Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Treatment of Anxiety Disorders        time to onset of effects Antidepressant drugs are used totreat anxiety disorders. T...
Anxiety Disorders   Panic Disorder (PD)   Obsessive Compulsive Disorder (OCD)   Social Anxiety Disorder (Social Phobia)...
Neurotransmitters Implicated inAnxiety   Gamma-amino butyric acid (GABA)     GABA-benzodiazepine receptor complex   Nor...
Anxiolytic Drugs   Discovery     meprobamate (1954)     chlordiazepoxide (1957)       First of many benzodiazepines
Panic Disorder   With and without agoraphobia   Panic attacks (unexpected)   Anticipatory anxiety   Generalized anxiet...
Pharmacologic Treatment of PanicDisorder   Antidepressants (latency to onset of effects)     TCAs - imipramine, clomipra...
Adverse Effects   SSRI/SNRI       Activation - may cause initial jitteriness             Gradual dose escalation recomm...
Non-pharmacologic Treatment of PanicDisorder   Cognitive Behavioral Therapy (CBT)   Frequently, pharmacologic treatment ...
Obsessive Compulsive DisorderCommon Obsessions     Common Compulsions Contamination        Checking Aggression         ...
Treatment of OCD   Drugs that increase synaptic serotonin
Treatment of OCDserotonin reuptake inhibitors (SRIs)                      clomipramine (Anafranil®) [a tricyclic]Approved...
Treatment of OCD   Full effects of drug treatment may take 10-12 weeks   Cognitive Behavioral Therapy (CBT) is effective...
Social Anxiety Disorder   Generalized       Nearly all social situations   Discrete       Performance anxiety
Treatment of Social Anxiety Disorder   SSRI/SNRI   High potency benzodiazepine (BZD)       alprazolam       clonazepam...
Post-traumatic Stress Disorder (PTSD)   Traumatic event   Re-experiencing the event       Recall, flashback, dreams    ...
Treatment of PTSD   SSRI - sertraline and paroxetine approved   Off label treatments     Beta blockers to ⇩ autonomic a...
Treatment of Generalized AnxietyDisorder (GAD)   Benzodiazepines   buspirone (Buspar®)   Antidepressants       TCA (e....
GABA-A Receptor   Endogenous ligand is GABA       GABA is the major inhibitory CNS        neurotransmitter       Opens ...
GABA-BZD receptor complex   Benzodiazepines     Allosterically modulate the GABA receptor     Potentiate the effect of ...
Benzodiazepine Indications   GAD   Panic Disorder   EtOH withdrawal   Hypnotic   Anticonvulsant       diazepam, lora...
Examples of benzodiazepinesAnxiolytics        Brand name   Dose rangechlordiazepoxide   (Librium®)   10-100 mgdiazepam    ...
Benzodiazepine Adverse Effects   Sedation       Effect exploited for use as hypnotics   Amnesia       Particularly wit...
Benzodiazepine Intoxication/Overdose   Intoxication is similar to alcohol       Sedation       Psychomotor impairment  ...
Benzodiazepine Withdrawal   Anxiety/agitation   Sleep disturbance   Myoclonic jerks   Sensory disturbances       Pare...
Drug-drug interactions   Potentiation of CNS depressants   BZDs increase the half-life of digoxin   Increase BZD levels...
Benzodiazepine antagonist   flumazenil (Romazicon®)       Reverses effects of drugs acting at the benzodiazepine        ...
Non-benzodiazepine Treatments forAnxiety   buspirone (Buspar®)   SSRI   SNRI       venlafaxine (Effexor®)       dulox...
Non-benzodiazepine Treatments forAnxiety   buspirone   clonidine
buspirone   Presynaptic 5-HT1A full agonist       Hypothesized 5-HT excess     ⇩ Neuronal firing     ⇩ 5-HT synthesis...
buspirone   Unlike BZD   Absence of:       Sedation       Muscle relaxant properties       Anticonvulsant effects    ...
buspirone   May be preferred for       Elderly       Patients with medical conditions   May improve sexual dysfunction...
buspirone adverse effects   Dizziness   Headache   Nausea   Nervousness   Lightheadedness   Agitation
clonidine   Alpha-2 agonist
clonidine   NE overactivity can cause anxiety    symptoms   Alpha-2 antagonists cause ⇧ NE   Alpha-2 agonist can be anx...
Hypnotics     OTC – diphenhydramine*     TCA*     trazodone (Desyrel®)*     doxepin (Silenor®) H1 antagonist*     Ben...
Examples of Benzodiazepine andNon-benzodiazepine Hypnotics               Benzodiazepine         flurazepam (Dalmane®)    ...
2. treatment of_anxiety_disorders_angel_
Upcoming SlideShare
Loading in …5
×

2. treatment of_anxiety_disorders_angel_

1,102 views

Published on

Published in: Health & Medicine

2. treatment of_anxiety_disorders_angel_

  1. 1. Treatment of Anxiety Disorders time to onset of effects Antidepressant drugs are used totreat anxiety disorders. These drugshave a latency to onset of clinicallymeaningful effects, typically 3 to 4weeks or longer Benzodiazepines have a rapid onsetof effect (30 minutes to one hour)
  2. 2. Anxiety Disorders Panic Disorder (PD) Obsessive Compulsive Disorder (OCD) Social Anxiety Disorder (Social Phobia) Post-traumatic Stress Disorder (PTSD) Generalized Anxiety Disorder (GAD) Specific Phobia (Simple Phobia)
  3. 3. Neurotransmitters Implicated inAnxiety Gamma-amino butyric acid (GABA)  GABA-benzodiazepine receptor complex Norepinephrine (NE)  Brainstem locus coeruleus Serotonin (5-hydroxytryptamine, 5-HT)
  4. 4. Anxiolytic Drugs Discovery  meprobamate (1954)  chlordiazepoxide (1957)  First of many benzodiazepines
  5. 5. Panic Disorder With and without agoraphobia Panic attacks (unexpected) Anticipatory anxiety Generalized anxiety Avoidance (agoraphobia) Somatic symptoms
  6. 6. Pharmacologic Treatment of PanicDisorder Antidepressants (latency to onset of effects)  TCAs - imipramine, clomipramine  MAOIs  SSRI/SNRI - first choice for many patients Benzodiazepines (rapid onset of effects)  First choice if rapid effect needed  alprazolam (Xanax®)  clonazepam (Klonopin®) Combinations
  7. 7. Adverse Effects SSRI/SNRI  Activation - may cause initial jitteriness  Gradual dose escalation recommended  Sexual dysfunction  Gastrointestinal side effects  Withdrawal syndrome Benzodiazepines  Sedation  Potentiation of alcohol, other CNS depressants  Dependence  Psychomotor impairment, Ataxia  Amnesia  Withdrawal syndrome
  8. 8. Non-pharmacologic Treatment of PanicDisorder Cognitive Behavioral Therapy (CBT) Frequently, pharmacologic treatment and CBT are used in combination
  9. 9. Obsessive Compulsive DisorderCommon Obsessions Common Compulsions Contamination  Checking Aggression  Cleaning/washing Religious  Counting/Mental rituals Safety/harm  Repeating Need for symmetry  Ordering/arranging Somatic fears  Hoarding
  10. 10. Treatment of OCD Drugs that increase synaptic serotonin
  11. 11. Treatment of OCDserotonin reuptake inhibitors (SRIs)  clomipramine (Anafranil®) [a tricyclic]Approved for OCD  fluoxetine (Prozac®)  fluvoxamine (Luvox®)  paroxetine (Paxil®) SSRIs  sertraline (Zoloft®)  *citalopram (Celexa®)  *escitalopram (Lexapro®)  *SNRI antidepressants are also used *Off label use
  12. 12. Treatment of OCD Full effects of drug treatment may take 10-12 weeks Cognitive Behavioral Therapy (CBT) is effective Combination (CBT + drug therapy) may be better Treatment is usually chronic Partial responders often receive augmentation with atypical antipsychotic drugs (not an approved indication for these drugs)
  13. 13. Social Anxiety Disorder Generalized  Nearly all social situations Discrete  Performance anxiety
  14. 14. Treatment of Social Anxiety Disorder SSRI/SNRI High potency benzodiazepine (BZD)  alprazolam  clonazepam MAOIs Beta blockers for performance anxiety  propranolol 10-40 mg one hour before  Reduces sympathetic symptoms (sweating, tremor) +CBT
  15. 15. Post-traumatic Stress Disorder (PTSD) Traumatic event Re-experiencing the event  Recall, flashback, dreams  Intense psychological distress with exposure Avoidance Increased arousal
  16. 16. Treatment of PTSD SSRI - sertraline and paroxetine approved Off label treatments  Beta blockers to ⇩ autonomic arousal  Li+ and antiepileptic drugs  development of PTSD resemblance to “kindling”  cf. Bipolar Disorder treatments
  17. 17. Treatment of Generalized AnxietyDisorder (GAD) Benzodiazepines buspirone (Buspar®) Antidepressants  TCA (e.g., imipramine)  SSRI  SNRI (venlafaxine, duloxetine)
  18. 18. GABA-A Receptor Endogenous ligand is GABA  GABA is the major inhibitory CNS neurotransmitter  Opens the Cl- ionophore  Inhibits neuronal firing The GABA-Benzodiazepine receptor complex  Ligand-gated ion channel  Selectively conducts Cl- through its pore  causes hyperpolarization of the neuron
  19. 19. GABA-BZD receptor complex Benzodiazepines  Allosterically modulate the GABA receptor  Potentiate the effect of GABA Other substances bind this receptor complex  e.g., EtOH, barbiturates Benzodiazepines increase the frequency of the chloride ion channel opening at the GABAA receptor Barbiturates increase the duration of chloride ion channel opening at the GABAA receptor
  20. 20. Benzodiazepine Indications GAD Panic Disorder EtOH withdrawal Hypnotic Anticonvulsant  diazepam, lorazepam Preanesthetic, procedural sedation  midazolam, lorazepam
  21. 21. Examples of benzodiazepinesAnxiolytics Brand name Dose rangechlordiazepoxide (Librium®) 10-100 mgdiazepam (Valium®) 2-20 mgalprazolam (Xanax®) .75-10 mglorazepam (Ativan®) .5-10 mgHypnoticsflurazepam (Dalmane®) 15-30 mgtriazolam (Halcion®) .125-.25mg
  22. 22. Benzodiazepine Adverse Effects Sedation  Effect exploited for use as hypnotics Amnesia  Particularly with triazolam  Effect exploited for use in anesthesia (midazolam) and conscious sedation/procedural sedation Psychomotor impairment, Ataxia Potentiation of alcohol, other CNS depressants Risk for dependence Withdrawal syndrome
  23. 23. Benzodiazepine Intoxication/Overdose Intoxication is similar to alcohol  Sedation  Psychomotor impairment  Dizziness/Ataxia  Amnesia Overdose  All of the above  Confusion/agitation  Severe sedation/lethargy  Respiratory depression  Unresponsiveness
  24. 24. Benzodiazepine Withdrawal Anxiety/agitation Sleep disturbance Myoclonic jerks Sensory disturbances  Paresthesias Muscle cramps Dizziness After high dose usage, withdrawal may include:  Seizures  Delirium
  25. 25. Drug-drug interactions Potentiation of CNS depressants BZDs increase the half-life of digoxin Increase BZD levels  cimetidine, disulfiram, isoniazid, estrogen  Inhibit metabolism  fluvoxamine ⇧ alprazolam levels (CYP3A4) Decrease BZD levels  Antacids ⇩ absorption  Tobacco, rifampin (enzyme induction)
  26. 26. Benzodiazepine antagonist flumazenil (Romazicon®)  Reverses effects of drugs acting at the benzodiazepine receptor  does not antagonize the central nervous system effects of drugs affecting GABA-ergic neurons by means other than the benzodiazepine receptor; e.g., ethanol, barbiturates, or general anesthetics)  does not reverse the effects of opioids  used to reverse BZD conscious sedation  may be useful in suspected BZD overdose  Onset 1-2 minutes; duration of effect 4-5 hours
  27. 27. Non-benzodiazepine Treatments forAnxiety buspirone (Buspar®) SSRI SNRI  venlafaxine (Effexor®)  duloxetine (Cymbalta®) clonidine (Catapres®)
  28. 28. Non-benzodiazepine Treatments forAnxiety buspirone clonidine
  29. 29. buspirone Presynaptic 5-HT1A full agonist  Hypothesized 5-HT excess  ⇩ Neuronal firing  ⇩ 5-HT synthesis Postsynaptic partial agonist  With 5-HT excess, acts as antagonist  With 5-HT deficit, acts as agonist No effects on BZD-GABA receptor complex
  30. 30. buspirone Unlike BZD Absence of:  Sedation  Muscle relaxant properties  Anticonvulsant effects  Abuse potential  Psychomotor performance impairment
  31. 31. buspirone May be preferred for  Elderly  Patients with medical conditions May improve sexual dysfunction secondary to SSRI May be antidepressant in higher doses Slower onset than BZD  Full effect may take days to weeks
  32. 32. buspirone adverse effects Dizziness Headache Nausea Nervousness Lightheadedness Agitation
  33. 33. clonidine Alpha-2 agonist
  34. 34. clonidine NE overactivity can cause anxiety symptoms Alpha-2 antagonists cause ⇧ NE Alpha-2 agonist can be anxiolytic Especially on adrenergic symptoms  Tachycardia  Sweating  Tremor
  35. 35. Hypnotics  OTC – diphenhydramine*  TCA*  trazodone (Desyrel®)*  doxepin (Silenor®) H1 antagonist*  Benzodiazepines  Non-benzodiazepine  Similar GABAergic mechanism  ramelteon (Rozerem®)*  melatonin agonist *Not a controlled substance
  36. 36. Examples of Benzodiazepine andNon-benzodiazepine Hypnotics Benzodiazepine  flurazepam (Dalmane®)  temazepam (Restoril®)  triazolam (Halcion®) Non-benzodiazepine  zolpidem (Ambien®)  zaleplon (Sonata®)  zopiclone (Imovane®)  eszopiclone (Lunesta®)

×