eMedicine Specialties > Psychiatry > Adult

Anxiety Disorders: Treatment & Medication

Author: William R Yates, MD, MS, Research Psychiatrist, Laureate Institute for Brain Research; Professor of Research, Department of Psychiatry, University of Oklahoma College of Medicine at Tulsa
Contributor Information and Disclosures

Updated: Oct 26, 2009

Treatment

Medical Care

Patients with panic disorder frequently present to the emergency department with chest pain or dyspnea, fearing that they are dying of myocardial infarction. Anxiety symptoms often accompany or can exacerbate respiratory conditions such as asthma and chronic obstructive pulmonary disease.

• If clinically indicated, obtain necessary studies to rule out myocardial infarction and pulmonary embolism (ECG, chest radiograph).
• Intravenous or oral acute sedation with benzodiazepines may be used. Untreated panic attacks can subside spontaneously within 20-30 minutes, especially with reassurance and a calming environment.
• If possible, avoid long-term benzodiazepines for chronic anxiety disorders. If this approach seems necessary, obtaining a confirming opinion from a consulting psychiatrist may be helpful.

Consultations

• Most often, psychiatrists are consulted.
• In anxiety disorders secondary to a general medical condition, specialty consultation may be indicated.

Diet

• Discontinue (or decrease to a low reasonable level) caffeine-containing products such as coffee, tea, colas, and Mountain Dew.
• Over-the-counter preparations and herbal remedies should be reviewed with special caution because ephedrine and other herbal compounds may precipitate or exacerbate anxiety symptoms.

Activity

• If no medical contraindication exists, recommend at least a mild-to-moderate daily exercise program.

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. 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.

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 trialsto more comprehensively describe this syndrome.³

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.

Lorazepam (Ativan)

Sedative hypnotic in the benzodiazepine class that has a short onset of effect and a relatively long half-life. By increasing action of gamma-aminobutyric acid (GABA), which is a major inhibitory neurotransmitter in the brain, may depress all levels of the CNS, including limbic and reticular formation. Available for PO, IV, or IM use.

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

These agents specifically inhibit presynaptic reuptake or serotonin but not noradrenaline.

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.

Sertraline (Zoloft)

FDA-approved for panic disorder, PTSD, social phobia, and OCD. May be helpful for other anxiety disorders.

Fluoxetine (Prozac)

FDA-approved for OCD and panic disorder. May be helpful for other anxiety disorders.

Fluvoxamine (Luvox)

FDA approved for OCD in children (8-17 y) and adults. May be helpful for other anxiety disorders.

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