Management of anxiety spectrum disorders

Management of
anxiety disorders
Guided by:
Dr. V.S. Pal
HOD and professor
Department of Psychiatry
MGMMC Indore
Dr. Prashant Maravi
Assistant Professor
Department of psychiatry
MGMMC Indore
Presented by:
Dr. Akhilesh Prajapati
Junior Resident
Department of psychiatry

• Introduction
• Pharmacological options
• Non pharmacological options
• NICE guidelines
• IPS guidelines
• Summary
Overview

Introduction
• Anxiety and fear are normal emotional responses to potential or actual
threat.
• In anxiety disorders (ADs), these responses are dysregulated, that is,
exaggerated or prolonged, in a manner that is disturbing to one’s life.
• The major ADs include GAD, panic disorder (PD), and phobias (social
phobia, agoraphobia, and specific phobia).

Subtypes of anxiety spectrum disorders
ICD 10 classification:
F40 Phobic anxiety disorders
F40.0 Agoraphobia
.00 Without panic disorder
.01 With panic disorder
F40.1 Social phobias
F40.2 Specific (isolated) phobias
F40.8 Other phobic anxiety disorders
F40.9 Phobic anxiety disorder, unspecified
F41 Other anxiety disorders
F41.0 Panic disorder [episodic paroxysmal
anxiety]
F41.1 Generalized anxiety disorder
F41.2 Mixed anxiety and depressive disorder
F41.3 Other mixed anxiety disorders
F41.8 Other specified anxiety disorders
F41.9 Anxiety disorder, unspecified
DSM 5 divides anxiety disorders into
following subtypes:
Separation Anxiety Disorder (309.21)
Selective Mutism (313.23)
Specific Phobia (300.29)
Social Anxiety Disorder (300.23)
Panic Disorder (300.01)
Agoraphobia (300.22)
Generalized Anxiety Disorder (300.02)
Substance/Medication-Induced Anxiety
Disorder
Anxiety Disorder due to Another Medical
Condition (293.84)
Other Specified Anxiety Disorder
(300.09)
Unspecified Anxiety Disorder (300.00)

Principles of management of
anxiety disorders
• Careful diagnostic assessment including
• medical and psychiatric comorbidities,
• life stressors
• genetic vulnerability
• Appropriate physical examination and laboratory assessments, as indicated.
• Psychoeducation
• adherence
• self-management techniques
• Systematic monitoring of treatment progress

Basic Investigations
Blood investigations should be done after thorough physical
examination which includes
• measurement of BMI, pulse, BP, temperature and respiratory
rate
• Observation for pallor and nutritional deficiencies,
• Palpation for lymph nodes, organ enlargement, and
• examination of CVS, Respiratory system and CNS.
Although there are no physiological tests that confirm any mental
illness, medical tests may be employed to exclude any co-occurring
medical conditions that may present with psychiatric symptoms.
These include blood tests measuring
• serum electrolytes, serum calcium and LFT to rule out a
metabolic disturbance,
• CBC to rule out a systemic infection or chronic disease.
• An ECG to detect any heart condition

Major Diagnostic scales
1. Hamilton Anxiety Rating Scale (HAM-A)- Each item is
scored on a scale of 0 (not present) to 4 (severe), with
a total score range of 0–56, where
• <17 indicates mild severity,
• 18–24 mild to moderate severity and
• 25–30 moderate to severe.
2. BECK ANXIETY INVENTORY (BAI) - Self reported with a
total of 21 items.
3. Generalised anxiety disorder 7 (GAD7) scale - GAD-7
total score for the seven items ranges from 0 to 21.
• 0–4: minimal anxiety
• 5–9: mild anxiety
• 10–14: moderate anxiety
• 15–21: severe anxiety
4. The Social Phobia Inventory (SPIN) - a 17-item
questionnaire.

PHARMACOLOGICAL OPTIONS FOR TREATING ANXIETY DISORDERS

Neurochemical Association with anxiety disorder Treatment approaches
Noradrenergic system Excess system activation SNRIs first-line therapy for anxiety
disorders (along with SSRIs)
Propranolol for performance
anxiety
Dopaminergic system Excessive mesocortical dopamine
release
persistently high levels of
dopamine in prefrontal cortex
Bupropion is an NDRI (an adjunct
for anxiety disorders)
Serotonergic system Low activity of postsynaptic 5HT1A
receptors in PD and SAD
SSRIs and SNRIs first line therapy
for anxiety disorders
Neurochemical Systems Involved in Anxiety Disorders and Related Treatment Approaches

Benzodiazepines • MOA-
• It binds to allosteric site and enhance the
frequency of opening of inhibitory chloride
channels. Thus, acts by positive allosteric
modulation of GABA receptor.
• Reduces excess amygdala activity. Thus, reducing
fear symptoms.
• Also modulate excessive output from worry loops
thereby reducing worry symptoms.
• Reduce pathological anxiety, agitation and tension.
• Useful in short term management of GAD either alone
or to augment SSRIs
• Addiction potential (Should not be prescribed for
longer than 1 month)

Alpha 2 delta ligands
• Gabapentin and pregabalin
• MOA-
• Bind to alpha2 delta subunit of N and P/Q
voltage sensitive calcium channels in open
state, block the release of excitatory
neurotransmitters. Thus, reducing fear and
worry
• Effective in social anxiety disorder and panic
disorder
• Also used in epilepsy and certain pain conditions
including neuropathic pain and fibromyalgia.

Antidepressants
SSRIs-
Fluoxetine
Sertraline
Paroxetine
Fluvoxamine
Citalopram
Escitalopram
SNRIs-
venlafaxine
Desvenlafaxine
duloxetine
• Key neurotransmitter that innervates both amygdala and
CSTC circuits is Serotonin
Others-
5HT1a partial
agonist- Buspirone
SPARI - Vilzadone
SSRI –
Mechanism of action:
Increases serotonin output by blocking serotonin
reuptake transporter (SERT)
SNRI –
SERT inhibition along with Nor epinephrine
transporter (NET) inhibition (dual action)
5HT1a partial agonist – Buspirone
Acts at both presynaptic and postsynaptic 5HT1A
receptors.
SPARI –
Mechanism of action- SERT inhibition plus 5HT1a
partial agonist

Amitriptyline
Nortriptyline
Desipramine
Imipramine
clomipramine
Tricyclic antidepressants

Side effects of Tricyclic
Antidepressants (TCAs)
• Blockage of cholinergic, histaminic, and alpha-1
adrenergic receptors, which contributes to their
burdensome side effect profile.
• Hypotension
• Dry mouth
• blurred vision
• constipation
• Decreased seizure threshold
• potentially harmful cardiac effects,
particularly in overdose
• Also associated with increased suicidality
and should be avoided in at-risk patients.

Novel Antidepressants
Mirtazapine –
• Noradrenergic and specific serotonergic antidepressant (NaSSA).
• Relatively free of sexual side effects with potential to increase appetite and
weight gain.
Bupropion-
• dual norepinephrine dopamine reuptake inhibitor
Vortioxetine -
• acts as an agonist and partial agonist at 5HT1A and 5HT1B receptors,
respectively, but as an antagonist at 5HT3, 5HT7, and 5HT1B receptors
Agomelatine –
• agonism of melatonin receptors MT1 and MT2 and antagonism of 5HT2C
receptors
• low likelihood of sexual dysfunction, weight gain or discontinuation symptoms

• Quetiapine to be a useful
agent, either as
monotherapy or as an
augmentation agent for both
acute and maintenance
treatment of GAD
• Risks (e.g., weight gain and
other adverse metabolic
effects) may outweigh the
benefits and other classes of
antianxiety agents are
preferred.
Antipsychotics

• Used in performance anxiety
• Reduces tachycardia (racing
heart) and tremor (shaking)
• propranolol and atenolol
• generally well tolerated, but
occasional side effects include
dizziness, lightheadedness, or
fatigue
Beta Blockers

Fear conditioning versus Fear extinction
Fear conditioning:
• There is increased efficiency of
neurotransmission at glutamatergic synapses
in lateral amygdala with sensory input from
thalamus or sensory cortex and output via
central amygdala.
• VMPFC and hippocampus modulate the input
to lateral amygdala
• If VMPFC is unable to suppress fear response,
fear conditioning proceeds.
• Beta blockers disrupt the reconsolidation of
fear and formation of fear conditioning.
• Others used to block reconsolidation of
activated memories: Psilocybin, MDMA and
ketamine.

Fear conditioning versus Fear extinction
Fear extinction:
• Progressive reduction of response to a feared
stimulus which occurs when a stimuli is
present without any adverse consequence
• Fear extinction dominates with synaptic
strengthening and long term potentiation but
it is more labile than consolidation and
reverses over time
• NMDA agonists can enhance long-term
potentiation (LTP) and synaptic plasticity
while the synapses are activated by exposure
therapy. Thus, facilitating fear extinction.

Non pharmacological management
• Goals:
1. Psychoeducation - direct
explanation of symptoms and
disorder to the patient and the
family
2. Monitoring of anxiety
3. Cognitive restructuring: corrects
the hypothesised cognitive
distortions and helps to identify
and counter fear of bodily
sensations

Cognitive behavioural therapy
Steps of CBT:
1. Psychoeducation
2. Self monitoring
3. Systemic exposure to panic inducing cues
4. Countering anxious beliefs
5. Exposure to fear cues
6. Modify maladaptive behaviors
7. Relapse prevention
8. Dealing with transference issues
9. Resolving interpersonal and other
emotional issues

• Patients are typically provided with a cognitive-behavioral formulation of
their specific diagnosis and a related treatment rationale that serves as a
guiding framework for future treatment sessions.
• Alternative treatments shown to have similar efficacy are discussed to
allow the patient to make an informed choice about treatment.
Psychoeducation

Cognitive Therapy The goal of cognitive therapy is to help patients to identify
unhelpful cognitions and cognitive distortions and to modify
them.
Three of the most common traditional cognitive therapy
procedures are
1. Socratic dialogue - uses a series of questions to help the
patient to identify and challenge unhelpful beliefs
2. The downward-arrow technique, in which the therapist
helps to uncover deeper beliefs and meanings by
repeatedly asking for greater clarification; and
3. Thought records, in which patients record automatic
beliefs, list evidence for and against those beliefs, review
potential cognitive errors that may be reflected in those
beliefs, and then generate more realistic and helpful
beliefs.

It involves intentionally confronting feared but otherwise not dangerous objects,
situations, thoughts, memories, and physical sensations for the purpose of reducing
fear reactions and avoidance associated with the same or similar stimuli.
Divided into three classes of procedures:
1. In vivo exposure
2. Imaginal exposure
3. Interoceptive exposure
Exposure
therapy

1. In vivo exposure-
• involves helping patients directly confront
feared objects, activities, and situations
• usually conducted in a graduated fashion
according to a mutually agreed-on
(between patient and therapist) hierarchy
Create a LIST of all feared situations
Rate them for levels of anxiety they
produce. Then order them from least
feared to most This is called a ‘FEAR
HIERARCHY
Plan and Practice Graduated Exposure to
the first situation on your list DAILY (if
possible) until the situation causes a
minimal amount of anxiety.

2. Imaginal exposure-
• typically involves having
the patient close their
eyes and imagine feared
stimuli as vividly as
possible.
• Imaginal flooding
• As a preparatory
exercise to facilitate
subsequent in vivo
exposures

3. Interoceptive exposure-
• Induced feared physiological
sensations under controlled
circumstances.
• most commonly used in the
treatment of panic disorder and
certain specific phobias
Shortness of breath
A feeling that you can’t breathe
ANXIOUS THOUGHTS
“I will stop breathing” “I
will suffocate”
BREATH THROUGH A STRAW for one
minute – with your nose held closed
DROP SAFETY BEHAVIOURS
ie. Don’t try to take deep breaths.
OBSERVE
The effects of anticipatory anxiety, misinterpretation,
catastrophisation and changes in the degree of belief in
the old thoughts as you implement your alternative
perspective.
REFLECT
ie. I did not stop breathing. Even when I tried to stop
breathing my body forced me to breath eventually

Stress inoculation training
Stress and anxiety has three modes, of responding:
• cognitive,
• physiological, and
• behavioral.
It involves training patients in the application of specific skills and techniques designed to
address each of these response modes in a flexible manner that is tailored to the
individual’s needs
For example,
1. Spiralling negative cognitions may be interrupted by the use of “thought stopping,”
2. The physiological manifestations may be addressed through training in diaphragmatic
breathing and progressive muscle relaxation (e.g., Jacobson’s “tense and relax” method).
3. Changes in overt behavior are promoted through the use of role playing and covert
rehearsal.

Acceptance and Mindfulness-Based Training
Three of the most popular treatments are
• Acceptance and Commitment Therapy
(ACT),
• Mindfulness-Based Stress Reduction (MBSR)
and
• Mindfulness-Based Cognitive Therapy.
All of these and other versions have in common the
idea that fighting one’s anxiety leads to a vicious
cycle of attempting to suppress which typically
backfires.
Therefore, acceptance-based techniques
emphasize the need to first acknowledge that the
anxiety exists and to try to objectively,
nonjudgmentally observe it.

Interpersonal Skills Training
Some individuals with SAD, as well as those with other anxiety disorders, avoid social
interactions when possible, thereby further limiting their ability to acquire effective social
skills and decreasing their social support.
Comprehensive treatment for anxiety provides explicit training to help patients acquire and
use appropriate social skills and thereby reverse the negative cycle when necessary.
These skills include assertiveness training and training in initiating, maintaining, and ending
conversations.
This helps individuals have more confidence in their own skills and stop engaging in
avoidance or safety behaviors.

MCQs
Q1) Beta blockers are commonly used in the treatment of:
1.GAD
2.OCD
3.Panic disorder
4.SAD

MCQs
Q2) Interoceptive exposure therapy is a specific type of exposure therapy
commonly used in the treatment of:
1. SAD
2. Panic disorder
3. GAD
4. OCD

MCQs
Q3) At the molecular level, benzodiazepines (BZDs) exert their
effects by:
1. Modulating N-methyl-D-aspartate (NMDA) receptors
2. Stimulating release of endogenous opioids
3. Inhibiting the synthesis of neuropeptides
4. Allosterically enhancing GABA-A receptor function

MCQs
Q4) Which of the following is a widely used self-report scale for assessing
anxiety symptoms?
1. Hamilton Anxiety Rating Scale (HAM-A)
2. GAD7
3. Beck’s Anxiety Inventory (BAI)
4. Mini International Neuropsychiatric Interview (MINI)

MCQs
Q5) Alpha 2 delta ligands, such as pregabalin, are used in all
of the following conditions EXCEPT
1.Anxiety
2.Insomnia
3.Fibromyalgia
4.Seizure disorder

Q6) Fear conditioning is process of:
1. Learning to associate a neutral stimulus with a fear response
2. Unlearning or reducing the fear response to a previously
feared stimulus
3. Developing an innate fear response to a specific stimulus
4. Conditioning a fear response to a conditioned stimulus
MCQs

Q7) In Stress Inoculation Therapy (SIT), modes of response include:
1. Fight, flight, or freeze
2. Avoidance, distraction, or numbing
3. Cognitive, affective, and behavioral
4. Activation, appraisal, and action
MCQs

Crisis management
Benzodiazepines Rapid effect but symptoms return rapidly when drug is
withdrawn
Not recommended by NICE
First line drug treatment
(In order of preference)
SSRI
(Upto max licensed dose)
Delayed therapeutic effects
Initial worsening of panic symptoms
Venlafaxine MR
(75-225mg)
Initiated at 37.5mg for 7 days
Panic Disorder
Onset of action may be as long as 6 weeks.
The optimal duration of treatment is unknown but should be at least 8 months.

Second line drug treatment
Mirtazepine
15-60mg/day
Helps with anxiety associated with this disorder
Moclobemide
300-600mg/day
MAO Inhibitor
(Phenelzine 10-60mg/day)
Poor tolerability
TCA
Clomipramine
25-250mg/day
Imipramine
25-300mg/day
Lofepramine
70-140mg/day in divided doses
Start with a low dose and increase dose as per response
and tolerability
Panic Disorder

Generalised anxiety disorder
Crisis management
Benzodiazepines Short term use only; Max- 2-4weeks
(In order of preference)
SSRI
Initial exacerbation of symptoms; lower starting dose is
recommended
Fluoxetine and Sertraline are preferred
SNRI
Initial exacerbation of symptoms; lower starting dose is
recommended
Pregabalin
150-600mg/day in divided dose
Response may be seen in first week of treatment
Modest benefit is usually seen within 6 weeks and continues to increase over time.
The optimal duration of treatment has not been determined but should be at least
one year

Generalised anxiety disorder
Second line drug treatment
Agomelatine(10-50mg/day) Shown to prevent relapse over a 6 month period
Betablockers
Propranolol (40-120mg/day in divided doses)
Initiate at 40mg and titrate up
useful for somatic symptoms particularly tachycardia
Buspirone (15-60mg/day in divided doses) Delayed onset of action; takes upto 6 weeks to show
effect
Hydroxyzine (50-100mg/day in divided doses) Anxiolytic or sedative effect
Quetiapine MR (50-300mg) Recommended as monotherapy
TCAs
Clomipramine (50-250mg/day)
Imipramine (75-200mg/day in divided doses)
Initiate at 10mg/day and increase the dose gradually
Initiate at 25mg every 4 days; After reaching 100mg can
increase by 50mg every 4 days
MAOI
Phenelzine (45-90mg/day in divided doses)
For mixed anxiety and depressive states
Need to avoid food high in tyramine
Mirtazepine (15-30mg)

(in order of preference)
SSRIs (upto max licensed doses) Paroxetine, sertraline or fluoxetine
(Recommended by NICE)
Venlafaxine modified release (37.5- 300mg) Recommended by NICE
PTSD
Second line treatment
Olanzapine (5-20mg)
Risperidone (0.5-6mg)
Quetiapine (50-800mg)
Effective for the intrusion symptoms(flashbacks and
nightmares)
Risperidone specifically mentioned by NICE
Mirtazepine (15-45mg/day) Recommended by NICE
Phenelzine (15-75mg/day) Recommended by NICE
Prazosin (2-15mg) For nightmares and sleep disturbances
Initiate at 1mg and titrate dose gradually to reduce the
risk of hypotension
Amitriptyline (50-300mg/day) -Recommended by NICE
Imipramine (50-300mg/say)
Start at low dose and increase dose according to
tolerability
IV ketamine Rapid reduction in symptom severity
Response is usually seen within 8 weeks, but can take up to 12 weeks.
Treatment should be continued for at least 6 months and probably longer.

First line drug treatment (in order of preference)
SSRI (upto maximum licensed dose) If no response to the first SSRI, try an alternative SSRI
Supporting evidence for fluvoxamine and citalopram
Venlafaxine MR (75-225mg/day)
Social phobia
Second line treatment
Olanzapine (5-20mg)
Atenolol (25-100mg/day) Reduces autonomic symptoms in performance situation
Benzodiazepines
Clonazepam (0.3-6mg/day)
Sertraline plus clonazepam (upto 3mg/day)
Gabapentin (900-3600mg/day)
Levetiracetam (300-3000mg/day in divided doses)
Moclobemide (600mg/day in divided doses) Initiate at 300mg/day in divided doses
NICE recommends CBT as first-line treatment for Social Anxiety
Some benefit is usually seen within 8 weeks, and treatment should be
continued for at least a year and probably longer.

Anxiety disorder management
OPD management IPD management
Most of the
anxiety disorders
can be treated in
outpatient
• Comorbid severe depression with suicidality
• Anxiety disorder is severe and treatment resistant
• Poor social support
• presence of chronic stressor and separation from
stressful situation is needed
• Concurrent medical illness and treatment

Anxiety spectrum
disorders
Panic disorder and
agoraphobia
Specific phobia GAD and social
anxiety disorder
PTSD
Acute attack –
mouth dissolving short
acting benzodiazepines and
reassurance
Long term management-
• First line – SSRI or SNRI
Treat for at least 6 to 8
months or longer to prevent
relapse
• CBT + anxiolytic
treatment can be used
Behaviour therapy
including systemic
desensitisation
If not responding
– SSRI or short
acting
benzodiazepines
• First line – SSRI, SNRI
and pregabalin
• Second line –
Buspirone and
hydroxyzine
• Duration- 6-12
months, some
evidence indicate
that treatment
should be long term.
• SSRI and venlafaxine
can be used
• Therapeutic
conversation
• Psychoeducation
• Regrief therapy

When to stop?
• Depends on clinical response of the patients
• Usually stopped in a tappering manner after at least six
months stability and asymptomatic status of the patient
• Before stopping the treatment one should discuss
• the nature of illness,
• possibility of recurrence
• response to triggers and
• ability to cope with situation
• Encourage to adapt alternative methods of intensity
reduction like yoga, Pranayam relaxation techniques including
PMR
• Mindfulness based CBT for reducing cognitive and somatic
anxiety and modifying dysfunctional cognition, such as
• worry postponement,
• Worry exposure and
• problem-solving

• Pregnancy –
• SSRI and TCA does not have increased risk of malformations
• Breastfeeding–
• SSRI, TCA are excreted in breast milk in very low concentration. Thus, no harm to the
new born
• If taking benzodiazepines- observe for signs of sedation lethargy and weight loss
• If long-term benzodiazepine use is required, breastfeeding should be discontinued
• Children and adolescents –
• SSRIs increase risk of suicidal ideation and behaviour.
• Patient’s with severe physical disease –
• SSRI and venlafaxine can be used
• Elderly –
• increase sensitivity for anticholinergic properties.
• Increased risk for ortho static hypotension
• ECG changes during treatment with TCA
• paradoxical reaction to benzodiazepine, which include depression with or without
suicidal tendencies, phobias, aggressive and as well as violent behaviour
• SSRIs appear to be safe
• TCA or benzodiazepine is less favourable
Special conditions

Treatment Resistance in Anxiety disorder
Patient who had a standard treatment for a minimum of 6 weeks without showing
response
Response is defined as a ≥50% reduction on the commonly used standard scales
(Dilbaz et al, 2011)
No response
Augment Switch

Switch to another
standard drug
• One SSRI to another SSRI
• SSRI to SNRI Or Vice versa
• TCA
• Pregabalin ( only in GAD)
Switch to a
second line drug
(World Federation of Societies of Biological Psychiatry (WFSBP)
Switching

Switch to a drug
which is approved for
other anxiety disorder
• e.g. moclobemide, hydroxyzine
Switch to a drug that is not approved for
the anxiety disorder but has been found
effective in RCTs
PD Mirtazapine, quetiapine, phenelzine
GAD Quetiapine, addition of risperidone or
Olanzapine to SSRI
SAD Mirtazapine ,gabapentin, pregabalin, olanzapine

Augmentation with antipsychotics was not associated with an
increased response, as compared with placebo
A small significant effect found in reduction in symptom severity
No significant differences between augmentation with medication
versus placebo found in ratings of functional impairment and
dropouts due to adverse events
Augmentation

Summary
NICE guidelines:
• Psychological therapy is more effective than
pharmacological therapy and should be used as
first line where possible.
• Panic disorder
• Benzodiazepines should not be used.
• An SSRI should be used as first line.
• If SSRIs are contraindicated or there is no
response, imipramine or clomipramine can
be used.
• Generalised anxiety disorder
• Benzodiazepines should not be used
except for crises.
• An SSRI should be used as first-line
treatment.
• SNRIs and pregabalin are second and third
choices, respectively.
IPS guidelines:
• Panic Disorder-
• Short acting BZD and assurance can
be given in acute management
• Long term- SSRI and SNRI are first line
and should be given for 6-8 months
• GAD-
• BZD can be initiated from minimum
adequate dose/ prescribed for a
limited Period (6-8 weeks)
• SSRI, SNRI, and pregabalin are
recommended as first line drugs.
• Duration – 6-12 months

References
• Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 10th edition
• Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Applications,
Sixth edition
• The Maudsley Prescribing Guidelines in Psychiatry, 14th edition
• Gautam S, Jain A, Gautam M, Vahia VN, Gautam A. Clinical Practice Guidelines for the
Management of Generalised Anxiety Disorder (GAD) and Panic Disorder (PD). Indian J
Psychiatry. 2017 Jan;59(Suppl 1):S67-S73. doi: 10.4103/0019-5545.196975. PMID:
28216786; PMCID: PMC5310105.
• Subramanyam AA, Kedare J, Singh OP, Pinto C. Clinical practice guidelines for Geriatric
Anxiety Disorders. Indian J Psychiatry. 2018 Feb;60(Suppl 3):S371-S382. doi:
10.4103/0019-5545.224476. PMID: 29535471; PMCID: PMC5840911.

A 32-year-old individual presents with persistent worry, muscle tension, and difficulty
concentrating over the past six months. The symptoms significantly impact daily
functioning. There is no history of substance use, and physical examination reveals no
abnormalities. Based on this scenario, what would be the initial recommended
approach for managing this patient's anxiety?
1. Immediate referral to a psychiatrist for specialized care.
2. Prescribe lorazepam for short-term relief.
3. Conduct a thorough assessment, including ruling out medical conditions, and
consider non-pharmacological interventions.
4. Start the patient on a Tricyclic antidepressants
Case 1:

A 29-year-old married male is seen in the emergency room with the chief complaint of, “I’m afraid I’m
having a heart attack.” He states a 2-month history of experiencing recurrent episodes of chest pain
and shortness of breath that last 10–20 minutes. He also describes associated tachypnea,
lightheadedness, tingling in his extremities, nausea, diaphoresis, anxiety, and fears that he may die.
These symptoms are now occurring almost daily but are not provoked by any situations or activities
such as exertion or exercise. He is significantly worried about having future episodes and is genuinely
concerned that he will suffer a myocardial infarction. He denies having any medical illnesses or taking
any medications. His physical examination reveals a slightly elevated BP and pulse. An ECG
demonstrates sinus tachycardia.
Which of the following medications would be most appropriate in the acute management of this
patient’s symptoms?
1. Bupropion
2. Buspirone
3. Imipramine
4. Lorazepam
5. Paroxetine
Case 2:

Case 3:
The patient is a 28-year-old female medical student who is referred to the Office of Student Affairs
due to receiving an incomplete on her surgery clerkship. Upon questioning, she admits to “sneaking
out” of the operating room in order to avoid participating in surgeries. When confronted with her
unprofessional behavior and expectations of the rotation, she claims to have significant anxiety
revolving around the operating room. She states, “It’s not that I mind the surgery itself, just the
blood.” She proceeds to reveal numerous instances of feeling dizzy, lightheaded, and even fainting
when seeing blood. As a result, she has been unable to donate blood while in college or medical
school and has, thus far, been able to “work around” drawing blood in other clerkships. How will you
manage this patient?
1. Administer an anti-anxiety medication before medical procedures.
2. Recommend exposure therapy to gradually confront the fear of blood.
3. Advise the individual to avoid all situations involving blood.
4. Suggest immediate desensitization through a one-time intense exposure.

Case 4:
A 28-year-old breastfeeding woman presents with symptoms of anxiety. She expresses
concerns about the impact of medications on her infant through breast milk. What is
the most appropriate initial management?
1. Discontinue breastfeeding and switch to formula feeding.
2. Initiate cognitive-behavioral therapy without medications.
3. Prescribe a selective serotonin reuptake inhibitor (SSRI) with a low excretion in
breast milk.
4. Recommend herbal supplements known for calming effects during breastfeeding.

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