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Anxiety Relief Guidelines for Dosage
The prolonged illness may cause depressive symptoms with emergence of suicidality and substance abuse. Many may continue to function in their social and occupational lives with some impairment, others may become severely incapacitated and give up their jobs and social duties. The impairment in different areas can be assessed self-administered visual analog scale. This can be addressed in following way.
The treatment of GAD may be long lasting hence the alliance is crucial. Understanding the life events, the extent and severity of symptoms requires confiding and lasting therapeutic relationship. Attention to the patient's worries and fears are essential for long term gains. The symptomatic improvement in psychological and autonomic symptoms leads to greater confidence in the treating doctor. The anxiety goes slowly with treatment and bursts of severe symptoms during the treatment need constant monitoring.
The drug treatment of GAD is some times is seen as a month treatment, some evidence indicate that treatment should be long term. Reduce psychological and autonomic symptoms and other co morbid conditions. Improve occupational and social functioning. Little Indian data to address the issue; mainly western data available.
Selective serotonin reuptake inhibitors SSRIs , serotonin-norepinephrine reuptake inhibitors SNRIs , and pregabalin are recommended as first line drugs due to their favorable risk-benefit ratio, with some differentiation regarding the various anxiety disorders. Majority of patients respond to the low dose of antidepressants with the exception of OCD. In the elderly, treatment should be started with half the recommended dose or less in order to minimize initial adverse drug events.
The antidepressant dose should be increased to the highest recommended therapeutic level if the initial treatment with a low or medium dose fails. For patients who do not improve with standard treatments, a number of alternative options should be tried including augmentation with small dose of antipsychotics or adding another anxiolytic agent or addition of non-pharmacological therapy like cognitive behavioral therapy CBT or Yoga, Meditation and increased physical activity as described below.
Non pharmacological treatment found useful in treatment of anxiety disorders include supportive therapy , Exposure therapy e. Psychoeducational advice, and suggesions to not to avoid feared situations are helpful in management.
Choosing between medications and CBT is determined by a number of factors, particularly the patient's preference, treatment options at hand, adverse drug effects, onset of efficacy, comorbidity e.
Several therapists have talked about Search of Indian module of psychotherapy and it is a felt need to have such a module, which is socially and culturally relevant.
Ancient Indian thought has provided very rich knowledge regarding mind and its functioning. From the Vedic period issues relating to mind, consciousness, understanding of human life, its existence and the concept of Atman have been widely studied and several explanations to improve the quality of human life are available in Vedic and Post Vedic literature.
The Bhagvad Gita contains in condensed form all the philosophical and psycholoical wisdom of the Upanishads. Bhagwad Gita describes all aspects of yoga, psychology and is unique among the psychlogical and philosophical teachings for a student of psychotherapy, various aspects of psychotherapeutic techniques are described in it. In this excellent module of Psychotherapy through 18 chapters way of self knowledge, the Yoga of action karma knowledge of renunciation and action, the path of meditation, knowledge of the absolute and eternal, yogic vision, yoga of devotion, profound knowledge of three Gunas and the wisdom of renunciation and liberation have been described at length, which leads to personality transformation of Arjuna.
In the modern psychotherapy, cognitive restructuring is the goal of psychotherapy, which has been accomplished a great deal through Bhagwad Gita. A Jain Meditational technique propounded by Acharya Mahapragya, which includes relaxation, meditation, yoga, asanas and pranayam, a comprehensive capsule of behavioural management has been tried in management of GAD.
On mental level, it proves to be an applied method to train the mind to concentrate. It offers a way to treat serious anxiety disorders with or without drugs. Large trials of this technique are still awaited. At present, few scientific studies are available. This seemingly unimportant aspect is most relevant to Indian settings where awareness of psychiatric illness and its realization and need for treatment with compliance is little.
Many feel dejected, angry, isolated and may have suicidal ideas. Family and the patient need to be told that this is like any other illness that needs treatment and success depends on compliance. The education that the illness is a chronic relapsing illness is essential and emergence of anxiety with or without treatment should be promptly treated.
Sudden discontinuation may lead to emergence of withdrawal symptoms thus early recognition by the patient and the family helps in prompt treatment. The treatment recommendations for the different anxiety disorders are summarized in Table I.
Some antianxiety drugs are effective in all anxiety disorders, whereas some drugs have only been studied in specific anxiety disorders and thus should be reserved for use in these particular disorders. Panic disorder and agoraphobia. In acute panic attacks, mouth desolving short-acting benzodiazepines and reassurance to the patient may be sufficient. Patients should be treated for atleast six to eight months or longer to prevent relapses.
A combination of CBT and anxiolytic medication has been shown to have the best treatment outcomes. Buspirone and hydroxyzine are second line treatment. Benzodiazepines should only be used for long-term treatment when other drugs or CBT have not shown results. Specific phobia should be treated with behaviour therapy including systematic desensatisation. SSRIs or short acting benzodiazepines should be tried in cases not responding to behaviour therapy.
Cognitive behaviour therapy CBT and exposure and response prevention are other proven techniques of management. Choice of treatments includes the SSRIs and venlafaxine. Therapeutic conversation, psychoeducation and regrief therapy are non-pharmacological treatment techniques advocated.
It is recommended to avoid paroxetine alprazolam use among pregnant women or women planning to become pregnant. SSRIs and TCAs are excreted into breast milk, they do not cause any harm to the new born because the concentration in breast milk is very small however infants of mothers on benzodiazepines, should be observed for signs of sedation, lethargy, poor suckling, and weight loss, and if high doses have to be used and long-term administration is required, breast feeding should probably be discontinued.
Treating children and adolescents. Choice of treatment should be SSRIs concerns about increased risk of suicidal ideation and behavior have ben reported therefore careful monitoring is advisable, presence of comorbid depression should be looked fore.
Elderly have increased sensitivity for anticholinergic properties, an increased risk for orthostatic hypotension, and ECG changes during treatment with TCAs, and possible paradoxical reactions to benzodiazepines, which include depression, with or without suicidal tendencies, phobias, aggressiveness, or violent behavior. Treatment of patients with severe Physical disease. Patients with cardiovascular, cerebrovascular and endocrine disease, irritable bowel syndrome, malignency, stroke, chronic obstructive pulmonary disease COPD hyperthyroidism may have associated anxiety reactions with their somatic disease state.
Such anxiety disorders may compound the management and the prognosis of these primary conditions. Decesion to stop treatment will depend on clinical response of the patients. Usualy the treatment is stopped in a tapering manner after atleast 6 months stability of clinical improvement and asymptomatic status of the patient. Patient's personal view should be included in decesion making of stopping the treatment. Mindfulness-Based Cognitive Behavior Therapy MBCBT for reducing cognitive and somatic anxiety and modifying dysfunctional cognitions in patients with anxiety disorders has been tried where in different versions of mindfulness meditation, cognitive restructuring, and strategies to handle worry, such as, worry postponement, worry exposure, and problem solving have been employed.
However, these studies are on small number of patients and need carefull review for further application. Diffrent side effects will emerge with different category of antianxiety medication. They should be carefully observed and addressed to. Side effects of medication can be drug related or dose related. If it is drug, related, alternative class of drug should be tried for adequate length of time.
If it is dose related then the dose of the drug has to be reduced. National Center for Biotechnology Information , U. Journal List Indian J Psychiatry v. Vahia , and Anita Gautam. Author information Copyright and License information Disclaimer. The symptoms should usually involve elements of: Natural history and course The age of onset is difficult to specify, as most of the patients have been anxious for long but report late. Open in a separate window. Pharmacotherapy The drug treatment of GAD is some times required as long as month treatment, some evidence indicate that treatment should be long term.
Psychotherapy Cognitive behaviour therapy. Goals Psycho-education Direct explanation of the symptoms and disorder to the patient and the family. Corrects the hypothesized cognitive distortions and helps to identify and counter fear of bodily sensations.
Efficacy Cognitive Behavioural Therapy has proven efficy other psychotherapies do help in ameliorating symptoms of anxiety. Adverse effects These are relatively benign. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not attributable to the physiological effects of a substance e. The disturbance is not better explained by another mental disorder e.
Reprinted with permission from the American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association; A number of scales are available to establish diagnosis and assess severity. The GAD-7 Table 2 7 has been validated as a diagnostic tool and a severity assessment scale, with a score of 10 or more having good diagnostic sensitivity and specificity.
Feeling nervous, anxious, or on edge. Total score for the 7 items ranges from 0 to Scores of 5, 10, and 15 represent cutoffs for mild, moderate, and severe anxiety, respectively.
Although designed primarily as a screening and severity measure for GAD, the GAD-7 also has moderately good operating characteristics for panic disorder, social anxiety disorder, and posttraumatic stress disorder. When screening for anxiety disorders, a recommended cutoff for further evaluation is a score of 10 or greater. Patient health questionnaire PHQ screeners. Accessed July 22, PD is characterized by episodic, unexpected panic attacks that occur without a clear trigger.
The most common physical symptom accompanying panic attacks is palpitations. 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:. The abrupt surge can occur from a calm state or an anxious state.
Palpitations, pounding heart, or accelerated heart rate. Sensations of shortness of breath or smothering. Chest pain or discomfort. Nausea or abdominal distress. Feeling dizzy, unsteady, light-headed, or faint. Chills or heat sensations. Paresthesias numbness or tingling sensations. Derealization feelings of unreality or depersonalization being detached from oneself. Such symptoms should not count as one of the four required symptoms.
At least one of the attacks has been followed by 1 month or more of one or both of the following:. Persistent concern or worry about additional panic attacks or their consequences e. A significant maladaptive change in behavior related to the attacks e.
When evaluating a patient for a suspected anxiety disorder, it is important to exclude medical conditions with similar presentations e. Other psychiatric disorders e. Complicating the diagnosis of GAD and PD is that many conditions in the differential diagnosis are also common comorbidities. Additionally, many patients with GAD or PD meet criteria for other psychiatric disorders, including major depressive disorder and social phobia.
Evidence suggests that GAD and PD usually occur with at least one other psychiatric disorder, such as mood, anxiety, or substance use disorders. Some studies evaluating anxiety treatments assess non-specific anxiety-related symptoms rather than the set of symptoms that characterize GAD or PD. When possible, the treatments described in this section will differentiate between GAD and PD; otherwise, treatments refer to anxiety-related symptoms in general.
Compassionate listening and education are an important foundation in the treatment of anxiety disorders. Common lifestyle recommendations that may reduce anxiety-related symptoms include identifying and removing possible triggers e.
Caffeine can trigger PD and other types of anxiety. Those with PD may be more sensitive to caffeine than the general population because of genetic polymorphisms in adenosine receptors. Many studies show an association between disordered sleep and anxiety, but causality is unclear. A number of medications are available for treating anxiety Table 4. Selective serotonin reuptake inhibitors. Duloxetine Cymbalta for GAD. Venlafaxine, extended release Effexor XR. Buspirone Buspar for GAD. Diazepam Valium for GAD.
They are listed from most to least commonly used. Generic price listed first; brand price listed in parentheses. Dependence, tolerance, and escalating doses to get the same effect over the long term can be problematic with use of benzodiazepines. Short-term prescribing with emphasis on acute management of uncontrolled anxiety is preferred. Slowly tapered dosing can prevent rebound symptoms.
Medications should be titrated slowly to decrease the initial activation. Because of the typical delay in onset of action, medications should not be considered ineffective until they are titrated to the high end of the dose range and continued for at least four weeks. Once symptoms have improved, medications should be used for 12 months before tapering to limit relapse. Benzodiazepines are effective in reducing anxiety, but there is a dose-response relationship associated with tolerance, sedation, confusion, and increased mortality.
The higher risk of dependence and adverse outcomes complicates the use of benzodiazepines. Pregabalin is more effective than placebo but not as effective as lorazepam Ativan for GAD. Weight gain is a common adverse effect of pregabalin.
There is limited evidence for the use of antipsychotics to treat anxiety disorders. Although quetiapine seems to be effective for GAD, the adverse effect profile is significant, including weight gain, diabetes mellitus, and hyperlipidemia. Its rapid onset can be appealing for patients needing immediate relief, and it may be a more appropriate alternative if benzodiazepines are contraindicated e.
Based on clinical experience, gabapentin Neurontin is sometimes prescribed by psychiatrists to treat anxiety on an as-needed basis when benzodiazepines are contraindicated. Psychotherapy includes many different approaches, such as cognitive behavior therapy CBT and applied relaxation Table 5.
Psychotherapy should be performed weekly for at least eight weeks to assess its effect. This intervention is useful in treating anxiety disorders.
The cognitive portion assists change in thinking patterns that support fears, whereas the behavior portion often involves training patients to relax deeply and helps desensitize patients to anxiety-provoking triggers. To be effective, therapy must be directed at the patient's specific anxieties and tailored to his or her needs.
There are minimal adverse effects, except that behavior desensitization is typically associated with temporary mild increases in anxiety. This intervention promotes focused attention on the present, acknowledgment of one's emotional state, and meditation for further stress reduction and relaxation.
Key features include moment to moment awareness cultivated with a nonjudgmental attitude, formal meditation techniques, and daily practice. Formal use of these interventions requires specialized training. In patients whose anxiety and impairment are severe, referral to a trained behavior health specialist should be considered.
Springer; , and Craske MG. American Psychological Association; Orsillo SM, Roemer L, eds. Acceptance and Mindfulness-Based Approaches to Anxiety: Information from references 33 and Mindfulness has similar effectiveness to traditional CBT or other behavior therapies, 38 particularly mindfulness-based stress reduction. After a treatment course, rebound symptoms may occur less often with psychotherapy than with medications. Although a number of complementary and alternative products have evidence for treating depression, most lack sufficient evidence for the treatment of anxiety.
Kava extract is an effective treatment for anxiety 44 ; however, case reports of hepatotoxicity have decreased its use. John's wort, tryptophan, 5-Hydroxytryptophan, and S-adenosyl- l -methionine should be used with caution in combination with SSRIs because of the increased risk of serotonin syndrome.
Evidence indicates that music therapy, aromatherapy, acupuncture, and massage are helpful for anxiety associated with specific disease states, but none have been evaluated specifically for GAD or PD. For patients with GAD or PD, psychiatric referral may be indicated if there is poor response to treatment, atypical presentation, or concern for significant comorbid psychiatric illness.
There is insufficient evidence to support a concise recommendation on the prevention of PD and GAD in adults. We searched Essential Evidence Plus, PubMed, and Ovid Medline using the keywords generalized anxiety disorder, panic disorder, diagnosis, treatment, medication, epidemiology, etiology, pathophysiology, differential diagnosis, and complementary and alternative medicine.
We searched professional and authoritative organizations on the topic of anxiety disorders, including the American Psychological Association, the National Institute of Mental Health, the National Institute for Health and Care Excellence, and the Cochrane Collaboration.
May to July Already a member or subscriber? Address correspondence to Amy B. Reprints are not available from the authors. Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. Int J Methods Psychiatr Res. Neural correlates of worry in generalized anxiety disorder and in normal controls: A twin study of lifetime generalized anxiety disorder GAD in older adults: Twin Res Hum Genet.
New dimensions of the neuroanatomical hypothesis of panic disorder. Anxiety disorders in older adults: A brief measure for assessing generalized anxiety disorder: Diagnostic co-morbidity in psychiatric out-patients presenting for treatment evaluated with a semi-structured diagnostic interview. National Institute for Health and Care Excellence.
Generalised anxiety disorder and panic disorder with or without agoraphobia in adults: Accessed July 10, Rate of improvement during and across three treatments for panic disorder with or without agoraphobia: Recent advances in the understanding and treatment of anxiety disorders.
Increased anxiogenic effects of caffeine in panic disorders. Frequent insufficient sleep and anxiety and depressive disorders among U. Reducing anxiety sensitivity with exercise. Exercise for the treatment of depression and anxiety.
Int J Psychiatry Med. A systematic review of yoga for state anxiety: Can J Occup Ther. An effect-size analysis of the relative efficacy and tolerability of serotonin selective reuptake inhibitors for panic disorder.
Diagnosis and Management of Generalized Anxiety Disorder and Panic Disorder in Adults
May 1, Benzodiazepines are effective in reducing anxiety symptoms, but their use is guidelines on GAD and PD in adults are a useful review of available . Dependence, tolerance, and escalating doses to get the same effect over. The purpose of these guidelines is to provide a summary of the current available information When using TCA to treat anxiety, start at very low doses. The risks. Feb 24, “Take one dropper of CBD per day,” is one of the most common dosage recommendations we hear. While this can definitely be a dosage.