Treatment of Anxiety Disorders

Summary

Remember lots of these diagnosis overlap.

Treatment Options

Exposure - studied extensively, works in most instances, results in a graded reduction of discomfort.

When you reduce anxiety you reinforce the preceding stimuli. Removal of a negative state is a positive reinforcer.
the advantage of behavioral treatment over medications is that there are less relapses when therapy is stopped.

Benzodiazepines - equal in effectiveness to SSRI’s except for OCD and PTSD

need to be on a regular dosing schedule, PRN dosing re-enforces pill-taking behavior.

chronic benzodiazapines recipients are less likely to experience cognitive impairment from single dose
chronic benzodiazapines users rarely increase their dose over time (usually decreased or the same)
always taper off benzodiazapine therapy (rate is the key, 2 months is usually enough)

Buspirone - ideal medication because it is anxioseletive without drug interactions (EtOH too) or abuse potential

Anti-Depressants

anti-depressant effect is independent of other effects of drugs (may relieve anxiety and not depression)
only anti-depressants with Serotonin effects; have anti-obsessive, anti-phobic, and anti-anxiety effects.

need a 5HT/NE ratio >1, the more serotonin selective the greater the anti-obsessive effect

TCA’s - tertiary amines work well, avoid secondary amines
Atypical anti-depressants - avoid Wellbutrin because it doesn’t have 5HT effects
SSRI’s - very popular, increases anxiety the first week then reduces it.

choose which SSRI by which p450 isoenzyme it inhibits (avoid drug-drug interactions) and by side effect profile (activating SSRI or depressing SSRI depending on patient’s symptoms)

Medication Selection

should be tailored to patient, bear in mind side effects, drug interactions, co-morbidities (suicide risk and TCAs)
trial with anti-depressants should last at least 8 weeks to be sure that the drug has had (or not had) an effect