Anxiety powerpoint

8/7/2019 Anxiety powerpoint

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AnxietyAnxietyis a psychological and physiological state characterized by cognitive,is a psychological and physiological state characterized by cognitive,somatic, emotional, and behavioral components. These componentssomatic, emotional, and behavioral components. These componentscombine to create an unpleasant feeling that is typically associatedcombine to create an unpleasant feeling that is typically associated

with uneasiness, apprehension, fear, or worry. Anxiety is awith uneasiness, apprehension, fear, or worry. Anxiety is ageneralized mood condition that can often occur without angeneralized mood condition that can often occur without an

identifiable triggering stimulus. As such, it is distinguished from fear,identifiable triggering stimulus. As such, it is distinguished from fear,which occurs in the presence of an observed threat. Additionally,which occurs in the presence of an observed threat. Additionally,fear is related to the specific behaviors of escape and avoidance,fear is related to the specific behaviors of escape and avoidance,whereas anxiety is the result of threats that are perceived to bewhereas anxiety is the result of threats that are perceived to be

uncontrollable or unavoidable.uncontrollable or unavoidable.Another view is that anxiety is "a futureAnother view is that anxiety is "a future--oriented mood state inoriented mood state in

which one is ready or prepared to attempt to cope with upcomingwhich one is ready or prepared to attempt to cope with upcomingnegative events" suggesting that it is a distinction between future vs.negative events" suggesting that it is a distinction between future vs.present dangers that divides anxiety and fear. Anxiety is consideredpresent dangers that divides anxiety and fear. Anxiety is considered

to be a normal reaction to stress. It may help a person to deal with ato be a normal reaction to stress. It may help a person to deal with a

difficult situation, for example at work or at school, by promptingdifficult situation, for example at work or at school, by promptingone to cope with it. When anxiety becomes excessive, it may fallone to cope with it. When anxiety becomes excessive, it may fall

under the classification of an anxiety disorder.under the classification of an anxiety disorder.


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MedicalMedicalManagementManagement


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MedicationMedication

The management of individual anxiety disorders is dependent onThe management of individual anxiety disorders is dependent onthe specific diagnosis.the specific diagnosis.

Selective serotonin reuptake inhibitors (SSRIs) are helpful in aSelective serotonin reuptake inhibitors (SSRIs) are helpful in avariety of anxiety disorders, including generalized anxiety disorder,variety of anxiety disorders, including generalized anxiety disorder,panic disorder, OCD, and social phobia.panic disorder, OCD, and social phobia.

Antidepressant agents are the drugs of choice in the treatment ofAntidepressant agents are the drugs of choice in the treatment ofanxiety disorders, particularly the newer agents that have a saferanxiety disorders, particularly the newer agents that have a saferadverse effect profile and higher ease of use than the older tricyclicadverse effect profile and higher ease of use than the older tricyclicagents; however, benzodiazepines often are used as adjunctagents; however, benzodiazepines often are used as adjuncttreatment.treatment.

Some anticonvulsant medications, such as divalproex andSome anticonvulsant medications, such as divalproex andgabapentin, may have a role in the treatment of anxiety disorders,gabapentin, may have a role in the treatment of anxiety disorders,especially in patients with high potential for abusingespecially in patients with high potential for abusingbenzodiazepines.benzodiazepines.


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Older antidepressants, such as tricyclic antidepressants and monoamineOlder antidepressants, such as tricyclic antidepressants and monoamineoxidase inhibitors (MAOIs) also are effective in the treatment of someoxidase inhibitors (MAOIs) also are effective in the treatment of someanxiety disorders. Caution in their use is warranted due to their higheranxiety disorders. Caution in their use is warranted due to their highertoxicity and potential lethality in overdose. Their use should be limited totoxicity and potential lethality in overdose. Their use should be limited tocases where SSRIs are ineffective or cannot be afforded. MAOIs may becases where SSRIs are ineffective or cannot be afforded. MAOIs may beespecially indicated in treatmentespecially indicated in treatment--refractory panic disorder and social anxietyrefractory panic disorder and social anxietydisorder. Clomipramine (Anafranil, a tricyclic agent) has a US Food anddisorder. Clomipramine (Anafranil, a tricyclic agent) has a US Food andDrug Administration (FDA) indication in the treatment of OCD and is theDrug Administration (FDA) indication in the treatment of OCD and is theonly tricyclic agent effective in the treatment of this condition. Indeed, itonly tricyclic agent effective in the treatment of this condition. Indeed, itcan be effective in cases refractory to treatment with SSRI agents. MAOIcan be effective in cases refractory to treatment with SSRI agents. MAOI

agents also may have a role in the treatment of certain subtypes of OCDagents also may have a role in the treatment of certain subtypes of OCDrefractory to conventional treatment, such as patients with symmetryrefractory to conventional treatment, such as patients with symmetryobsessions or associated panic attacks.obsessions or associated panic attacks.

The FDA has granted specific indications to the following disorders andThe FDA has granted specific indications to the following disorders andagents: generalized anxiety disorder (venlafaxine, buspirone, escitalopram,agents: generalized anxiety disorder (venlafaxine, buspirone, escitalopram,paroxetine, duloxetine), social phobia (paroxetine, sertraline, venlafaxine),paroxetine, duloxetine), social phobia (paroxetine, sertraline, venlafaxine),OCD (fluoxetine, sertraline, paroxetine, fluvoxamine), and PTSD (sertraline,OCD (fluoxetine, sertraline, paroxetine, fluvoxamine), and PTSD (sertraline,paroxetine).paroxetine).


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All SSRIs may be equal in the treatment of anxiety disorders; however,All SSRIs may be equal in the treatment of anxiety disorders; however,higher doses may be necessary in the treatment of OCD. Antidepressantshigher doses may be necessary in the treatment of OCD. Antidepressantsthat are not FDAthat are not FDA--approved for the treatment of a given anxiety disorder,approved for the treatment of a given anxiety disorder,such as nefazodone and mirtazapine, still may be beneficial. Patients withsuch as nefazodone and mirtazapine, still may be beneficial. Patients withpanic disorder may be more sensitive to treatment with antidepressants andpanic disorder may be more sensitive to treatment with antidepressants andfrequently need lower initial doses and slower titration to accomplishfrequently need lower initial doses and slower titration to accomplishsuccessful therapy.successful therapy.

Benzodiazepines are especially useful in the management of acuteBenzodiazepines are especially useful in the management of acutesituational anxiety disorder and adjustment disorder where the duration ofsituational anxiety disorder and adjustment disorder where the duration ofpharmacotherapy is anticipated to be 6 weeks or less and for the rapidpharmacotherapy is anticipated to be 6 weeks or less and for the rapid

control of panic attacks. If longcontrol of panic attacks. If long--term use of benzodiazepines seemsterm use of benzodiazepines seemsnecessary, obtaining a confirmatory opinion from a second clinician may benecessary, obtaining a confirmatory opinion from a second clinician may behelpful because chronic benzodiazepine use may be associated withhelpful because chronic benzodiazepine use may be associated withtolerance, withdrawal, and treatmenttolerance, withdrawal, and treatment--emergent anxietyemergent anxiety

The risk of addiction potential with benzodiazepines should be carefullyThe risk of addiction potential with benzodiazepines should be carefullyconsidered before use in the anxiety disorders. Avoid use in patients with aconsidered before use in the anxiety disorders. Avoid use in patients with aprior history of alcohol or other drug abuse. Closely monitor for evidence ofprior history of alcohol or other drug abuse. Closely monitor for evidence of

unauthorized dose escalation or obtaining benzodiazepine prescriptionsunauthorized dose escalation or obtaining benzodiazepine prescriptionsfrom multiple sourcesfrom multiple sources.. Initiation of antidepressant agents are thought to cause early worsening ofInitiation of antidepressant agents are thought to cause early worsening of

anxiety, agitation, and irritability, particularly when used to treat anxiety.anxiety, agitation, and irritability, particularly when used to treat anxiety.


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Sinclair et al use the term jitteriness/anxiety syndrome to describeSinclair et al use the term jitteriness/anxiety syndrome to describethese effects and completed a systematic search of articles thatthese effects and completed a systematic search of articles that

describe these effects. No validated rating scales fordescribe these effects. No validated rating scales forjitteriness/anxiety syndrome were identified among 107 articlesjitteriness/anxiety syndrome were identified among 107 articlesincluded in the review. No evidence indicated a difference inincluded in the review. No evidence indicated a difference inincidence of jitteriness/anxiety syndrome between selectiveincidence of jitteriness/anxiety syndrome between selectiveserotonin reuptake inhibitors (SSRIs) and tricyclic antidepressantsserotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants(TCAs), and a higher incidence was not observed in anxiety(TCAs), and a higher incidence was not observed in anxietydisorders. Incidence rates of jitteriness/anxiety syndrome varieddisorders. Incidence rates of jitteriness/anxiety syndrome varied

widely in the published literature (4widely in the published literature (4--65%). The authors concluded65%). The authors concludedthat jitteriness/anxiety syndrome is poorly characterized, butthat jitteriness/anxiety syndrome is poorly characterized, butperception of this syndrome influences clinician prescribing. Theyperception of this syndrome influences clinician prescribing. Theyrecommend more evaluation of side effects at early points duringrecommend more evaluation of side effects at early points duringantidepressant trials to more comprehensively describe thisantidepressant trials to more comprehensively describe thissyndrome.syndrome.


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Buspirone (BuSpar)Buspirone (BuSpar)

FDAFDA--approved for generalized anxiety disorder in adults. Does not appearapproved for generalized anxiety disorder in adults. Does not appearto be helpful as primary treatment for panic disorder or OCD.to be helpful as primary treatment for panic disorder or OCD.

Tricyclic antidepressantsTricyclic antidepressants

A complex group of drugs that have central and peripheral anticholinergicA complex group of drugs that have central and peripheral anticholinergiceffects, as well as sedative effectseffects, as well as sedative effects..

Imipramine (Tofranil)Imipramine (Tofranil)

Tricyclic antidepressant that has norepinephrine and serotonin reuptakeTricyclic antidepressant that has norepinephrine and serotonin reuptake--inhibition properties. One of the oldest agents available for the treatment ofinhibition properties. One of the oldest agents available for the treatment of

depression and has established efficacy in the treatment of panic disorder.depression and has established efficacy in the treatment of panic disorder.Elderly and adolescent patients may need lower dosing or slower titration.Elderly and adolescent patients may need lower dosing or slower titration.


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Antidepressant, Serotonin Reuptake InhibitorAntidepressant, Serotonin Reuptake Inhibitor

Paroxetine (Paxil)Paroxetine (Paxil)FDAFDA--approved for panic disorder, depression, social anxiety disorder,approved for panic disorder, depression, social anxiety disorder,

generalized anxiety disorder, posttraumatic stress disorder, and OCD.generalized anxiety disorder, posttraumatic stress disorder, and OCD.

Escitalopram (Lexapro)Escitalopram (Lexapro)

FDA approved for generalized anxiety disorder. SSRI and SFDA approved for generalized anxiety disorder. SSRI and S--enantiomer of citalopram. Used for the treatment of depression. Mechanismenantiomer of citalopram. Used for the treatment of depression. Mechanismof action is thought to be potentiation of serotonergic activity in centralof action is thought to be potentiation of serotonergic activity in centralnervous system resulting from inhibition of CNS neuronal reuptake ofnervous system resulting from inhibition of CNS neuronal reuptake ofserotonin. Onset of depression relief may be obtained after 1serotonin. Onset of depression relief may be obtained after 1--2 wk, which is2 wk, which issooner than other antidepressantssooner than other antidepressants..

DosingDosing InteractionsInteractions

ContraindicationsContraindications

PrecautionsPrecautions


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Nursing ManagementNursing Management


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MedicationMedicationWhen medication is indicated SSRIs, such as fluoxetine (Prozac), sertralineWhen medication is indicated SSRIs, such as fluoxetine (Prozac), sertraline(Zoloft), paroxetine (Paxil) and escitalopram (Lexapro) are generally(Zoloft), paroxetine (Paxil) and escitalopram (Lexapro) are generallyrecommended as first line agents. SNRIs such as venlafaxine (Effexor) arerecommended as first line agents. SNRIs such as venlafaxine (Effexor) arealso effective. Benzodiazepines, such as alprazolam (Xanax), clonazepamalso effective. Benzodiazepines, such as alprazolam (Xanax), clonazepam(Klonopin) and diazepam (Valium) are also sometimes indicated for short(Klonopin) and diazepam (Valium) are also sometimes indicated for short--term or PRN use. They are usually considered as a second line treatmentterm or PRN use. They are usually considered as a second line treatment

due to disadvantages such as cognitive impairment and due to their risks ofdue to disadvantages such as cognitive impairment and due to their risks ofdependence and withdrawal problems. MAOIs such as phenelzine (Nardil)dependence and withdrawal problems. MAOIs such as phenelzine (Nardil)and tranylcypromine (Parnate) are also considered an effective treatmentand tranylcypromine (Parnate) are also considered an effective treatmentand are especially useful in treament resistant cases, however dietaryand are especially useful in treament resistant cases, however dietaryrestrictions and medical interactions may limit their use. There is alsorestrictions and medical interactions may limit their use. There is alsoevidence that certain newer medications including the GABA analogueevidence that certain newer medications including the GABA analoguepregabalin (Lyrica), and the novel antidepressant mirtazapine (Remeron)pregabalin (Lyrica), and the novel antidepressant mirtazapine (Remeron)are also effective treatments for anxiety disorders. TCAs such asare also effective treatments for anxiety disorders. TCAs such as

imipramine, as well as atypical antipsychotics such as quetiapine, andimipramine, as well as atypical antipsychotics such as quetiapine, andpiperazines such as hydroxyzine are also occasionally prescribed.piperazines such as hydroxyzine are also occasionally prescribed.These medications need to be used with extreme care among older adults,These medications need to be used with extreme care among older adults,who are more likely to suffer side effects because of coexisting physicalwho are more likely to suffer side effects because of coexisting physicaldisorders. Adherence problems are more likely among elderly patients, whodisorders. Adherence problems are more likely among elderly patients, whomay have difficulty understanding, seeing, or remembering instructions.may have difficulty understanding, seeing, or remembering instructions.


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Natural TreatmentsNatural TreatmentsRegular aerobic exercise, improving sleep hygiene[Regular aerobic exercise, improving sleep hygiene[citation neededcitation needed] and reducing] and reducing

caffeine[caffeine[citation neededcitation needed are often useful in treating anxiety.are often useful in treating anxiety.Herbal drugs are often used in patients with somatoform disorders. In one clinical trial,Herbal drugs are often used in patients with somatoform disorders. In one clinical trial,

butterbur in a fixed herbal drug combination (Ze 185 = 4butterbur in a fixed herbal drug combination (Ze 185 = 4--combination versus 3combination versus 3--combination without butterbur and placebo) was used in patients with somatoformcombination without butterbur and placebo) was used in patients with somatoformdisorders. For a 2disorders. For a 2--week treatment in patients with somatization disorder (F45.0) andweek treatment in patients with somatization disorder (F45.0) andundifferentiated somatoform disorder (F45.1), 182 patients were randomized for a 3undifferentiated somatoform disorder (F45.1), 182 patients were randomized for a 3--arm trial (butterbur root, valerian root, passionflower herb, lemon balm leaf versusarm trial (butterbur root, valerian root, passionflower herb, lemon balm leaf versusvalerian root, passionflower herb, lemon balm leaf versus placebo). Anxiety (visualvalerian root, passionflower herb, lemon balm leaf versus placebo). Anxiety (visualanalogue scaleanalogue scale -- VAS) and depression (Beck's Depression InventoryVAS) and depression (Beck's Depression Inventory -- BDI) were usedBDI) were used

as primary parameters, and Clinical Global Impression (CGI) was used a secondaryas primary parameters, and Clinical Global Impression (CGI) was used a secondaryparameter. The 4parameter. The 4--combination was significantly superior to the 3combination was significantly superior to the 3--combination andcombination andplacebo in all the primary and secondary parameters (PPplacebo in all the primary and secondary parameters (PP--population), without seriouspopulation), without seriousadverse events.adverse events.

Many other natural remedies have been used for anxiety disorder. These include kava,Many other natural remedies have been used for anxiety disorder. These include kava,where the potential for benefit seems greater than that for harm with shortwhere the potential for benefit seems greater than that for harm with short--term useterm usein patients with mild to moderate anxiety. Based on Cochrane's systematic review ofin patients with mild to moderate anxiety. Based on Cochrane's systematic review ofseven RCTs (n = 380), with findings supported by five lowerseven RCTs (n = 380), with findings supported by five lower--quality trials (n = 320),quality trials (n = 320),

the American Academy of Family Physicians (AAFP) recommends use of kava forthe American Academy of Family Physicians (AAFP) recommends use of kava forpatients with mild to moderate anxiety disorders who are not using alcohol or takingpatients with mild to moderate anxiety disorders who are not using alcohol or takingother medicines metabolized by the liver, but who wish to use natural remedies.other medicines metabolized by the liver, but who wish to use natural remedies.Side effects of kava in the clinical trials were rare and mild.Side effects of kava in the clinical trials were rare and mild.

Inositol has been found to have modest effects in patients with panic disorder orInositol has been found to have modest effects in patients with panic disorder orobsessiveobsessive--compulsive disorder. St. John's wort and Sympathyl have also been used tocompulsive disorder. St. John's wort and Sympathyl have also been used totreat anxiety, but with little scientific evidence.treat anxiety, but with little scientific evidence.

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