Nejm 1993;329:631; Jama 2001;286:450; 2000;283:2573

Cause:
Strong genetic component perhaps; incr in families w h/o alcoholism

Types:

• Generalized anxiety (most common) (GAD) (Nejm 2004;351:675)
• Panic disorder (PD) (Nejm 2006;354:2360)
• Specific phobia
• Social phobia (Nejm 2006;355:1029)
• Obsessive-compulsive disorder (OCD) (Nejm 2004;350:259)
• Post-traumatic stress disorder (PTSD) (Nejm 2002;346:108)

Pathophys:In PD, dysfunctional brain neurotransmitter alarm system (Jama 2000;283:2573). In social phobia increased amygdala reactivity (Nejm 2006;355:1029)

GAD lifetime prevalence = 5%. PD lifetime prevalence = 1.5-3.5%; 2/3 of pts have another primary psychiatric dx, esp depression; 2 peaks—late adolescence and mid 30s; PD rare in childhood. Specific phobia lifetime prevalence = 4-8.8%. Social phobia lifetime prevalence = 3-13%; fem > male; most cases missed. OCD lifetime prevalence = 2.5%; peaks at prepubertal and age 22-36 yr. PTSD lifetime prevalence = 5-14%.

Sx:

GAD: >6 months persistent and excessive worry with impairment in functioning.

PD: Discrete episodes of intense fear and discomfort paired with somatic sx including hyperventilation, palpitations, pains, fears, flushes; h/o long medical workups, +/– agoraphobia

PTSD: Onset may be delayed months to years, manifested by reexperiencing of traumatic event and avoidance of assoc stimuli and emotional numbing, hyperarousal, insomnia (Jama 1999;282:755); seen esp in wounded veterans and incest/abuse victims; manifest by hyperalertness and difficulty falling asleep (Nejm 1987;317:1630); often associated w confounding chemical substance abuse. Similar sx in 1st 4 weeks after a trauma termed acute stress disorder.

Social phobia: Avoidance of social and performance situations where embarrassment may occur.

OCD: Decreased functionality related to need to perform rituals, slowness related to obsessional thinking.

Si:Sympathomimetic si’s; obsessive-compulsive rituals in OCD (Nejm 1989;321:540)

Often chronic and disabling

Suicide in panic disorder debatably; school avoidance in children with GAD.

r/o alcohol and/or substance abuse; CAFFEINE ADDICTION/WITHDRAWAL, esp with headache and fatigue (Jama 1994;272:1043, 1065; Nejm 1992;327:1109)

Lab: TSH, Ca²⁺, toxicology

Rx:

(Nejm 2004;351:675; Med Let 2005;47:5)

of GAD:

• Cognitive behavioral therapy (CBT) to train to substitute positive thoughts; perhaps relaxation therapy
• SSRIs in gradually increasing doses; also helpful in panic d/o, OCD, social phobia. (Brit J Psych 1999;175:120; Jama 1998;280:708); superior to usual care in pts age >60 yr (Jama 2009;301:1460) and younger populations (Arch Gen Psych 2005;62:1332)
• Venlafaxine (Effexor)
• Buspirone 5-15 mg tid-qid; can prevent emergence of but not acute sx
• Tricyclics like nortriptyline, imipramine
• Benzodiazepines like clonazepam, etc, for 2-4 wk, then taper

of social phobias: SSRI or SNRI (venlafaxine); propranolol for stage fright type of anxiety, 40 mg 1.5 h before stress, can improve performance (Med Let 1984;26:61); also reduces violent out-bursts in the elderly (M. Beers UCLA 1/92)

of OCD: SSRIs, including in children and adolescents (Nejm 2001;344:1279; RCT—Jama 1998;280:1752); CBT is 1st line (Jama 2004;292:1969)

of specific phobias (eg, of animals): desensitization and response prevention (CBT)

of OCDs (Nejm 2004;350:259): SSRIs in incr doses, even in children and adolescents (Nejm 2001;344:1279; RCT—Jama 1998;280:1752); try several × 2-3 mos each; cognitive behavioral therapy (Jama 2004;292:1969); clomipramine (Anafranil) 50-250 mg po qd, which helps obsessive/compulsive behaviors, esp trichotillomania (Nejm 1989;321:497), as do SSRIs

of panic disorder: cognitive-behavioral therapy helps, adds to SSRI or imipramine rx (Jama 2000;283:2529); then benzodiazepines, clonazepam (Klonopin) for panic disorder, but addicting so taper (pts often resistant) after SSRI, TCA, or MAOI on board (Med Let 2005;47:5)

of PTSD: critical-incident stress debriefing with virtual-reality reliving of srressful stimuli, sometimes in conjunction with blockers; used especially in war survivors (Int J Em Med Health 2004a;6:175)