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Advances in Anxiety Manageldent William R J Am Board Fam Pract: first published as 10.3122/jabfm.2.1.37 on 1 January 1989. Downloaded from Advances In Anxiety ManagelDent William R. Yates, M.D., and Robert B. Wesner, M.D. Abstract: Recent developments in neurobiology, di­ lation, have reemphasized the importance of anxi­ agnostic classification, and drug/psychotherapy tri­ ety disorders in family practice. This review als have increased our ability to manage patients presents treatment recommendations, including with anxiety disorders. These recent develop­ dosage, products, guidelines for monitoring, and ments, along with epidemiologic surveys showing discontinuation. Advances in the neurobiology of the high frequency of anxiety disorders in the gen­ anxiety are also included. (J Am Bd Fam Pract eral population as well as in the primary care popu- 1989; 2:37-42.) Advances in treatment, including medication and Adjustment Disorders psychotherapy, demand accurate classification of Adjustment disorders describe a stress syndrome anxiety disorders. An accurate diagnosis is impor­ of maladaptive anxiety to a specific psychosocial tant in predicting the natural course and prognosis stressor. Maladaptive anxiety is medically signifi­ for individual patients. Table 1 presents the classi­ cant when there is impairment in occupational or fication scheme for anxiety disorders as outlined social function or the symptoms exceed appropri­ in the revised version of the Diagnostic and Statisti­ ate reaction to the stressor. Adjustment disorders cal Manual of Mental Disorders (DSM III_R).1 Al­ are short-term reactions lasting no longer than 6 though epidemiologic surveys of anxiety SUbtypes months. Patients with acute medical illness, inter­ in family practice populations are sparse, general­ personal problems, or work difficulties commonly ized anxiety disorder, adjustment disorder with have adjustment disorders with prominent anxi­ anxious features, and simple phobias appear to be ety. For example, a person unable to sleep and 2 the most common. ,3 with poor concentration during a period of work layoffs may meet criteria for adjustment disorder. Although other persons may be undergoing simi­ Generalized Anxiety lar levels of stress, intensity of symptoms, func­ Generalized anxiety is a disorder of excessive tional impairment, and the request for help from a anxiety or worry related to two or more life cir­ physician will identify an adjustment disorder cumstances. Often patients with generalized anxi­ with anxiety. ety can be described as "worry warts" ruminating http://www.jabfm.org/ about finances, family problems, or job diffict:·· ties. Such anxiety is nonproductive and does not Simple Phobias lead to changes in behavior that would reduce Simple phobias appear to be quite common, but anxiery. An example is the anxious patient who often they are mild and infrequently treated by focuses on problems that cannot be changed. By primary care physicians. They include excessive definition, generalized anxiety disorder must also fear of a specific animal, blood, closed spaces, on 23 September 2021 by guest. Protected copyright. include somatic symptoms (muscle tension, auto­ heights, or air travel. Phobias related to health and nomic hyperactivity, and hypervigilance). Initial health care are more commonly encountered by insomnia is common because the patient is unable family physicians. They include fear of venipunc­ to modulate voluntarily worry at bedtime. Gener­ ture, injections, dental procedures, and irrational alized anxiety disorder is not diagnosed if it occurs fear of illness. concurrently with depression or is related to pri­ mary organic factors, such as hyperthyroidism or excessive caffeine use. Other Anxiety Disorders Two anxiety disorders, while less frequently seen by family physicians, are important because of From the Department of Psychiatry, University of Iowa Col­ their potential to be quite severe and occasionally lege of Medicine, Iowa City. Address reprint requests to Wil­ liam R. Yates, M.D., Psychiatric Hospital, 500 Newton Road, disabling. Panic disorder with or without agorapho­ Iowa City, IA 52242. bia may become severe but is highly responsive to Anxiety Mana9ement 37 ., J Am Board Fam Pract: first published as 10.3122/jabfm.2.1.37 on 1 January 1989. Downloaded from Table 1. Relative Prevalence and Severity of Anxiety needed to assess their importance to family prac­ Disorders. tice. Additionally, a discrete anxiety disorder, per­ formance anxiety, has been described in which pa­ Diagnosis Prevalence Severity tients are symptomatic when they are required to function in front of a large group of people. This ++ Panic disorder with or +++ disorder may be especially devastating for musi­ without agoraphobia cians, actors, and public speakers. Generalized anxiety disorder +++ + Adjustment disorder with +++ + anxious mood Social phobia + ++ Drug Treatment Simple phobia +++ + Tricyclic Antidepressants Posttraumatic stress disorder + ++ Although best studied for depression, tricyclics Obsessive-compulsive disorder + +++ playa key role in drug management of primary 6 8 anxiety disorders. - Imipramine and desipra­ + = low, ++ = intermediate, +++ = high. mine (100 to 300 mg daily) are the tricyclic agents of choice for panic disorder. They have the advantage of requiring no special dietary re­ medical treatment. Recurrent and spontaneous strictions as do monoamine oxidase inhibitors, panic attacks are discrete periods of acute anxiety and they can be taken safely for a long time. usually accompanied by physical symptoms, such Disadvantages include anticholinergic side ef­ as palpitations, chest pain, dizziness, and short­ fects and cardiovascular toxicity in overdose. ness of breath. These attacks are the hallmark of Tricyclics may be helpful for some patients with panic disorder. DSM III-R requires at least four generalized anxiety disorder, although their use panic attacks in a 4-week period to make a panic for patients with this condition is less well stud­ disorder diagnosis. Patients often are young wom­ ied. Adjustment disorder patients with promi­ en who commonly present with concerns that nent anxious features, including insomnia, may they are having heart attacks. Agoraphobia is a be­ benefit from more sedative antidepressants such havioral syndrome that can complicate this dis­ as amitriptyline, doxepin, or trazodone. Trazo­ order. It is characterized by phobic avoidance of done has the advantage of a low anticholinergic crowds, shopping malls, churches, or other places profile but also the disadvantage of reports of where patients perceive they are separated from priapism. Preliminary studies of post-traumatic sources of security. stress disorder have suggested benefits from the http://www.jabfm.org/ Obsessive-compulsive disorder (OeD) is another same medications that are effective against panic, potentially severe and disabling anxiety condi­ primarily desipramine and monoamine oxidase 9 lo tion.4 In OeD, patients may be tormented by inhibitors. • Although some patients with ob­ such intrusive thoughts as fear of killing their sessive-compulsive disorder are benefited by children, blasphemy, contamination with dis­ currently available antidepressants, clomipra­ eases such as AIDS, or fear of forgetting to turn mine appears to be the drug of choice and is off appliances and sources of gas or electricity in currently in FDA trials for release in the United on 23 September 2021 by guest. Protected copyright. their homes. These obsessions are often paired States. with compulsive rituals, e.g., frequent hand­ washing, counting, touching, and checking be­ haviors. Obsessive-compulsive disorder often Monoamine Oxidase (MAO) Inhibitors produces clinical depression that can be severe MAO inhibitors are excellent drugs for anxiety and precipitate contact with a physician. Recent disorders and for mixed anxiety-depression con­ developments in the understanding of oeD have ditions. Phenelzine (45 to 90 mg daily) and tran­ produced more drug research, and several drugs ylcypromine (30 to 60 mg daily) are two com­ may soon be available to treat this disorder ef­ monly used agents of this class. Some efficacy in fectively. social phobias has also been shown. Patients con­ Three other anxiety disorders are also recog­ sidered for MAO inhibitors need to be assessed for nized. Social phobia 5-an intense fear of em­ their ability to comply with a tyramine-free diet, barrassment-and post-traumatic stress disorder especially avoiding beer, wines, and cheese. Alco­ (PTSD) are less well-defined, and more research is hol abusers should not receive these drugs. 38 The Journal of the American Board of Family Practice-Vol. 2 No.1 / January - March 1989 J Am Board Fam Pract: first published as 10.3122/jabfm.2.1.37 on 1 January 1989. Downloaded from Benzodiazepines (BZD) of alcohol or drug problems, a family history Benzodiazepines are effective drugs for a variety of alcohol or drug abuse, or patients with anti­ of anxiety conditions and, when used properly, social personality disorder. Nonbenzodiaze­ will provide additional help for the anxious pa­ pines should be preferred in patients with any tient. ll, 12 Diazepam (5 to 30 mg daily) and al­ risk factor for substance abuse. prazolam (0.75 to 3.0 mg daily) are examples of long- and short-acting benzodiazepines, each having specific indications. A primary advantage Other Drugs of benzodiazepines is their rapid onset of anxi­ Buspirone (15 to 60 mg daily) represents the first olytic effect, which can be quite helpful in acutely
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