Anxiety pdf

Click here to learn more about phobias and how they develop. Agoraphobia: This is a fear and avoidance of places, events, or situations from which it may be difficult to escape or in which help would not be available if a person becomes trapped. People often misunderstand this condition as a phobia of open spaces and the outdoors, but it is not so simple. A person with agoraphobia may have a fear of leaving home or using elevators and public transport. Click here to learn about agoraphobia, an often-misunderstood psychological disorder.

Selective mutism: This is a form of anxiety that some children experience, in which they are not able to speak in certain places or contexts, such as school, even though they may have excellent verbal communication skills around familiar people.

It may be an extreme form of social phobia. Social anxiety disorder, or social phobia: This is a fear of negative judgment from others in social situations or of public embarrassment. Social anxiety disorder includes a range of feelings, such as stage fright, a fear of intimacy, and anxiety around humiliation and rejection.

This disorder can cause people to avoid public situations and human contact to the point that everyday living is rendered extremely difficult. Click here to learn all you need to know about social anxiety disorder. Separation anxiety disorder: High levels of anxiety after separation from a person or place that provides feelings of security or safety characterize separation anxiety disorder.

Separation might sometimes result in panic symptoms. Learn all about separation anxiety by clicking here. The causes of anxiety disorders are complicated. Many might occur at once, some may lead to others, and some might not lead to an anxiety disorder unless another is present. To learn more about the causes and diagnosis of anxiety disorders, click here.

Alcohol dependence, depression , or other conditions can sometimes have such a strong effect on mental well-being that treating an anxiety disorder must wait until any underlying conditions are brought under control.

In some cases, a person can treat an anxiety disorder at home without clinical supervision. However, this may not be effective for severe or long-term anxiety disorders. There are several exercises and actions to help a person cope with milder, more focused, or shorter-term anxiety disorders, including:.

A standard way of treating anxiety is psychological counseling. This can include cognitive-behavioral therapy CBT , psychotherapy, or a combination of therapies. This type of psychotherapy aims to recognize and change harmful thought patterns that form the foundation of anxious and troublesome feelings. In the process, practitioners of CBT hope to limit distorted thinking and change the way people react to objects or situations that trigger anxiety.

For example, a psychotherapist providing CBT for panic disorder will try to reinforce the fact that panic attacks are not really heart attacks. Exposure to fears and triggers can be a part of CBT. This encourages people to confront their fears and helps reduce sensitivity to their usual triggers of anxiety. Medicines that might control some of the physical and mental symptoms include antidepressants , benzodiazepines, tricyclics, and beta-blockers. A doctor may prescribe these for certain people with anxiety, but they can be highly addictive.

These drugs tend to have few side effects except for drowsiness and possible dependence. Diazepam, or Valium, is an example of a commonly prescribed benzodiazepine. These commonly help with anxiety, even though they also target depression.

People often use serotonin reuptake inhibitors SSRI , which have fewer side effects than older antidepressants but are likely to cause jitters, nausea, and sexual dysfunction when treatment begins.

The onset of efficacy is earlier than with antidepressants. A new antidepressant, vortioxetine, was investigated in several controlled studies in GAD. However, according to a meta-analysis, significant improvement for vortioxetine could not be demonstrated compared with placebo. The comparison studies only used low doses of the comparators, eg, 20 mg paroxetine per day 66 or one tablet of lorazepam 0.

Studies with Kava-kava Piper methysticum showed inconsistent results, 70 - 72 and the extract was been withdrawn from the market in some countries due to hepatotoxicity in some preparations. Valerian extract was not effective in placebo-controlled studies in anxious patients. Some other phytotherapeutics have been investigated in individuals with anxiety conditions. Due to the low quality of these studies, the evidence for the investigated products is not sufficient for a review, see Sards et al Standardization may be an issue in herbal preparations.

For example, it was shown that different preparations of St. John's wort exhibited large differences in the content of the putatively effective ingredients. In a meta-analysis of all available drug studies in anxiety disorders, 77 the pre -post effect sizes of the different drugs were determined. We simply looked at the absolute difference in anxiety scale scores before and after treatment, without regard to the relative efficacy compared with placebo.

This approach makes it possible to include hundreds of studies in comparisons of differential efficacy of all available drugs and not only the few direct head-to-head comparisons.

From the patients' point of view, the improvement in anxiety symptoms as measured by the change from baseline to end point is more relevant than the difference from a control group. The available medications for anxiety disorders showed considerably large differences in pre-post effect sizes.

Quetiapine, however, is not licensed for the treatment of any anxiety disorder in most countries. However, these drugs are not recommended for routine treatment.

Patients must be informed about possible adverse effects, interactions, safety warnings, and contraindications, as indicated in the current summary of product characteristics.

If patients are educated about the possibility that some early side effects might later decrease in intensity, compliance may improve. Patients with anxiety disorders are often hesitant to take psychotropic drugs because they are afraid of adverse effects.

In particular, patients with PDA may easily discontinue antidepressants because of initial jitteriness and nervousness. Doses for drug treatments are shown in Table II. In patients with severe hepatic impairment, a dosage adjustment or use of medications that are cleared primarily by the kidney eg, pregabalin may be required.

For all drugs recommended in this article, relapse prevention studies in at least one anxiety disorder have been conducted in patients who have responded to previous open treatment with a certain drug and were then randomized to placebo or ongoing blind treatment with the same drug for periods of between 6 and 18 months. All of these studies showed a significant advantage for staying on active medication when compared with switching to placebo.

Based on the findings from these relapse prevention studies and clinical experiences, drug treatment should be continued for 12 months or more after remission has occurred. Given the chronic course of anxiety disorders, it is regrettable that there are almost no controlled studies that investigate treatment periods over 12 months.

To avoid withdrawal syndromes, the dose should be slowly tapered off over a period of 2 weeks at treatment termination. It is a common opinion that patients treated with drugs show immediate relapse after stopping medication, whereas gains of psychological therapies are maintained for months or years after treatment termination.

This would offer psychological therapies considerable advantage over drug treatment. However, in naturalistic studies following up anxiety patients, substantial relapse rates were also found years after CBT treatment.

When treating anxiety disorders with medications, drug interactions have to be monitored. Additive CNS depression may occur when drugs with sedating properties are combined, eg, TCAs, benzodiazepines, or pregabalin, resulting in unwanted sedation, drowsiness, or increased reaction time.

Additive effects at the neurotransmitter level can occur when medications are combined that have antagonistic effects on the same receptors, eg, two drugs with anticholinergic effects. Before considering a patient to be treatment unresponsive, it should be ascertained that the diagnosis was correct, adherence to the treatment plan was sufficient, the dose prescribed had covered the full range, and there had been a trial period of adequate duration.

When patients report previous treatment failures, it often turns out that a drug was only prescribed in the lowest dose or was stopped within the first 2 weeks due to side effects that occurred in the initial phase before the patient could experience improvement.

Concurrent drugs may interfere with efficacy, eg, metabolic inhibitors or enhancers. Psychosocial factors may affect response, and comorbid personality or substance abuse disorders are especially likely to complicate anxiety disorders. When initial treatment fails, the physician has to decide when to change the treatment plan. There have been few systematic trials of treatment-refractory patients with anxiety disorders. If after treatment at what is considered an adequate dose for 4 to 6 weeks a patient shows no response, the medication should be changed.

If partial response is seen after this period, there is still a chance that the patient will respond after another 4 to 6 weeks of therapy with increased dosages. For some antidepressants, the studies on a potential dose-response relationship are inconclusive, perhaps due to the lack of statistical power for showing a difference between lower and higher doses.

According to clinical experience, however, a trial with a higher dose in patients with insufficient response is warranted. Elderly patients may take longer to show a response. Table III contains options in case of drug inefficacy or intolerance. In patients who are unresponsive to psychotropic drugs, the addition of CBT is generally recommended. A combination of antidepressants and benzodiazepines is sometimes used in treatment-refractory cases. When all standard treatments have failed, the off-label use of drugs may be considered, for example, drugs licensed for another anxiety disorder or that are not licensed but have shown efficacy in clinical studies.

Such drugs include quetiapine and agomelatine. With the exception of GAD, anxiety disorders are less common in patients over 65 years of age. Therefore, only a few studies for the treatment of GAD have been performed with older patients. Controlled studies have shown the efficacy of duloxetine, venlafaxine, pregabalin, and quetiapine in patients over 65 years old. In the elderly, effect sizes for CBT tend to be somewhat smaller than those found in mixed-age populations. There are some randomized, placebo-controlled studies of pharmacotherapy for anxiety disorders in children and adolescents showing efficacy of sertraline, fluoxetine, and duloxetine in young patients with GAD, of venlafaxine and paroxetine in SAD, and of sertraline, fluvoxamine, and fluoxetine in mixed samples, including patients with separation anxiety disorder, GAD, and SAD.

There had been concerns about increased risk for suicidal ideation not suicides in children and adolescents treated for major depression with SSRIs escitalopram, citalopram, paroxetine, and sertraline , mirtazapine, and venlafaxine.

For children and youths with separation anxiety disorder, several treatment studies exist. There is also a paucity of treatment studies for children with selective mutism. Small studies have shown that psychotherapeutic approaches were at least better than waitlist controls. For pregnant women, the risk of an untreated anxiety disorder must be weighed against the risk of damage to the unborn child as a result of treatment. A large study suggested no substantial increase in the risk of cardiac malformations attributable to antidepressant use during the first trimester.

In such cases, CBT should be considered as an alternative to medication treatment. All patients with anxiety disorders require supportive talks and attention to the emotional problems that are associated with the anxiety disorder.

Psychoeducation includes information about the physiology of the bodily symptoms of anxiety reactions and the rationale of available treatment possibilities. Many patients may require formal psychological treatment interventions, which are mostly done on an outpatient basis. The treatment of anxiety disorders by CBT is described in more detail in the article by Borza in this issue of Dialogues in Clinical Neuroscience p The efficacy of CBT for all anxiety disorders has been shown in a large number of controlled studies.

If avoidance of feared situations is a relevant factor in phobic disorders, exposure techniques should be included in the treatment schedule, in which patients are confronted with their feared situations.

In comparison with CBT the evidence for psychodynamic therapy is weaker. For specific phobias, there are only studies with behavioral therapy, which should be performed as exposure treatment. In the available treatment studies, it was shown that only a few sessions eg, one to five were necessary for effective treatment of specific phobias.

In recent years, many studies have investigated psychological therapies that are performed via the Internet, usually involving minimal or no contact with a therapist. However, at present, evidence is lacking that these treatments are as effective as individual CBT with face-to-face contact.

They are also less expensive than face-to-face psychotherapies. Both psychotherapy and pharmacotherapy have been shown to be more effective than control groups. Therefore, our research group conducted a large meta-analysis of all available controlled short-term studies for anxiety disorders and compared the pre-post effect size differences before and after treatment between medications and psychotherapies. It was also found that patients included in psychotherapy studies were less severely ill than those recruited for medication trials.

Moreover, it was shown that the average pre-post effect sizes for pill placebos were of similar strength to the gains achieved with psychotherapies. This surprising finding cannot be explained by heterogeneity, publication bias, or by allegiance effects.

However, this does not mean that psychotherapy is not helpful, as the average effect size obtained with psychotherapies is still strong—it only means that a placebo pill is a very powerful treatment, at least for the first weeks or months of treatment. Nevertheless, patients should be informed about the relative efficacy of the treatment options they are offered.

However, only a few combination studies were available for this comparison, and some of these have not been conducted with the most powerful drugs. Exercise eg, aerobic training, such as jogging 5 km three times a week has been studied in PDA. However, it was found that exercise was less effective than clomipramine and no more effective than a control condition, relaxation.

Hypnosis, autogenic training, and biofeedback or complementary medicine methods such as acupuncture, osteopathy, or homeopathy are often recommended for the treatment of clinical anxiety.

However, controlled studies fulfilling at least basic methodological standards are lacking. Although controlled studies on the usefulness of self-help groups are lacking, patients should be encouraged to participate if appropriate. GAD and other anxiety disorders are the most prevalent mental disorders. A large amount of data available from randomized controlled trials permits the formulation of robust evidence-based recommendations for the treatment of GAD, PDA, and SAD.

In the past 3 years, B. Bandelow has served as a paid consultant to Lundbeck, Mundipharma, and Pfizer. He has received honoraria for lectures at scientific meetings and continuing medical education events from Lundbeck, Pfizer, and Servier and honoraria for scientific articles from Servier. National Center for Biotechnology Information , U. Journal List Dialogues Clin Neurosci v. Dialogues Clin Neurosci.

Author information Copyright and License information Disclaimer. All rights reserved. This article has been cited by other articles in PMC. Keywords: drug treatment , generalized anxiety disorder , panic disorder , psychotherapy , social anxiety disorder , treatment.

Introduction Anxiety disorders are the most prevalent psychiatric disorders and are associated with a high burden of illness. Diagnosis A short description of the anxiety disorders is given in Table I. Adapted from reference World Health Organization. Geneva, Switzerland: World Health Organization; Panic attacks can arise out of the blue; however, many patients start to avoid situations in which they fear that panic attacks might occur.

Agoraphobia F Fear of being alone is also common. Generalized anxiety disorder F Social Phobia F They are afraid of appearing clumsy, embarrassing themselves, or being judged negatively. Specific Isolated Phobias F Mixed Anxiety and Depressive Disorder F However, neither component is sufficiently severe to justify a diagnosis of anxiety or depression in itself. If the diagnostic criteria for anxiety or depression or both are fulfilled, then the corresponding diagnosis should be made, rather than mixed anxiety and depressive disorder.

Separation Anxiety Disorder of Childhood F In ICD, the disorder can only be diagnosed in children. Selective Mutism F Open in a separate window. Treatment Box 1 contains a case vignette of the treatment of a patient with GAD. Box 1. Case vignette: generalized anxiety disorder. Pharmacotherapy Whereas many studies have shown the efficacy of medications for GAD, PDA, and SAD, there are very few studies on drug treatment for specific phobias, for example, there is a small study suggesting the efficacy of paroxetine.

Pharmacological treatment recommendations for anxiety disorders in adults. Not all drugs are licensed for these indications in all countries.

Stepwise plan for drug treatment if the initial standard drug treatment was ineffective or was poorly tolerated. World Federation of Societies of Biological Psychiatry WFSBP guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders - first revision.

World J Biol Psychiatry. GAD - Ziprasidone SAD - Levetiracetam, topiramate, tranylcypromine; in refractory cases, addition of buspirone to an SSRI Switch to a drug or drug combination that has been reported to be effective in case reports PDA - The addition of lithium to clomipramine and the combination of valproate and clonazepam have been reported to be effective in refractory cases GAD, generalized anxiety disorder; PDA, panic disorder with agoraphobia; RCT, randomized controlled trial; SAD, social anxiety disorder also known as social phobia ; SNRI, selective serotonin norepinephrine reuptake inhibitors; SSRI, selective serotonin reuptake inhibitors; TCA, tricyclic antidepressant.

Tricyclic antidepressants The traditional tricyclic antidepressants TCAs imipramine and clomipramine are as effective as second-generation antidepressants in the treatment of anxiety disorders.

Buspirone Buspirone, a 5-hydroxytryptamine receptor 1A 5HT 1A agonist, has been shown in some controlled studies to be effective in the treatment of GAD. Benzodiazepines The anxiolytic effects of benzodiazepines begin soon after oral or parenteral application. Moclobemide Moclobemide is a selective and reversible inhibitor of monoamine oxidase A. Other drugs Some other drugs have shown efficacy in anxiety disorders in randomized controlled studies but are not licensed for the treatment of these disorders in most countries.

Agomelatine The antidepressant agomelatine—which acts as an agonist for melatonin MT 1 and MT 2 receptors and as an antagonist for serotonin 5-HT 2C receptors—was shown to be effective in four studies in GAD.

Quetiapine The atypical antipsychotic quetiapine was shown to be effective in a number of studies in GAD. Vortioxetine A new antidepressant, vortioxetine, was investigated in several controlled studies in GAD. Relative efficacy of drugs In a meta-analysis of all available drug studies in anxiety disorders, 77 the pre -post effect sizes of the different drugs were determined.

General treatment principles Patients must be informed about possible adverse effects, interactions, safety warnings, and contraindications, as indicated in the current summary of product characteristics.

Drug-drug interactions When treating anxiety disorders with medications, drug interactions have to be monitored.

Unresponsiveness to standard treatments Before considering a patient to be treatment unresponsive, it should be ascertained that the diagnosis was correct, adherence to the treatment plan was sufficient, the dose prescribed had covered the full range, and there had been a trial period of adequate duration. Pregnancy and breastfeeding For pregnant women, the risk of an untreated anxiety disorder must be weighed against the risk of damage to the unborn child as a result of treatment.

Psychotherapy All patients with anxiety disorders require supportive talks and attention to the emotional problems that are associated with the anxiety disorder. Combining psychotherapy and medication Both psychotherapy and pharmacotherapy have been shown to be more effective than control groups. Other treatment options Exercise eg, aerobic training, such as jogging 5 km three times a week has been studied in PDA. Conclusions GAD and other anxiety disorders are the most prevalent mental disorders.

Acknowledgments In the past 3 years, B. Kessler RC. Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. Wittchen HU. Eur Neuropsychopharmacol. Chisholm D. Lancet Psychiatry. Jacobi F. Results from the National Comorbidity Survey. Arch Gen Psychiatry. Dissertation topics of obstetrics and gynaecology. Case study on demand elasticity online essay writing tutorial? Case study on bipolar disorder.

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