1. ANXIETY DISCUSSION | 15 June 2016
JADE ABUDIA 1
ANXIETY
 Anxiety: Anemotional state causedbythe perceptionof real orperceiveddangerthat
threatensthe securityof anindividual,whomayexperience psychological andphysiologic
arousal
 Anxietydisorder: Mostfrequentmental disorderthatcan be uncomfortable anddebilitating
due to symptomsthatimpairsa patient’squalityof life
o AnxietySymptomscharacterizedby:
 autonomichyperactivity;vigilance
General AnxietyDisorder
 Excessive,unrealisticworryandanxietyforthe majorityof daysin six-monthperiod
 Psychological
o Examples: feelingkeyedup;poorconcentration
 Physical
o Examples:muscle tension;sleepdisturbance;irritability

2. ANXIETY DISCUSSION | 15 June 2016
JADE ABUDIA 2
 Medications:
o FirstLine/Non-Acute  SSRIorSNRI
 FDA ApprovedTx (Venlafaxine,Duloxetine,Escitalopram,Paroxetine)
 Initiate athalf the initial dose usedfordepression
o SecondLine (Non-Acute) Imipramine,Buspirone,Hydroxyzine,Pregabalin
o Acute  Benzodiazepines
Panic Disorder
 Series of unexpected(spontaneous) panicattacks involvinganintense,terrifyingfear
 Attack isfollowedby>1 monthof 1 (ormore) of the following:
o Persistentconcernaboutattack
o Consequencesof the attack
o Behavioral changes
 Medications:
o FirstLine (Non-Acute) SSRIor Venlafaxine
 FDA ApprovedTx (Venlafaxine,Fluoxetine,Sertraline,Paroxetine)
 Initiate athalf the initial dose usedfordepression
o SecondLine (Non-Acute)  Imipramine
o ThirdLine (Non-Acute) Benzodiazepines,Gabapentin,AtypicalAntipsychotics
o Acute  Benzodiazepines
Social AnxietyDisorder
 Persistentfearassociatedwith1(or more) social orperformance situations(6+months)
o Situationprovokesanxiety andpossiblepanicattack
o Fear isknownto be unreasonable andexcessive
o Situationis avoidedorenduredundermuchdistress
o Symptomsinterfere withdailyworkandsocial activities
 Medications:
o FirstLine (Non-Acute) SSRIor Venlafaxine
 FDA ApprovedTx (Venlafaxine,Sertraline,Paroxetine)
 Initiate athalf the initial dose usedfordepression
o SecondLine (Non-Acute)  Phenelzine,Buspirone,Clonazepam
o ThirdLine (Non-Acute) Gabapentin,Pregabalin
o Acute  Benzodiazepines
Post-Traumatic Stress Disorder
 Anxietydisorderthatmaydevelopafterexposuretoa terrifyingeventorordeal inwhichsevere
physical harmoccurredor wasthreatened
 Clinical Presentation:
o 1 re-experiencingsymptoms
o 2 avoidance symptoms
o 3 hyperarousal symptoms
 Medications:

3. ANXIETY DISCUSSION | 15 June 2016
JADE ABUDIA 3
o FirstLine (Non-Acute) SSRIor SNRI
 FDA ApprovedTx (Sertraline,Paroxetine)
 Paroxetine is approvedforacute treatmentof PTSD,whereassertraline is
approvedforacute and chronic treatmentof thisanxietydisorder
o SecondLine (Non-Acute)  TCA,Mirtazipine (BothasAugmentation)
o ThirdLine (Non-Acute) Phenelzine
Melton ST, Kirkwood CK. Chapter 53 in Dipiro JT et al. 9th ed.
Obsessive-CompulsiveDisorder
 Anxietydisordercharacterizedbyunreasonable thoughtsandfears(obsessions) thatleadto
repetitivebehaviors(compulsions);these behaviorsare time-consuming(>1hour/day) and
cause severe distress
o Obsession:Recurrent,persistentidea,thought,impulse orimage thatisexperiencedas
intrusive andinappropriate
o Compulsion:Repetitive behaviorormental act generallyperformedinresponse toan
obsession
 Cognitive behavioraltherapy(CBT) andSSRIare first-linetreatment.
 Medications:
o FirstLine (Non-Acute) SSRI
 FDA ApprovedTx (Sertraline,Paroxetine,Fluvoxamine,Fluoxetine)
 Dosesof antidepressantswill be higherthanotheranxietydisorders
o Second Line (Non-Acute)  Clomipramine
o ThirdLine (Non-Acute) Risperidone,Quetiapine orOlanzapine)
o FirstLine (Acute)  Benzodiazepines

4. ANXIETY DISCUSSION | 15 June 2016
JADE ABUDIA 4
Benzodiazepines
 Short half-lifeand/orhigh-potency:rapidacting(i.e.quicktocontrol symptoms);tolerance can
developrapidly;withdrawal iscommon
 Long half-life and/orlowpotency:longer-lastingeffects;withdrawal symptomscanoccur,but
are lesspronounced;“hangoversymptoms”;accumulationamongelderlypatients
 Adverse events:CNSdepression,confusion,disorientation,irritability,aggression,excitement,
memoryimpairment
 On BEERS list;cautioninelderlypatients  Lorazepam, Oxazepam andTemazepamare less
harmful
 Avoiduse inpregnancy:riskof cleftlipand/orpalate  If needed,diazepamand
chlordiazepoxide are preferredagents
 Taper 25% per weekuntil 50%of dose is reached,thendecrease by1/8 every4 to 7 days.
 Alprazolm(Xanax®)
o IntermediateOnset
o Short Durationof Action
o HighPotency
o Dosing:
 For Anxiety:IR:Initial:0.25-0.5 mg 3 times/day;titrate dose upwardevery3-4
days;usual maximum:4 mg/day
 For PanicDisorder: IR:Initial:0.5 mg 3 times/day;dose maybe increasedevery
3-4 daysin increments≤1mg/day.
 For PanicDisorder:ER: 0.5-1 mg once daily;mayincrease dose every3-4daysin
increments≤1mg/day
 Chlordiazepoxide(Librium®)
o IntermediateOnset
o Short-to-IntermediateDurationof Action
o Low Potency

5. ANXIETY DISCUSSION | 15 June 2016
JADE ABUDIA 5
o Chlordiazepoxideisusedforthe short-termmanagementof anxietydisorders,forthe
managementof acute alcohol withdrawal symptomsandforthe relief of pre-operative
apprehension
o Chlordiazepoxidedoesnotappeartoofferanyadvantagesoverdiazepam
o Dosing:
 For Anxiety:Mild-moderate anxiety:Usual dailydose:5-10mg 3-4 timesdaily;
severe anxiety:Usual dailydose:20-25 mg 3-4 timesdaily

 Diazepam(Valium®)
o RapidOnset
o Long Durationof Action
o Moderate Potency
o Dosing:
 For Anxiety:2to 10 mg 2 to 4 timesdailyif needed
 IM, IV:2 to 10 mg; may repeatin3 to 4 hours,if needed
o Since itis long-acting,itispreferredforsustained levelsof anxietywhileshorter-acting
benzodiazepinesare preferredforepisodicanxiety
 Lorazepam(Ativan®)
o IntermediateOnset
o IntermediateDurationof Action
o Moderate-to-HighPotency
o Dosing:
 For Anxiety:Initial: 2 to 3 mg daily in 2 to 3 divided doses; usual dose: 2 to 6 mg
daily in divided doses; however, daily dose may vary from 1 to 10 mg/day
 Lorazepamhas a shortereliminationhalf-life thandiazepam, withmetabolism
to inactive metabolites.Therefore,agingandliverorrenal diseaseshave little
effectonlorazepamdisposition.
 Clonazepam(Klonopin®)
o IntermediateOnset
o Long Durationof Action
o HighPotency
o Dosing:
 For Panic disorder: 0.25 mg twice daily; increase in increments of 0.125 to 0.25
mg twice daily every 3 days; target dose: 1 mg daily (maximum: 4 mg daily)
 Oxazepam(Serax®)
o Intermediate-to-SlowOnset
o Short-to-IntermediateDurationof Action
o Low Potency
o Dosing:
 For mild/moderate Anxiety:10-15mg 3-4 timesdaily
 For Severe Anxiety/Depression-basedAnxiety:15-30 mg 3-4 timesdaily
o Place intherapyisin the treatmentof anxietyinpatientswithhepaticdisease,since
accumulationof the drug inthese patientsisminimal
Buspirone

6. ANXIETY DISCUSSION | 15 June 2016
JADE ABUDIA 6
 Doesnot cause dependence,tolerance,abuse orwithdrawal
 It cannot be usedforshort-termrelief due todelayedonsetandlackof antidepressanteffect
o Dosing:
 Initial dose: 7.5 mg orally twice daily
 Dose titration: Increase by 5 mg/day at 2- to 3-day intervals as needed
 Usual dose: 20 to 30 mg daily, in divided doses 2 or 3 times daily
 Maximum dose: 60 mg/day
Hydroxyzine
o Riskof QTc prolongation
o Good alternative indrugaddiction
o Dosing:
 For Anxiety:50to 100 mg PO4 timesdaily
 50 to 100 mg IMimmediately,thenevery4to 6 hours as needed
Gabapentin(Neurontin®)
o Dosing:
 For Social Anxiety (Off-labelUse):300 mg twice daily;increase dose basedon
response andtolerabilityinincrementsof nomore than 300 mg/dayup to a
maximumof 3,600 mg/daygivenin3 divideddoses