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Anxiety Disorders

Anxiety Disorders are typically the most common psychiatric disorder occurring in approximately 15% of the population over a lifetime.  Panic Disorder is commonly characterized by very intense bursts of anxiety.

Panic attacks are like an exaggeration of the "fight or flight" response with symptoms like tight chest, shortness of breath and rapid heart beat.  Panic Disorders are blocked well by long acting benzodiazepines also known as minor tranquilizers.  Typically, Clonazepam and Clorazepate are drugs that I select first.  These are particularly beneficial when panic attacks occur frequently within a week’s time.  Panic Attacks may also be blocked with the use of anti-depressant medication.  This can help when the attacks occur less frequently.  A group of anti-depressants known as Selective Serotonin Reuptake inhibitors (SSRI), which include Prozac, Paxil, Zoloft, Celexa, Luvox, and Lexapro become effective in providing blockade typically after about two weeks at a therapeutic level.  Older anti-depressants known as tricyclic anti-depressants, examples of which would be Desipramine or Nortriptyline, have also a good track record at blocking panic attack.  Monoamine Oxidase Inhibitor type anti-depressants as well have been effective in blocking panic attack, but are used much less frequently because these medications have dietary restrictions associated with their use.

A helpful reference book regarding this is The Anxiety Disorder by David Sheehan, M.D.  Reading this is helpful in terms of putting one’s symptoms in context.  Panic Disorder typically is best treated by the use of medications to block the panic attacks themselves and subsequently, with the use of behavioral techniques such as self-hypnosis, aerobic activity and appropriate use of journaling.

Generalized Anxiety Disorder (GAD) is characterized by significant physical symptoms that typically occur nearly half the time over at least six months.  The symptomotology tends to be one that occurs over a person’s lifetime.  This condition may respond to the use of anti-depressants for their anti-anxiety properties.  It is helpful to think of GAD as over focus on physical symptoms.

Obsessive Compulsive Disorder and obsessive-compulsive symptomotology occur at approximately a 1% or 2% rate in the population.  Typically it is possible to get significant reduction of symptoms with the use of anti-depressants that affect the neurotransmitter serotonin.  The SSRI’s are commonly my first drug of choice for these conditions.  Anafranil is also a drug that can be helpful.  Some patients will also benefit from the addition of a minor tranquilizer medicine as referred to above.

Anxiety symptoms may also occur in conditions best described as Adjustment Disorders in which the person is reacting to significant life stressors, but does not have a longer course as is generally required for these other diagnoses.  At times, significant anxiety that has not responded well to conventional treatment may also occur in Bipolar Disorder also known as Manic Depressive Disorder.

Social Phobia, previously thought of as excessive shyness, is characterized by blushing, sweating and tremor.  It is best managed by high doses of Selective Serotonin Reuptake Inhibitors.

Post Traumatic Stress Disorder is a disorder associated with an exposure to an extremely unusual event.  The prototype would be people who have experienced horrors in war and at times with significant accidents as well as issues of abuse or assault.  The syndrome is characterized by one of recurrent disturbing nightmares and easy startling.  Many people benefit from the use of SSRI medications and at times, the use of other psychotropic drugs.

In using minor tranquilizer medications, most typically Clonazepam or Clorazepate, the usual goal is to find a dose that completely blocks panic attack while not producing sedating side effects.  Most typically, I would start a patient with Clonazepam at a 0.5 mg. with an instruction to take anywhere from a dose as low as half a tablet (0.25 mg.) up to three tablets (1.5 mg.) at bedtime.  There certainly are patients that may need higher doses of Clonazepam.  I generally recommend when starting the drug beginning with a dose and then judging how one is doing in the morning regarding any side effects of sedation.  If there is minor sedation, continue with that dose.  If there is significant sedation, the dose should be reduced.  I recommend evaluating the efficacy and side effects in increments of 3-4 days.  I typically use Clorazepate in a dose of 3.75 mg. tablets for those people that have problems with too much sedation with Clonazepam.  Both of these drugs are interactive with alcohol and so, it is advisable to be particularly observant about those interactions.  While I do not prohibit the use of any alcohol with these medications, I certainly advise particular attention to the interaction.

Selective Serotonin Reuptake Inhibitors (SSRI) have become the anti-depressants of choice because of their relatively low profile of side effects.  Most typically, patients may have some problems of gastrointestinal upset and/or nausea typically in the first few days of taking the medication.  It is common to select a lower dose during that time and after those side effects have cleared, an increase of dose.  Some sexual side effects are also common with these medications and generally are most helpful to review at the first follow-up visit.  Side effects of agitation from these drugs generally are signs that a person should discontinue the medication.