months)

• Antidepressants include:
• Citalopram (SSRI)
• Escitalopram (SSRI)
• Fluoxetine (SSRI)
• Paroxetine (SSRI)
• Sertraline (SSRI)
• Venlafaxine ( SNRI)
• Duloxetine ( SNRI)
• Tricyclic antidepressants (Imipramine)
Side effects:
For SSRI (sexual dysfunction i.e delayed orgasm or even absent orgasm), CNS
    stimulation (nervousness and insomnia) and GI distrubances (e.g. nausea and
    diarrhea)
For tricyclic antidepressants
Sedation, ant-cholinergic effect, cardivascular adverse effects (quinidine like effects i.e
    cardiac depressant effect.

• For SNRIs
• Similar to those of SSRIs
• High doses can cause elevation of blood
  pressure.
• As a role doluxetine should not be prescribed
  to patients with extensive alcohol use or
  evidence of chronic liver disease owing to the
  potantialty of liver injury (hepatotoxic)

• Mirtazapine (alpha2 adrenergic antagonist
  and post synaptic serotonin receptor
  antagonist)
• Side effects
Sedation, weight gain

Treatment of Panic Disorder
The main objectives of treatment are to reduce
the severity of panic attacks, reduce
       anticipatory anxiety and agoraphobic
  behavior
• Treatment options include medications,
  psychotherapy or a combination of both.
• In some cases, pharmacotherapy will follow
  psychotherapy when full response is not realized.
• Patients with panic disorder without agoraphobia
  may respond to pharmacotherapy alone

• Agoraphobic symptoms usually take longer time to respond than
  panic symptoms.
• The acute phase of panic disorder treatment lasts about 12 weeks
• Non-pharmacologic therapy:
• Like that of generalized anxiety disorder
• Pharmacologic Therapy
• Tricyclic antidepressants
• SSRIs
• SNRIs
• MAOIs
• Benzodiazepines
• B-blockers (pindolo) is effective as adjunctive therapy with SSRIs

• Treatment Of Social Anxiety Disorder:
• Symptoms of this disorder include fear of social
  situations and phobic behaviors
• Treatment aims at restoring the social functioning and
  improve the patients quality of life
• Nonpharmacologic Therapy:
• Patient education on disease course, treatment
  options, and expectations is essential
• Support groups may be beneficial for some patients

•   Pharmacologic therapy:
•   SSRIs (drug of choice)
•   Benzodiazepines
•   Gabapentin
•   Pergabaline
•   B-blockers (useful for reducing performance
    anxiety)

Major Depressive Disorder
                (MDD)
• Major depressive disorder is a serious medical
  condition with a biologic foundation and respond
  to biological and psychological treatments
• Individuals that suffer from MDD experience
  pervasive symptoms that can affect mood,
  thinking, physical health, work and relationships.
• Suicide is often the result of MDD that has not
  been diagnosed and treated adequately

• Clinical presentation:
• Patient typically present with a combination of emotional, phsical
  and cognitive symptoms:
• 1-Emotional:
• Sadness
• Anhedonia (can not experience pleasure from activities that are
  enjoyable e.g hobbies, music, sexual activities or social interactions)
• Pessimism
• Feeling of emptiness
• Irritability
• Anxiety
• Worthlessness

•   Physical:
•   Disturbed sleep
•   Change in appetite/ weight
•   Decreases energy
•   Fatigue
•   Bodily aches and pains
•   Cognitive:
•   Impaired concentration
•   Indecisveness
•   Poor memory

• Symptoms of major depressive episode usually develop
  over days or weeks, but mild depressive and anxiety
  symptoms may last for days or months prior to the
  onset of the full syndrome.
• Nonpharmacologic Therapy:
• Interpersonal therapy
• Cognitive therapy
• Electroconvulsive therapy (highly effective but
  confusion and memory impairment may result as a
  side effects)
• Light therapy but lead to eye strain, headach, insomnia
  and hypomania.

• Pharmacologic Therapy
• Antidepressants
• A combination of pharmacologic and
  nonpharmacologic treatment insure more good
  results than any individual therapy.
• Each antidepressant has a response rate of
  approximately 60-80% and no one or class has
  been shown to be more efficacious than another.
• Various factors must be taken in consideration
  when selecting antidepressant therapy for an
  individual patient:

• 1-the patient history of response (including
  efficacy and side effects)
• 2-The potential drug-drug interactions
• 3-The presence of comorbid psychiatric
  condition e.g for a patient who suffer from
  MDD and panic disorder, SSRI is a good choice
• 4-The patient must be willing and able to
  comply with dosing schedule (e,g upward
  titration of tricyclic antidepressants)

• Duration of therapy:
• Three phase of treatment : Acute, continuation, and
   maintenance
• The acute phase aims at attaining remission
(6-12 weeks)
The continuation phase aims at prevention of relapse
(additional 4-9 months)
Maintenance phase to prevent recurrence (development
   of future episode)
(last for years and may be for lifetime)