Anxiety

is a psychological and physiological state characterized by cognitive,

somatic, emotional, and behavioral components. These components
combine to create an unpleasant feeling that is typically associated
with uneasiness, apprehension, fear, or worry. Anxiety is a
generalized mood condition that can often occur without an
identifiable triggering stimulus. As such, it is distinguished from fear,
which occurs in the presence of an observed threat. Additionally, fear
is related to the specific behaviors of escape and avoidance, whereas
anxiety is the result of threats that are perceived to be uncontrollable
or unavoidable.
Another view is that anxiety is "a future-oriented mood state in
which one is ready or prepared to attempt to cope with upcoming
negative events" suggesting that it is a distinction between future vs.
present dangers that divides anxiety and fear. Anxiety is considered
to 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 prompting one
to cope with it. When anxiety becomes excessive, it may fall under
the classification of an anxiety disorder.
 Sign and Symptoms
 Physical effects of anxiety may include heart palpitations, muscle weakness and tension, fatigue,
nausea, chest pain, shortness of breath, stomach aches, or headaches. The body prepares to
deal with a threat: blood pressure and heart rate are increased, sweating is increased, bloodflow
to the major muscle groups is increased, and immune and digestive system functions are
inhibited (the fight or flight response). External signs of anxiety may include pale skin, sweating,
trembling, and pupillary dilation. Someone who has anxiety might also experience it as a sense of
dread or panic. Although panic attacks are not experienced by every person who has anxiety,
they are a common symptom. Panic attacks usually come without warning, and although the fear
is generally irrational, the perception of danger is very real. A person experiencing a panic attack
will often feel as if he or she is about to die or pass out.
 Anxiety does not only consist of physical effects; there are many emotional ones as well. They
include "feelings of apprehension or dread, trouble concentrating, feeling tense or jumpy,
anticipating the worst, irritability, restlessness, watching (and waiting) for signs (and
occurrences) or danger, and, feeling like your mind's gone blank” as well as "nightmares/bad
dreams, obsessions about sensations, deja vu, a trapped in your mind feeling, and feeling like
everything is scary."
 Cognitive effects of anxiety may include thoughts about suspected dangers, such as fear of
dying. "You may...fear that the chest pains [a physical symptom of anxiety] are a deadly heart
attack or that the shooting pains in your head [another physical symptom of anxiety] are the
result of a tumor or aneurysm. You feel an intense fear when you think of dying, or you may
think of it more often than normal, or can’t get it out of your mind."
 Medical
Management
 Medication
 The management of individual anxiety disorders is dependent on
the specific diagnosis.
 Selective serotonin reuptake inhibitors (SSRIs) are helpful in a
variety of anxiety disorders, including generalized anxiety disorder,
panic disorder, OCD, and social phobia.
 Antidepressant agents are the drugs of choice in the treatment of
anxiety disorders, particularly the newer agents that have a safer
adverse effect profile and higher ease of use than the older tricyclic
agents; however, benzodiazepines often are used as adjunct
treatment.
 Some anticonvulsant medications, such as divalproex and
gabapentin, may have a role in the treatment of anxiety disorders,
especially in patients with high potential for abusing
benzodiazepines.
 Older antidepressants, such as tricyclic antidepressants and monoamine
oxidase inhibitors (MAOIs) also are effective in the treatment of some
anxiety disorders. Caution in their use is warranted due to their higher
toxicity and potential lethality in overdose. Their use should be limited to
cases where SSRIs are ineffective or cannot be afforded. MAOIs may be
especially indicated in treatment-refractory panic disorder and social anxiety
disorder. Clomipramine (Anafranil, a tricyclic agent) has a US Food and
Drug Administration (FDA) indication in the treatment of OCD and is the
only tricyclic agent effective in the treatment of this condition. Indeed, it
can be effective in cases refractory to treatment with SSRI agents. MAOI
agents also may have a role in the treatment of certain subtypes of OCD
refractory to conventional treatment, such as patients with symmetry
obsessions or associated panic attacks.

 The FDA has granted specific indications to the following disorders and
agents: generalized anxiety disorder (venlafaxine, buspirone, escitalopram,
paroxetine, duloxetine), social phobia (paroxetine, sertraline, venlafaxine),
OCD (fluoxetine, sertraline, paroxetine, fluvoxamine), and PTSD (sertraline,
paroxetine).
 All SSRIs may be equal in the treatment of anxiety disorders; however,
higher doses may be necessary in the treatment of OCD. Antidepressants
that are not FDA-approved for the treatment of a given anxiety disorder,
such as nefazodone and mirtazapine, still may be beneficial. Patients with
panic disorder may be more sensitive to treatment with antidepressants and
frequently need lower initial doses and slower titration to accomplish
successful therapy.
 Benzodiazepines are especially useful in the management of acute
situational anxiety disorder and adjustment disorder where the duration of
pharmacotherapy is anticipated to be 6 weeks or less and for the rapid
control of panic attacks. If long-term use of benzodiazepines seems
necessary, obtaining a confirmatory opinion from a second clinician may be
helpful because chronic benzodiazepine use may be associated with
tolerance, withdrawal, and treatment-emergent anxiety
 The risk of addiction potential with benzodiazepines should be carefully
considered before use in the anxiety disorders. Avoid use in patients with a
prior history of alcohol or other drug abuse. Closely monitor for evidence of
unauthorized dose escalation or obtaining benzodiazepine prescriptions
from multiple sources.
 Initiation of antidepressant agents are thought to cause early worsening of
anxiety, agitation, and irritability, particularly when used to treat anxiety.
 Sinclair et al use the term jitteriness/anxiety syndrome to describe
these effects and completed a systematic search of articles that
describe these effects. No validated rating scales for
jitteriness/anxiety syndrome were identified among 107 articles
included in the review. No evidence indicated a difference in
incidence of jitteriness/anxiety syndrome between selective
serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants
(TCAs), and a higher incidence was not observed in anxiety
disorders. Incidence rates of jitteriness/anxiety syndrome varied
widely in the published literature (4-65%). The authors concluded
that jitteriness/anxiety syndrome is poorly characterized, but
perception of this syndrome influences clinician prescribing. They
recommend more evaluation of side effects at early points during
antidepressant trials to more comprehensively describe this
syndrome.
Benzodiazepines
Several drugs in the benzodiazepine class can be used for the short-term (£ 6 wk)
control of anxiety. Drugs in this class include lorazepam, diazepam, clonazepam,
and chlordiazepoxide.

Serotonin and norepinephrine reuptake inhibitors

Pharmacologic agents with both reuptake inhibition of serotonin and
norepinephrine may be helpful in a variety of mood and anxiety disorders .

Venlafaxine (Effexor XR)

FDA-approved for generalized anxiety disorder, panic disorder and social
anxiety disorder in adults. May be helpful for other anxiety disorders.

Duloxetine (Cymbalta)
Potent inhibitor of neuronal serotonin and norepinephrine reuptake.
Indicated for generalized anxiety disorder.

Antianxiety agents
Buspirone is a novel antianxiety agent with no other members in its
class.
Buspirone (BuSpar)
FDA-approved for generalized anxiety disorder in adults. Does not appear to
be helpful as primary treatment for panic disorder or OCD.

Tricyclic antidepressants
A complex group of drugs that have central and peripheral anticholinergic
effects, as well as sedative effects.

Imipramine (Tofranil)
Tricyclic antidepressant that has norepinephrine and serotonin reuptake-
inhibition properties. One of the oldest agents available for the treatment of
depression and has established efficacy in the treatment of panic disorder.
Elderly and adolescent patients may need lower dosing or slower titration.
 Antidepressant, Serotonin Reuptake Inhibitor

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

generalized anxiety disorder, posttraumatic stress disorder, and OCD.

Escitalopram (Lexapro)
 FDA approved for generalized anxiety disorder. SSRI and S-
enantiomer of citalopram. Used for the treatment of depression. Mechanism
of action is thought to be potentiation of serotonergic activity in central
nervous system resulting from inhibition of CNS neuronal reuptake of
serotonin. Onset of depression relief may be obtained after 1-2 wk, which is
sooner than other antidepressants.
 Dosing
 Interactions
 Contraindications
 Precautions
Nursing Management
 Medication
When medication is indicated SSRIs, such as fluoxetine (Prozac), sertraline
(Zoloft), paroxetine (Paxil) and escitalopram (Lexapro) are generally
recommended as first line agents. SNRIs such as venlafaxine (Effexor) are
also effective. Benzodiazepines, such as alprazolam (Xanax), clonazepam
(Klonopin) and diazepam (Valium) are also sometimes indicated for short-
term or PRN use. They are usually considered as a second line treatment
due to disadvantages such as cognitive impairment and due to their risks of
dependence and withdrawal problems. MAOIs such as phenelzine (Nardil)
and tranylcypromine (Parnate) are also considered an effective treatment
and are especially useful in treament resistant cases, however dietary
restrictions and medical interactions may limit their use. There is also
evidence that certain newer medications including the GABA analogue
pregabalin (Lyrica), and the novel antidepressant mirtazapine (Remeron) are
also effective treatments for anxiety disorders. TCAs such as imipramine, as
well as atypical antipsychotics such as quetiapine, and piperazines such as
hydroxyzine are also occasionally prescribed.
These medications need to be used with extreme care among older adults,
who are more likely to suffer side effects because of coexisting physical
disorders. Adherence problems are more likely among elderly patients, who
may have difficulty understanding, seeing, or remembering instructions.
 Natural Treatments
Regular aerobic exercise, improving sleep hygiene[ citation needed] and reducing
caffeine[citation needed are often useful in treating anxiety.
Herbal drugs are often used in patients with somatoform disorders. In one clinical trial,
butterbur in a fixed herbal drug combination (Ze 185 = 4-combination versus 3-
combination without butterbur and placebo) was used in patients with somatoform
disorders. For a 2-week treatment in patients with somatization disorder (F45.0) and
undifferentiated somatoform disorder (F45.1), 182 patients were randomized for a 3-
arm trial (butterbur root, valerian root, passionflower herb, lemon balm leaf versus
valerian root, passionflower herb, lemon balm leaf versus placebo). Anxiety (visual
analogue scale - VAS) and depression (Beck's Depression Inventory - BDI) were used
as primary parameters, and Clinical Global Impression (CGI) was used a secondary
parameter. The 4-combination was significantly superior to the 3-combination and
placebo in all the primary and secondary parameters (PP-population), without serious
adverse events.
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 short-term use
in patients with mild to moderate anxiety. Based on Cochrane's systematic review of
seven RCTs (n = 380), with findings supported by five lower-quality trials (n = 320),
the American Academy of Family Physicians (AAFP) recommends use of kava for
patients with mild to moderate anxiety disorders who are not using alcohol or taking
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.
Inositol has been found to have modest effects in patients with panic disorder or
obsessive-compulsive disorder. St. John's wort and Sympathyl have also been used to
treat anxiety, but with little scientific evidence.