Anxiety_disorder for pharmacy student(1) (1).pdf

It very important material for all Pharmacy student

1. Anxiety disorders
BY: Mubarik Fetu (B.Pharm, M.Sc, Clinical
pharmacy specialist)
1
1/13/2023

2. Objectives
2
Upon completion of the chapter, the students will be able to:
1. Describe pathophysiology of generalized anxiety, panic, and
social anxiety disorders (SAD).
2. List common presenting symptoms of generalized anxiety, panic,
and SAD.
3. Identify the desired therapeutic outcomes for patients with
generalized anxiety, panic, and SAD.
5. Recommend psychotherapy and pharmacotherapy interventions
for patients with generalized anxiety, panic, and SAD.
6. Develop a monitoring plan for anxiety patients placed on
specific medications.
7. Educate patients about their disease state and appropriate
lifestyle modifications, as well as psychotherapy and
pharmacotherapy for effective treatment

3. Introduction (1)
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Anxiety: an emotional state commonly caused by the
perception of real or perceived danger that
threatens the security of an individual.

Anxiety is normal or adaptive response

Common or situational anxiety
a normal response to a stressful circumstance
last no more than 2 or 3 weeks

4. Introduction (2)
4
Anxiety can produce uncomfortable and potentially
debilitating
Psychological arousal(e.g., worry, fear, difficulty
concentrating or feeling of threat, apprehension) and
physiologic arousal (e.g., tachycardia, shortness of breath,
trembling, pacing)
Some individuals experience persistent, severe anxiety
symptoms and possess irrational fears that significantly
impair normal daily functioning.
These persons often suffer from an anxiety disorder.

5. Introduction (3)
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Anxiety disorders
are often missed or attributed incorrectly to other
medical illnesses and
most patients are treated inadequately
Individuals with anxiety disorders develop
cardiovascular, cerebrovascular, gastrointestinal (GI),
and respiratory disorders at a significantly higher rate
than the general population

6. Epidemiology (1)
6
Anxiety disorders are the most common psychiatric
illnesses
Anxiety disorders are more prevalent among women
than men(2:1).
The lifetime prevalence of
anxiety disorders collectively is 28.8%
specific phobia (12.5%)
social anxiety disorder (SAD) (12.1%)
generalized anxiety disorder (GAD) for those 18
years of age and older to be 5.7%,
panic disorder (PD), 4.7%

7. Epidemiology (2)
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Prevalence rates across the anxiety spectrum
increase from the younger age group (18–29
years) to older age groups (30–44 and 45–59
years)
substantially lower for those older than age 59
years

8. Etiology
8
Genetics

Stress

9. Medical Conditions That Can Cause
Anxiety (1)
9
Psychiatric Disorders
Mood disorders, hypochondriasis, personality disorders,
alcohol or substance abuse, alcohol or substance
withdrawal, other anxiety disorders
Neurologic Disorders
CVA, seizure disorders, dementia, stroke, migraine,
encephalitis, vestibular dysfunction
Cardiovascular Disorders
Angina, arrhythmias, congestive heart failure, mitral
valve prolapse, myocardial infarction
CVA, cerebrovascular accident

10. Medical Conditions That Can Cause
Anxiety (2)
10
Endocrine and Metabolic Disorders
Hypothyroidism or hyperthyroidism, hypoglycemia,
Cushing disease, Addison disease, pheochromocytoma,
hyperadrenocorticism, hyponatremia, hyperkalemia,
vitamin B12 deficiency
Respiratory Disorders
Asthma, COPD, pulmonary embolism, pneumonia,
Hyperventilation
Other
Carcinoid syndrome, anemias, SLE
COPD, chronic obstructive pulmonary disease; SLE, systemic lupus erythematosus

11. Medications Associated with Anxiety
Symptoms
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12. Pathophysiology (1)
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The thalamus
provides the first real processing region to organize
sensory data obtained from the environment
passes information to
higher cortical centers for finer processing and
amygdala for rapid assessment of highly charged emotional
information.
The amygdala provides emotional valence or the
emotional importance of the information
Helps to act quickly on ambiguous, but vital events

13. Pathophysiology (2)
13
The cortex performs
a more detailed analysis and sends updates to the amygdala
for comparison and any needed course corrections,
thus enabling a decision on a course of action
Direct and indirect connections to the reticular activating
system (RAS), a region spanning the medulla, pons, and
midbrain,
help to regulate arousal, vigilance, and fear.
These connections are modulated by serotonin (5-HT)
and norepinephrine (NE)

14. Pathophysiology (3)
14
Figure 1: Neurocircuitry and key neurotransmitters involved in mediating
anxiety disorders

15. Pathophysiology (4)
15
Noradrenergic System
Increased activity locus ceruleus (LC) (where
Norepinephrine-producing cells reside) elevated
levels of NE Anxiety
Serotonergic System
Activity of 5-HT cells in the raphe nuclei over time inhibits
firing of noradrenergic cells in the LC
Regulate cells in the prefrontal cortex and amygdala
γ-Aminobutyric acid (GABA)
Enhancing the activity of GABA at the GABA type A (GABA
A) receptor neuronal excitability is reduced
decrease anxiety
GABA inhibits 5-HT, NE, and dopamine (DA) systems

16. Pathophysiology (5)
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Hypothalamic–Pituitary–Adrenal Axis
stress increase the synthesis and release of cortisol
serves to mobilize and to replenish energy stores and
contributes to increased arousal

17. Generalized anxiety disorder (GAD)
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GAD is excessive anxiety and worry about several events
or activities for most days during at least a 6-month
period
GAD has a gradual onset with an average age of 21
years
In GAD there is a bimodal distribution (the mid teens and
mid-50s )
Onset occurs
earlier when GAD is the primary presentation and
later when GAD is secondary

18. Generalized anxiety disorder (GAD)
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The course of the illness is
chronic
recurrent
and low rates of recovery
Lifetime comorbidity with another psychiatric disorder
occurs in 50%-90% of patients with GAD
depression being found in over 60%
Panic disorder being found in 25%

19. DSM-5 Diagnostic Criteria for GAD
19
A.Excessive anxiety and worry (apprehensive expectation), occurring more days than
not for at least 6 months, about a number of events or activities (such as work or
school performance).
B.The individual finds it difficult to control the worry.
C.The anxiety and worry are associated with three (or more) of the following six
symptoms (with at least some symptoms having been present for more days than not
for the past 6 months): Note: Only one item is required in children.
1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying
sleep).
D.The anxiety or worry causes significant distress or functional impairment and is NOT
attributable to another substance, medical, or psychiatric condition

20. GAD
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Differential Diagnosis
Rule out underlying medical or psychiatric disorders
and medications that may cause anxiety

21. GAD - Treatment
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Desired outcome
The goals of therapy in the acute management of GAD
are:
to reduce the severity and duration of the anxiety
symptoms and
to improve overall functioning.
The long-term goals in GAD are:
remission with minimal or no anxiety symptoms, no
functional impairment, and
increased QOL
Prevention of recurrence

22. GAD-Nonpharmacologic Therapy
22
Nonpharmacologic treatment modalities in GAD include
Psychoeducation
short-term counseling
stress management
Psychotherapy
cognitive-behavioral therapy (CBT) - self-monitoring of worry,
cognitive restructuring, relaxation training, and rehearsal of coping
skills
supportive, and
insight oriented: uncovering unconscious conflicts and identifying
ego strengths
Exercise

23. GAD - Pharmacologic Therapy
23
The medicines used in the treatment of GAD are;
Benzodiazepines
Antidepressants
Selective serotonin reuptake inhibitors (SSRI)
Serotonin and norepinephrine reuptake inhibitors (SNRIs)
Tricyclic Antidepressants
Buspirone
Anticonvulsant medications
Pregabalin
Hydroxyzine
Atypical antipsychotics

24. GAD – Treatment duration
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Drug treatment of generalized anxiety disorder is
sometimes seen as a 6- to 12-month treatment,
some evidence indicates that treatment should be
long term, perhaps lifelong
About 25 percent of patients relapse in the first
month after the discontinuation of therapy, and
60 to 80 percent relapse over the course of the next
year

25. Antidepressants Therapy (1)
25
Antidepressants are considered first-line agents in the
management of GAD
Antidepressants reduce the psychic symptoms (e.g.
worry and apprehension) of anxiety
They have a modest effect on autonomic or somatic
symptoms (e.g. tremor, rapid heart rate, and/or
sweating
The onset of antianxiety effect is delayed 2 to 4 weeks
Antidepressants are the treatment of choice for the
management of chronic anxiety

26. Antidepressants Therapy (2)
26
Antidepressants are efficacious for acute and long-term
management of GAD
SSRIs, extended-release venlafaxine, and duloxetine are
effective in acute therapy (response rates of 60%–68%
and remission rates of 30%.).
Imipramine is considered a second-line agent
Venlafaxine ER, Sertraline, Fluoxetine, and Fluvoxamine
have demonstrated benefits in children and adolescents
with GAD
Duloxetine, escitalopram, sertraline, venlafaxine are
efficacious in the treatment of GAD in the elderly

27. Table 1:Antidepressant Antianxiety
Agents for GAD

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28. Table 2: Monitoring of Adverse Effects Associated
with Medications Used for Anxiety Disorders
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29. Table 2: Monitoring of Adverse Effects Associated
with Medications Used for Anxiety Disorders
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30. Table 2: Monitoring of Adverse Effects Associated
with Medications Used for Anxiety Disorders
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31. Buspirone (1)
31
Buspirone:
a nonbenzodiazepine anxiolytic
lacks anticonvulsant, muscle relaxant, hypnotic, motor
impairment, and dependence properties
a second-line agent for GAD
is effective for the psychic symptoms of anxiety

32. Buspirone (2)
32
It has partial agonist activity at the 5-HT1A presynaptic
receptors -reducing the firing of 5-HT neurons
Buspirone is a treatment option for patients with GAD,
particularly
for patients with uncomplicated GAD,
in patients who fail other anxiolytic therapies, or
in patients with substance abuse
It is not useful in clinical situations requiring immediate
anxiolysis or for situations requiring as-needed anxiolytic
therapy
It showed efficacy in elderly patients with GAD

33. Buspirone - Dosing and Administration
33
The dose of buspirone
initiated at 7.5 mg twice daily
can be titrated in increments of 5 mg/day every 2 to 3
days as needed to a usual target dose of 20 to 30
mg/day.
maximum therapeutic benefit might not be evident for 4 to
6 weeks
It may be less effective in patients
who have been treated previously (4 weeks–5 years) with
benzodiazepines
Buspirone pharmacokinetics are not affected by sex or
age

34. Buspirone – Drug interactions
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Drugs that inhibit cytochrome P450 3A4 (eg,
verapamil, itraconazole, fluvoxamine) can increase
buspirone levels.
Rifampin caused a 10-fold reduction in buspirone
levels.
Buspirone reportedly elevates blood pressure in
patients taking a monoamine oxidase inhibitor
(MAOI).

35. Pregabalin
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Has anxiolytic properties being a calcium channel
modulator,
selectively binds to the α-2delta subunit of voltage-gated
calcium channels
effective for both somatic and psychic symptoms
reduces the risk of relapse
has a short elimination half-life dosed two to three
times daily
excreted renally with a low risk of drug–drug interactions
not beneficial for depression or other anxiety disorders

36. Table 3:Nonbenzodiazepine Antianxiety
Agents for GAD

36
a. Elderly patients are usually treated with approximately one half of the dose listed.
b. No dosage adjustment is required in elderly patients

37. Table 4: Adverse Effects Associated with other
Medications Used for Anxiety Disorders
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38. Benzodiazepine Therapy (1)
38
BDZs are recommended
for acute treatment of GAD when short-term relief is
needed,
 an as-needed basis
as an adjunct during initiation of antidepressant therapy,
or to improve sleep
They are more effective for somatic and autonomic
symptoms of GAD
65% to 75% of patients with GAD have a marked to
moderate response to BDZs

39. Benzodiazepine Therapy (2)
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The use of a benzodiazepine with an intermediate
half-life (8 to 15 hours) will likely avoid
some of the adverse effects associated with the use of
benzodiazepines with long half-lives
The use of divided doses prevents
the development of adverse effects associated with
high peak plasma levels

40. Benzodiazepine Therapy (3)
40
Intermediate- or short-acting benzodiazepines are
preferred for chronic use
in the elderly and
those with liver disorders
because of minimal accumulation and achievement of steady
state within 1 to 3 days
Lorazepam and oxazepam
are preferred agents for patients with reduced hepatic
function secondary to aging or disease
IM lorazepam provides rapid and complete absorption

41. Benzodiazepine Therapy (4)
41

Table 5: Benzodiazepine Antianxiety Agents
a Available generically. b Orally disintegrating formulation. c. Panic disorder dose.

42. Benzodiazepine Therapy(5)
42
Table 6: Pharmacokinetics of Benzodiazepine Antianxiety Agents
Desmethyldiazepam (DMDZ) half-life 50–100 hours

43. Benzodiazepine - Dosing and
Administration
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Start with low doses, and adjust weekly
Treatment of acute anxiety generally should not
exceed 4 weeks.
Manage persistent symptoms with antidepressants.
Long half-life benzodiazepines may be dosed once
daily at bedtime,
providing nighttime hypnotic and next day anxiolytic
effects.
Use low doses of short-elimination half-life agents in
the elderly

44. Benzodiazepine Therapy Disadvantages
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Major benzodiazepine disadvantages are
lack of effectiveness for depression;
risk for dependency, tolerance and abuse; and
potential interdose rebound anxiety, especially with
short-acting benzodiazepines
Withdrawal effect

45. Table 7: Monitoring of Adverse Effects
Associated with Benzodiazepine
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46. Benzodiazepine discontinuation (1)
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Discontinuation of benzodiazepines may be
associated with
Withdrawal (anxiety, insomnia, agitation, muscle
tension, irritability, nausea, diaphoresis, nightmares,
depression, hyperreflexia, tinnitus, delusions,
hallucinations, and seizures)
Rebound anxiety
Recurrence or relapse

47. Benzodiazepine discontinuation (2)
47
Discontinuation strategies include:
A 25% per week reduction in dosage until 50% of the
dose is reached, and
then reduce by 10% - 12% every 4 to 7 days
Patients on BDZs therapy for 2 to 6 months should be
tapered over 2 to 8 weeks, but
patients receiving 12 months of treatment should be
tapered over 2 to 4 months
Adjunctive use of pregabalin can help to reduce
withdrawal symptoms during the benzodiazepine taper.

48. 48
Figure 2: Treatment algorithm for generalized anxiety disorder.

49. Evaluation of Therapeutic Outcomes (1)
49
Anxious patients should be monitored once every 2
weeks for
a reduction in the frequency, duration, and severity of
anxiety symptoms
improvement in functioning
Treatment resistance is defined as a poor, partial, or lack
of response with at least two antidepressants from
different classes.
Increase the dose in patients exhibiting a partial response
after 2 to 4 weeks on an antidepressant or
2 weeks on a benzodiazepine

50. Evaluation of Therapeutic Outcomes (2)
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Treatment strategies for patients who do not
achieve an appropriate response with a first-line
agent include
increasing the dose of the SSRI/SNRI,
Changing to a different agent in the same class,
changing to a different agent of a different class, or
augmentation of therapy

51. Panic disorder (PD)
51
Panic attacks: an abrupt surge of intense fear or intense
discomfort
The unexpected panic attacks are followed by at least
1 month of persistent concern about having another panic
attack,
worry about the possible consequences of the panic attack, or
a significant maladaptive change in behavior related to the
attacks
It usually last no more than 20 to 30 minutes, with the peak
intensity of symptoms within the first 10 minutes

Panic disorder: recurrent unexpected panic attacks

52. DSM-5 Diagnostic Criteria for Panic
Disorder (1)
52
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of
intense fear or intense discomfort that reaches a peak within minutes and during
which time four (or more) of the following symptoms occur: Note: The abrupt
surge can occur from a calm state or an anxious state.
1. Palpitations, pounding heart, or accelerated heart rate.
2. Sweating.
3. Trembling or shaking.
4. Sensations of shortness of breath or smothering.
5. Feelings of choking.
6. Chest pain or discomfort.
7. Nausea or abdominal distress.
8. Feeling dizzy, unsteady, light-headed, or faint.
9. Chills or heat sensations.
10. Paresthesias (numbness or tingling sensations).
11. Derealization (feelings of unreality) or depersonalization (being detached from one-self).
12. Fear of losing control or "going crazy."
13. Fear of dying.

53. DSM-5 Diagnostic Criteria for Panic
Disorder (2)
53
B. At least one of the attacks has been followed by 1 month
(or more) of one or both of the following:
1. Persistent concern or worry about additional panic attacks or
their consequences (e.g., losing control, having a heart attack, "going
crazy").
2. A significant maladaptive change in behavior related to the
attacks (e.g., behaviors designed to avoid having panic attacks, such
as avoidance of exercise or unfamiliar situations).
C. The disturbance is not attributable to
the physiological effects of a substance e.g., a drug of abuse, a
medication)
another medical condition e.g., hyperthyroidism, cardiopulmonary
disorders).
D. The disturbance is not better explained by another mental
disorder

54. Panic disorder
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Differential Diagnosis
Rule out underlying medical or psychiatric disorders
and medications that may cause anxiety
Laboratory Evaluation
• Urine drug screen
• Basic metabolic panel (HgbA1C)look at guideline
• Thyroid-stimulating hormone
• Electrocardiogram

55. Panic disorder
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Complications of panic disorder include
depression (10%-65% have major depressive
disorder),
alcohol abuse, and
high use of health services and emergency rooms

56. Panic disorder - treatment
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Desired Outcomes
The main objectives of treatment are
to reduce the severity and frequency of panic attacks,
to reduce anticipatory anxiety and agoraphobic
behavior, and
to minimize symptoms of depression or other comorbid
disorders
The long-term goal is to achieve and sustain remission
and restore overall functioning

57. Nonpharmacologic Therapy
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Avoid caffeine, nicotine, alcohol, drugs of abuse,
and stimulants
Aerobic exercise (e.g., walking for 60 minutes or
running for 20-30 minutes 4 day/wk.)
Cognitive Behavioral Therapy (CBT) - 16 to 20
hours in length conducted over a period of 4 months
short-term improvement in 80% to 90% of patients and
6-month improvement in 75% of patients
Bibliotherapy (the use of self-help books)

58. Pharmacologic Therapy
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SSRIs
SNRI - venlafaxine
TCA - imipramine, and
Benzodiazepines - alprazolam and clonazepam
MAOI

59. Pharmacologic Therapy
59
Antidepressants
typically require 4 weeks for onset of antipanic effect
Show optimal response at 6 to 12 weeks
should be initiated at lower doses in PD patients than in
depressed patients (1/4 or ½ dose).
Target doses are similar to those used for depression
should be tapered when treatment is discontinued to
avoid withdrawal symptoms,
including irritability, dizziness, headache, and
dysphoria

60. Pharmacologic Therapy
60
PD patients more likely experience stimulant-like side
effects of antidepressants than patients with major
depression
SSRIs are the first-line agents because of their tolerability
and efficacy in acute and long-term studies
All SSRIs have demonstrated effectiveness in controlled
trials, with 60% to 80% of patients achieving a panic-
free state

61. Pharmacologic Therapy
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Serotonin Norepinephrine Reuptake Inhibitors
(SNRI)
The dosage of venlafaxine extended-release is
37.5 mg/day for the first 3 to 7 days, and then
increased to a minimum of 75 mg/day
Increasing the dose to 150 mg/day after initial
nonresponse or partial response is recommended
Venlafaxine reduces the severity of anticipatory
anxiety, fear, and avoidance

62. Pharmacologic Therapy
62
Tricyclic anti depressant - Imipramine
Treatment with imipramine, leaves 45% to 70% of patients
panic free
Imipramine effectively blocks panic attacks within at least 4
weeks
maximal improvement (including antiphobic response) does not occur
until 8 to 12 weeks
With imipramine, treatment should be slowly increased by 10
mg every 2 to 4 days as tolerated
PD patients taking TCAs may experience
anticholinergic effects, orthostatic hypotension, sweating, sleep
disturbances, dizziness, fatigue, sexual dysfunction, and weight
gain

63. Pharmacologic Therapy
63
Benzodiazepines – Alprazolam and Clonazepam
Therapeutic response to benzodiazepines occurs in 1 to 2 weeks
The dose of benzodiazepine required for PD improvement
generally is higher than that used in other anxiety disorders
Alprazolam is associated with significant panic reduction after 1
week of therapy (e.g., 55%–75% panic free)
Increase doses of clonazepam by 0.25 or 0.5 mg every 3 days
to 4 mg/day if needed
Patients with PD experience greater rebound anxiety and
relapse when discontinuing benzodiazepines than do patients
with GAD
There is no evidence that tolerance to therapeutic effect occurs

64. Pharmacologic Therapy
64
Beta Blockers
Pindolol 25 mg three times a day is an effective
adjunctive treatment with an SSRI
Propranolol 120 to 240 mg/day has been found
equivalent to alprazolam in reduction of panic attacks
β-blockers are not expected to reduce psychic
anxiety or avoidance behavior
 heart rate and blood pressure reduction are dose-
related adverse events that may limit use

65. Pharmacologic Therapy
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Monoamine Oxidase Inhibitors (MAOIs)
are used refractory cases
dietary restriction of tyramine and avoid
sympathomimetic drugs to avoid hypertensive crisis

66. 66
Figure 3:Algorithm for the pharmacotherapy of panic disorder.

67. Pharmacologic Therapy
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Increasing order of effectiveness:
citalopram, sertraline, paroxetine, fluoxetine, and
venlafaxine for panic symptoms and
paroxetine, fluoxetine, fluvoxamine, citalopram,
venlafaxine, and mirtazapine for overall anxiety
symptoms

68. Table 8: Drug used in the treatment
of PD
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69. Outcome Evaluation
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Assess patients
weekly - for symptom improvement during the first 4 weeks of
therapy
then every 2 to 4 weeks to adjust drug dosages based on
improvement in panic symptoms and to monitor for adverse
events
After the dose is stabilized and symptoms have
decreased, visits every 2 months should suffice
Alter the therapy of patients who do not achieve a
significant reduction in panic symptoms after
6 to 8 weeks on an adequate dose of antidepressant
3 weeks on a benzodiazepine

70. Outcome Evaluation
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Regularly evaluate patients for adverse effects and
medication adherence
When significant response to drug therapy is
achieved,
continue treatment for at least 1 year
Evaluate for symptom relapse and adverse effects
Remission is defined as equal to or less than 3 with no
or mild agoraphobic avoidance, anxiety, disability, or
depressive symptoms

71. Social anxiety disorder (SAD)
71
SAD
is characterized by marked fear about one or more
social situations
in which the individual is exposed to possible scrutiny by
others
mean age of onset is the mid-teens
rate higher among women than men and more frequent
in younger cohorts
chronic disorder with a mean duration of 20 years
fear of embarrassment from social interaction typifies
SAD
fear of anxiety symptoms is characteristic of panic disorder,

72. DSM-5 Diagnostic Criteria for Social
Anxiety Disorder (1)
72
A. Marked fear or anxiety about one or more social situations in
which the individual is exposed to possible scrutiny by others.
Examples include social interactions (e.g., having a conversation, meeting
unfamiliar people), being observed (e.g., eating or drinking), and
performing in front of others (e.g., giving a speech).
Note: In children, the anxiety must occur in peer settings and just during
interactions with adults.
B. The individual fears that he or she will act in a way or show
anxiety symptoms that will be negatively evaluated (i.e., will be
humiliating or embarrassing; will lead to rejection or offend others).
C. The social situations almost always provoke fear or anxiety. Note:
In children, the fear of anxiety may be expressed by crying,
tantrums, freezing, clinging, shrinking, or failing to speak in social
situations.
D. The social situations are avoided or endured with intense fear or
anxiety.

73. DSM-5 Diagnostic Criteria for Social
Anxiety Disorder (2)
73
E. The fear of anxiety is out of proportion to the actual threat posed by the
social situations and to the sociocultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months
or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physiological
effects of a substance (e.g., a drug of abuse, a medication) or another
medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms
of another mental disorder, such as panic disorder, body dysmorphic
disorder, or autism spectrum disorder.
J. If another medical condition (e.g., Parkinson's disease, obesity,
disfigurement from burns or injury) is present, the fear, anxiety, or
avoidance is clearly unrelated or is excessive.
Specify if: Performance only: If the fear is restricted to speaking or
performing in public.

74. SAD -treatment
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74
The goal of acute treatment (4-12 wks.)is to reduce
physiologic symptoms of anxiety,
fear of social situations, and
phobic behaviors
The long-term goal (3-6 months)is
to restore social functioning and
to improve the patient’s quality of life
Patients with comorbid depression should have a
significant reduction in depressive symptoms

75. Nonpharmacologic Therapy
1/13/2023
75
Patient education on disease course, treatment
options, and expectations is essential
Support groups may be beneficial for some patients
CBT (exposure therapy, cognitive restructuring,
relaxation training techniques, and social skills
training)

76. Pharmacologic therapy
76
Several pharmacologic agents have demonstrated
effectiveness in SAD, including the
SSRIs, venlafaxine, phenelzine, benzodiazepines,
gabapentin, and pregabalin
TCAs are not effective in SAD
SSRIs are considered the drugs of choice based on
their tolerability and efficacy
The onset of effect was delayed 4 to 8 weeks, and
maximum benefit was often not observed until 12 weeks
or longer
treatment for at least 1 year

77. Pharmacologic therapy
77
Selective Serotonin Reuptake Inhibitors
improve social anxiety and phobic avoidance and reduce overall
disability
Initiate doses similar to those used for the treatment of depression
administered as a single daily dose
If the patient has comorbid panic - one-fourth or one-half of
depression dose
The dose–response curve for SSRIs tends to be relatively flat
Increase the dose as tolerated in patients who have not responded
after 4 weeks of therapy
When discontinuing an SSRI,
the dosage should be tapered monthly
i.e., decreasing sertraline by 50 mg or paroxetine by 10 mg
to reduce risk of relapse and discontinuation symptoms

78. Pharmacologic therapy
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78
Venlafaxine
Venlafaxine extended release, in doses of 75 to 225
mg/day, has similar efficacy to SSRIs
Venlafaxine should be tapered slowly (ie, decreasing
by 37.5 mg/mo)
to decrease the risk of relapse during discontinuation

79. Pharmacologic therapy
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79
Monoamine Oxidase Inhibitors and Reversible
Inhibitors of Monoamine Oxidase
Phenelzine,
effective in 64% to 69% of SAD patients
reserved for treatment-refractory patients owing to
dietary restrictions,drug interactions, and side effects

80. Pharmacologic therapy
80
Alternative Agents
Benzodiazepines
Clonazepam should be gradually tapered at a rate not to
exceed 0.25 mg every 2 weeks
Anticonvulsants – Gabapentin, pregabalin
considered for patients with inadequate response to
SSRI/SNRIs
β-Blockers
decrease the physiologic symptoms of anxiety
reduce performance anxiety
Propranolol (10-80mg)or atenolol (25-100mg)should be
administered 1 hour before a performance situation
β-blockers are not used daily in SAD

81. 81
Figure 4: Algorithm for the pharmacotherapy of social anxiety disorder

82. Outcome evaluation
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82
Monitor patients
weekly during acute treatment (eg, initiation and
titration of pharmacotherapy) and
monthly once stabilized
Pharmacotherapy for patients with SAD should lead
to improvement in anxiety and fear, functionality,
and overall well-being
Inquire about adverse effects, SAD symptoms,
suicidal ideation, and symptoms of comorbid
psychiatric conditions at each visit

83. Conclusion
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83
Anxiety disorders are common in the population and occur
concurrently with other psychiatric disorders
Nonpharmacologic interventions often are effective alone
or when combined with drug therapy
Benzodiazepines are 1
st
line for situational anxiety
Antidepressants are first-line therapy for GAD, panic
disorder, and SAD
Antidepressants, including the SSRIs and SNRIs, and the
benzodiazepines clonazepam and alprazolam are used
extensively in patients with GAD, panic disorder, and SAD

84. References
84
Barbara G. Wells, Joseph T. DiPiro, Terry L.
Schwinghammer, Cecily V. DiPiro Pharmacotherapy
Handbook, 10
th
Edition, New York McGraw-Hill Education
,2017
Dipiro JT, Talbert RL, Yee GC, et.al. Pharmacotherapy, A
Pathophysiologic Approach, 10
th
edition, McGraw-Hill
Education,2017
Caroline S. Zeind, Michael G. Carvalho. Applied
Therapeutics, The Clinical Use of Drugs, 11
th
edition, 2018
Benjamin James Sadock, Virginia Alcott Sadock, Pedro
Ruiz. Synopsis of psychiatry Behavioral Sciences/Clinical
Psychiatry, 11
th
edition, Wolters Kluwer , 2015

85. 1/20/2023
85

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