This document provides an overview of anxiety disorders, including their epidemiology, etiology, pathophysiology, clinical presentation, subtypes, and treatment approaches. It discusses the characteristics and management of several specific anxiety disorders, including generalized anxiety disorder, panic disorder, social anxiety disorder, specific phobia, and post-traumatic stress disorder. Pharmacologic and non-pharmacologic treatment options are described.

1. Mariam D. (B.Pharm, MSc in clinical pharmacy)
Email: yemariamju@gmail.com
Anxiety Disorder

2. Introduction
• Anxiety is a normal response to stressful or fearful circumst
ances.
• Most people experience some degree of anxiety in reactio
n to stressful situations, such as final exams or giving a spe
ech.
• Anxiety symptoms generally are short-lived and do not nec
essarily impair function.
• Anxiety that becomes excessive, causes irrational thinking
or behavior, and impairs a person’s functioning is considere
d an anxiety disorder.
2

3. Epidemiology
– Specific phobias … 9.1% (the most common anxiety disor
der)
– GAD…2.7%
– Panic disorder …2.7%
– SAD…7.1%
• Anxiety disorders develop …before age 30
• More common in ….
– Women, individuals with social issues,
– those with a family history of anxiety and depression.
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4. Etiology
 Hypotheses on the etiology of anxiety disorders are based
on interactions between a combination of factors including
genetic predisposition and stress.
 Furthermore, anxiety disorders are associated with chronic
medical illness, drugs, substances of abuse.
4

5. Pathophysiology
• Pathologic anxiety states is associated with abnormal funct
ion in several neurotransmitter systems, including norepin
ephrine (NE), γ-aminobutyric acid (GABA), serotonin (5-HT)
, dopamine(DA),
5

6. Clinical presentation
• The characteristic features of these illnesses are anxiety an
d avoidance behavior.
• Anxiety symptoms must cause significant distress and impa
irment in social, occupational, or other areas of functioning
.
• Should not be secondary to a drug or illicit substance or a g
eneral medical disorder or occur solely as part of another p
sychiatric disorder
6

7. Subtypes of anxiety disorders/DSM IV TR
 Generalized anxiety disorder (GAD)
 Panic disorder (PD)
 Social anxiety disorder (SAD)
 Specific phobia
 Agoraphobia
 Obsessive-compulsive disorder (OCD)
 Posttraumatic stress disorder (PTSD)
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8. GAD
• Excessive anxiety and worry about events or activities for m
ost days for at least 6 months.
• Accompanied by 3 or more of following symptoms
– restlessness
– easily fatigued,
– difficulty concentrating,
– irritability, muscle tension,
– sleep disturbance
• Social, occupational impairment; poor coping skills
8

9. Cont’d…
• Has a gradual onset Women: Men 2:1
• High percentage of relapse, low rates of recovery.
• Lifetime comorbidity with another psychiatric disorder occ
urs in 90% of pts with GAD.
– Depression … >60%
9

10. 10
 Panic attack: a discrete period of intense fear in which 4
of the following symptoms abruptly develop and peak withi
n 10 min
 depersonalization, fear of losing control or going crazy,
fear of dying
 abdominal distress, feeling of choking, nausea, chills, s
weating, shaking, paresthesia, dizziness or light-heade
dness, hot flushes, palpitations, tachycardia, chest pain
, SoB.
 Recurrent unexpected panic attacks, involving an intense,
terrifying fear in the absence of danger and for a one mont
h period or more of:
 persistent worry about having additional attacks
 worry about the consequences of the attacks
Panic Disorder

11. Cont’d…
 Complications of panic disorder include …
– depression (10% to 65% have MDD)
– alcohol abuse
– high use of health services and emergency rooms
• Pts with panic disorder have high lifetime risk for suicide a
ttempt
• Female: male 2-3:1
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12. Agoraphobia
• ~ 70% of pts develop agoraphobia….. 2o to panic attacks
• Agoraphobia is fear and avoidance of situations and places
in which they would feel unsafe in the event of a panic atta
ck.
• The individual fears or avoids these situations because esca
pe might be difficult or help might not be available.
• Marked fear or anxiety for more than 6 months about two
or more of the following situations:
– Market places, Using public transportation
– Being in enclosed spaces; Being in a crowd
– Being outside of the home alone
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13. SAD
• It is an intense, irrational & persistent fear of being negatively
evaluated in at least one social or performance situation; last
s more than 6 months.
– Exposure to the feared circumstance usually provokes an i
mmediate situation-related panic attack.
• Physical symptoms: Blushing, diarrhea, sweating, tachycardia,
– Blushing …main physical indicator used to distinguishes S
AD from other anxiety disorders.
• People with SAD can be reluctant to seek professional help
– perceived as feared social interaction
13

14. Cont’d…
• Generalized SAD ….
– fear and avoidance extend to various social situations
• Non-generalized SAD ….
– fear is confined to only one/two social situations
• Panic attacks occur in both SAD and panic disorder, but the distinctio
n between the two is the rationale behind fear.
– fear of anxiety symptoms is x/tic of panic disorder
– fear of embarrassment from social interaction typifies SAD.
14

15. Cont’d…
• Some feared situations in SAD
• Eating or writing in front of others
• Interacting with authority figures
• Speaking in public
• Talking with strangers
• Use of public toilet
Slightly higher in women than men
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16. Specific Phobia
• Specific phobia is marked and persistent fear (>6 months) of a
specific object or situation (e.g., insects or heights).
– the patient is usually free of symptoms…when no contact
with the feared object or situation
– Most persons simply avoid the feared object and adjust to
certain restrictions on their activities.
– Up to 15% of general population
– Female: Male 2:1
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17. PTSD
• Exposure to a traumatic event is required for a diagnosis of
PTSD
• The patient’s response to trauma must include intense fear
, helplessness or horror
• Resulting symptoms include
– Persistently re-experiencing of the traumatic event
– Avoidance of stimuli associated with trauma
17

18. Cont’d…
• Symptoms must be present longer than 1 month and cause
significant distress or impairment.
• One-third of patients with PTSD have a poor prognosis, and
about 80% have a concurrent depression or anxiety disord
er.
• Over half of men with PTSD have comorbid alcohol abuse o
r dependence, and about 20% of patients attempt suicide.
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19. OCD
• Obsessions
– Repetitive thoughts, e.g., feeling contaminated after touchi
ng an object, doubting whether the stove was turned off
– Repeated doubts
– Intense need to have orderliness and symmetry
– Repeated sexual thoughts or images
• Compulsions
– Repetitive activities (e.g., hand washing, checking, ordering
)
– Repetitive mental acts (e.g., counting, repeating words sile
ntly) 19

20. Treatment Goals
• Short-term goals
– to reduce the severity, duration and frequency of the a
nxiety symptoms
– to improve overall functioning
• Long-term goals
– remission with minimal/no anxiety symptoms/no functi
onal impairment
– increased QOL
– prevention of recurrence
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21. Non-pharmacologic therapy
• Cognitive behavioral therapy (CBT) ….the most effective psy
chologic therapy
– CBT includes relaxation training, rehearsal of coping skill
s, etc
• Anxious patients should be instructed to avoid caffeine, non
prescription stimulants, diet pills, and excessive use of alco
hol.
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22. Generalized Anxiety Disorder
– First Line Drugs- SSRIs and SNRIs
• Paroxetine, Sertraline, Escitalopram, Duloxetine, Ve
nlafaxine XR…FDA approved for mgt of GAD
– Second Line Drugs
• Benzodiazepines, Buspirone, Imipramine
– Alternatives
• Hydroxyzine, Pregabalin, Quetiapine
22

23. Cont’d…
• Antidepressants have replaced benzodiazepines as the dru
gs of choice for chronic GAD owing to
– a tolerable side effect profile,
– no risk for dependency, and
– efficacy in common comorbid conditions including depr
ession, panic, obsessive compulsive disorder (OCD), an
d SAD.
 Their antianxiety response …delayed by 2 to 4wks or lo
nger
23

24. Cont’d…
• SSRIs and SNRIs for acute therapy
– 8 to 12-week trials
– Paroxetine….most likely to achieve remission of GAD sympto
ms
• 20 mg/day….max 50md/d
– Sertraline …the most well tolerated.
• Initial 50 mg/day …. may titrate to max 200 mg/day
– Venlafaxine XR …37.5 or 75 mg/day….max 225mg/day
– Duloxetine…30 or 60 mg/day….max 120mg/day
– Imipramine ….2nd-line (50 mg/day…usual dose: 75–200mg/d
)
• Elderly pts are usually treated with ~1/2 of the adult dose
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25. Adverse Effects
• SSRIs and SNRIs ….generally well tolerated, with …
– GI adverse effects & sleep disturbances …most commo
n.
– Headaches and diaphoresis …early in treatment, transi
ent
– weight gain & sexual dysfunction ….in long-term treatm
ent.
• TCAs: sedation, anticholinergic effects, weight gain in some
pts, risk of toxicity in overdose.
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26. Benzodiazepines
• Most effective and commonly prescribed
– For rapid relief of acute anxiety symptoms
• All BDZs possess anxiolytic properties
– Clonazepam ….an anti- panic agent and anticonvulsant
– Alprazolam…..for the treatment of panic disorder with
or without agoraphobia, and GAD.
• Elderly pts are treated with ~one-half of the adult dose.
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27. Cont’d…
• When appropriately dosed, all agents have similar anxiolytic
and sedative–hypnotic activity.
• High lipophilicity,
– diazepam, and clorazepate ….absorbed rapidly & distrib
uted quickly into the CNS.
– onset of anxiolytic effect …. 30 to 60 min
– most of the improvement occur in the first 2wks of ther
apy
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28. Adverse Effects
• CNS depression ….most common
– Eg, drowsiness, sedation, psychomotor impairment.
• Impairment of memory and recall
– events occurring after drug ingestion (anterograde amne
sia)
 Two serious complications of BDZ therapy
– potential for abuse
– physical dependence
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29. Dosing
• Duration of BDZ therapy for acute management of anxiety
– should be 2 to 4wks
• BDZs should be used with a regular dosing regimen
– should not be used on an as-needed basis
• Persistent symptoms should be managed with antidepressants…
– because of the risk of dependence with continued BDZ ther
apy.
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30. Buspirone
• Buspirone is a non-BDZ anxiolytic
– lacks anticonvulsant, muscle relaxant, hypnotic, motor imp
airment, and dependence properties.
• 2nd-line agent for GAD
– b/c of inconsistent efficacy on long term,
– delayed onset of effect (2wks or longer),
– lack of efficacy for other concurrent depressive & anxiety d
isorders
30

31. Cont’d…
• Initial dose: 7.5 mg BID……..dosage range: 15–60mg/day
• Its dose can be titrated in increments of 5 mg/day every 2 t
o 3 days as needed.
• Maximum therapeutic benefit …. might take 4 to 6wks.
– not useful in immediate anxiolysis
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32. Treatment resistance
• Treatment resistance is defined as a poor, partial, or lack of
response with at least two antidepressants from different c
lasses.
• Treatment include
– increasing the dose of the SSRI/SNRI,
– changing to a different agent in the same class,
– changing to a different agent of a different class, or
– augmentation of therapy.
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33. Panic disorder
• Drug choices for panic disorder
– First Line Drugs
• SSRIs and Venlafaxine XR…. similar response
• b/c of tolerability and efficacy in acute and long-ter
m studies
– Second Line Drugs
• Alprazolam, Clonazepam, Citalopram, Clomipramine,
Imipramine
• BDZs ….the most commonly used
– Alternative ….. phenelzine 33

34. Cont’d…
• All SSRIs are effective in panic disorder.
• Its anti-panic effect is delayed for at least 4wks, and some
pts do not respond for 8 to 12wks.
• Venlafaxine XR ….37.5 mg/day for the first 3 to 7 days
– then increase to a minimum of 75 mg/day
– Increasing the dose to 150 mg/day after initial nonresp
onse or partial response is recommended.
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35. Imipramine (TCA)
• Alleviate panic attacks in 75% of pts …. 2nd-line agent
• blocks panic attacks within at least 4wks and maximal improve
ment (including anti-phobic response) takes 8 to 12wks.
• Initial dose10 mg/day….antipanic dosage range 75–250mg/d
– dose slowly by 10 mg every 2 to 4 days as tolerated.
35

36. Benzodiazepines
• 2nd-line…b/c of risk of dependency
• Should not be used as monotherapy in depressed pts or has
a history of depression.
– potential emergence of depressive symptoms during tre
atment
• The high-potency BDZs–clonazepam & alprazolam are prefer
red agents.
• Diazepam and lorazepam are effective at high doses.
36

37. Cont’d…
• Acute phase: main goal ….reduction of symptoms
– resolution of panic attacks
– reduction in anxiety and phobic fears
– resumption of the patient’s usual activities
• Duration …1 to 3 months depending on the choice of drug.
• Therapy should be altered …
– if no response after 6 to 8 weeks of an adequate dose.
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38. Cont’d…
• The guiding principle for SSRIs and SNRIs in panic disorder
– start with low doses (~¼ to ½ of the starting doses for
depression), and treat for about 12 weeks.
• Maintenance phase & discontinuation
_The optimal length of therapy is unknown
– Total The dose used in the acute phase is continued
– When drugs are discontinued too early…high rate of re
lapse
• duration of therapy ….12 to 24 months before drug dis
continuation over 4 to 6 months is attempted.
38

39. Social Anxiety Disorder
– First line drugs
• Escitalopram, Fluvoxamine CR, Paroxetine, Sertraline,
Venlafaxine XR
• b/c of efficacy and tolerability
• safe for patients with substance abuse.
– Second line drugs: Clonazepam, Citalopram
• TCAs are not effective in SAD
• BDZs ..for pts intolerant or fail to respond to antidepressants
.
– not first-line therapy for SAD 39

40. Cont’d …
• β-Blockers
–  the perception of anxiety by blunting the peripheral a
utonomic symptoms of arousal (e.g., rapid HR, sweating,
blushing, tremor)
– Used to decrease anxiety in performance-related situatio
ns.
– For patients with specific SAD,
• 10 to 80mg of propranolol or 25 to 100 mg of atenolo
l
• taken 1hr before a performance as needed
40

41. SAD in children
• CBT and social skills training are effective non pharmacologic
therapies in children.
• SSRI or SNRI for children 6 to 17 years.
– should be closely monitored for increased risk of suicidal i
deation.
• BDZs should be reserved as the last-line agents in children wi
th SAD.
– If prescribed, ….should be for the shortest time period po
ssible
41

42. Cont’d…
• About 1/5th of pts with SAD also suffer from an alcohol use d
isorder.
– Many people with SAD use alcohol to cope with anxiety.
– SSRIs are the drugs of choice.
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43. Specific Phobia
• Specific phobia ….. unresponsive to drug therapy
– highly responsive to CBT
• BDZs or Paroxetine
– in pts who failed CBT …..but supported by limited data
43

44. Post Traumatic Stress Disorder
• Immediately after the trauma, patients should receive trea
tment individualized to their presenting symptoms.
• If symptoms persist for 3 to 4 weeks and there is social or o
ccupational impairment, patients should receive pharmaco
therapy or psychotherapy, or both.
44

45. Cont’d…
• The SSRIs are first-line pharmacotherapy for PTSD.
– Sertraline and paroxetine …..for acute treatment of PTS
D
– Sertraline ….for long-term management of PTSD
– Sertraline 50 – 200 mg/day; Paroxetine 20 – 60 mg/day
• Amitriptyline and imipramine, and the MAOI phenelzine, …
…2nd or 3rd -line
• Mirtazapine and venlafaxine may also be effective
45

46. Obsessive Compulsive Disorder
• SSRIs are the drugs of choice for the treatment of OCD.
• If an inadequate response to an SSRI for OCD occurs after 4
to 6 weeks at the maximum dose, switch to another SSRI.
• Medication taper can be considered after 1 to 2 years of tre
atment in patients with OCD.
46

47. Summary
• Antidepressants (SSRIs & SNRIs) & BDZs (clonazepam & alpr
azolam)
– used extensively in pts with GAD, panic disorder & SAD.
• Antidepressants …. 1st-line for GAD, panic disorder, and SAD.
• BDZs are reserved for …..immediate anxiety relief during the
first 2 to 4 weeks of therapy with a long-term agent antidepr
essant.
• BDZs …drugs of choice for situational anxiety
• Augmentation with atypical antipsychotics show some promi
se in treatment-resistant cases.
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48. Buspirone ….
• Buspirone is a treatment option for patients…
– with uncomplicated GAD
– who fail other anxiolytic therapies,
– with substance abuse
– without comorbid depression or other anxiety disorders
 It is effective for the psychic symptoms of anxiety, unl
ike BDZs
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49. thanks..