ANXIETY

Anxiety is a cardinal symptom of many psychiatric disorders and an almost inevitable component of many medical and surgical conditions. Indeed, it is a universal human emotion, closely allied with appropriate fear and presumably serving psychobiologically adaptive purposes. A most important clinical generalization is that anxiety is rather infrequently a “disease” in itself. Anxiety that is typically associated with the former “psychoneurotic” disorders is not readily explained in biological or psychological terms; contemporary hypotheses implicate over activity of adrenergic systems or dysregulation of serotonergic systems in the CNS .In addition, symptoms of anxiety commonly are associated with depression and especially with dysthymic disorder (chronic depression of moderate severity), panic disorder, agoraphobia and other specific phobias, obsessive-compulsive disorder, eating disorders, and many personality disorders .Sometimes, despite a thoughtful evaluation of a patient, no treatable primary illness is found, or if one is found and treated, it may be desirable to deal directly with the anxiety at the same time. In such situations antianxiety medications are frequently and appropriately used.

Currently, the benzodiazepines and the SSRIs are the most commonly employed medicinal treatments for the common clinical anxiety disorders. Some high-potency benzodiazepines (alprazolam, clonazepam, and lorazepam) are effective in severe anxiety with strong autonomic over activity (panic disorder), as are several antidepressants, as discussed above. For generalized or nonspecific anxiety, the benzodiazepine selected seems to make little difference. In the elderly or in patients with impaired hepatic function, oxazepam in small, divided doses sometimes is favoured due to its brief action and direct conjugation and elimination. The latter property is shared by lorazepam, but not by alprazolam. Benzodiazepines sometimes are given to patients presenting with anxiety mixed with symptoms of depression, although the efficacy of these agents in altering the core features of severe major depression has not been demonstrated.

The most favourable responses to the benzodiazepines are obtained in situations that involve relatively acute anxiety reactions in medical or psychiatric patients who have either modifiable primary illnesses or primary anxiety disorders. However, this group of anxious patients also has a high response rate to placebo and is likely to undergo spontaneous improvement. Antianxiety drugs also are used in the management of more persistent or recurrent primary anxiety disorders; guidelines for their appropriate long-term use for such disorders are less clear.

Although there has been concern about the potential for habituation and abuse of benzodiazepines, some studies suggest that physicians tend to be conservative and may even undertreat patients with anxiety. They may either withhold drug unless symptoms or dysfunction are severe, or cease treatment within a few weeks, with a high proportion of relapses. Patients with personality disorders or a past history of abuse of sedatives or alcohol may be particularly at risk of dose escalation and dependence on benzodiazepines. Benzodiazepines carry some risk of impairing cognition and skilled motor functions, particularly in the elderly, in whom they are a common cause of confusion, delirium (sometimes mistaken for primary dementia), and falls with fractures. Risk of fatality on acute overdose of benzodiazepines is limited in the absence of other cerebrotoxins, including alcohol.

A particularly controversial aspect of the use of benzodiazepines, especially those of high potency, is in long-term management of patients with sustained or recurring symptoms of anxiety. Clinical benefit has been found for at least several months in such cases, but it is unclear to what extent the long-term benefits can be distinguished from nonspecific (“placebo”) effects following development of tolerance on the one hand, or prevention of related withdrawal-emergent anxiety on the other.

It is hard to bring all possible treatments and effective drugs use in a single page, so I promise to bring in light other effective drugs used in anxiety treatment with some emotional therapies.

By: Ammarah Khan

    

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