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28.04.2015

Treatment for anxiety attacks, definition of clinical depression - Plans Download

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Despite high prevalence and negative consequences of anxiety disorders in later life, this area has received little research attention.
Approximately half of older patients diagnosed with an anxiety disorder in primary care are prescribed an anxiolytic or antidepressant medication (Stanley et al., 2001). This article provides a clinically relevant overview of issues related to social anxiety disorder (SAD), with particular emphasis on its diagnosis and treatment.
Given the scope of the problem, its robust association with other forms of psychopathology, and the overwhelming human burden of this illness, clinicians should be proficient in detecting and diagnosing SAD, and should be knowledgeable about evidence-based treatment modalities.
As the boundaries and core features of the syndrome were being discerned, behaviorally oriented clinicians were simultaneously laying the groundwork for both reliable measurement and behavioral and cognitive treatments of social anxiety-related difficulties. With the publication of the DSM–III,19 SAD was formally acknowledged as an independent diagnosis in its own right. As a consequence of these key developments, the past 2 decades have been characterized by substantial progress in understanding the origins, nature, and treatment of SAD.
To qualify for the diagnosis of SAD, an individual must have a marked or persistent fear of one or more social situations wherein there is exposure to unfamiliar people or possible scrutiny by others. When the diagnostic criteria for SAD were first published in the DSM-III,19 it was noted that generally, an individual has only one social phobia. As currently defined, SAD encompasses excessive fears and resultant avoidance of one or more social or performance situations in which there is the potential for scrutiny by others and the possibility of embarrassment or humiliation. One of the most common forms this fear takes is that of public speaking in both large and small groups. Research clearly suggests a largely chronic and unremitting course, which can last for decades if left untreated. Thorough assessment of SAD and social anxiety symptoms is a key part of the treatment process. The clinical interview typically serves as the point of departure in assessing for SAD and social-evaluative anxieties. Identification of comorbid psychopathology is an especially important part of the diagnostic process, as people with co-occurring conditions pose a more significant treatment challenge. The SCID-IV is broad and comprehensive in its coverage and has become an industry standard for clinical research requiring thorough diagnostic evaluations.
Another structured interview that focuses more precisely on the diagnosis of anxiety disorders is the Anxiety Disorders Interview Schedule for the DSM-IV (ADIS-IV).49 This interview is also administered by a clinical examiner in a semi-structured format, and identifies the presence of SAD, its generalized subtype, and the various other anxiety syndromes. The Brief Fear of Negative Evaluation Scale (BFNE)52 is a useful 12-item self-report measure based on the original 30-item scale developed by Watson and Friend.13 Whereas the LSAS focuses on the dimensions of fear and avoidance in various social situations, the BFNE assesses the degree to which patients have core components of social-evaluative anxiety, including thoughts, expectations, and associated distress over possible negative social judgments and embarrassing behaviors. Historically, treatments for social-evaluative anxieties and SAD have included both psychopharmacologic and psychotherapeutic strategies. Although pharmacotherapy of SAD was relatively neglected early on,18 recent years have witnessed a dramatic increase in progress of medication-based treatment.
Several comprehensive narrative and quantitative reviews of the pharmacotherapy literature in SAD have been presented elsewhere.18,55-60 This article emphasizes fundamentally practical medication treatments that have received the greatest attention and been subjected to rigorous empirical investigation (typically through randomized, double-blinded, placebo-controlled clinical trials), and that are generally viewed by a consensus of the research community as first- or second-line treatments for SAD. As a group, these studies have been characterized by some degree of methodological heterogeneity, such as varying research designs, number and nature of comparison conditions, sample composition, duration of acute treatment, medication dosage, and follow-up intervals. The MAOIs were one of the first groups of medications to receive intensive systematic evaluation in the treatment of SAD via controlled clinical trials.
Despite the proven effectiveness of the irreversible MAOIs in the treatment of SAD, and of phenelzine in particular, their use has been limited by an adverse side-effect profile, including the potential danger of hypertensive crisis if dietary restrictions on tyramine-rich foods are not carefully followed.
SSRIs are also well tolerated and are highly efficacious for both depressive and other anxiety disorders, which are often comorbid with SAD. Given the preponderance of evidence in support of the SSRIs, at present these medications are widely accepted and strongly recommended as first-line treatments for SAD and its generalized subtype. Despite demonstrated efficacy in treating other anxiety disorders (eg, panic disorder, obsessive-compulsive disorder [OCD]), there is little existing data to support the efficacy of tricyclic antidepressants in the treatment of SAD. Interestingly, Jefferson114 points out that there has been a general reluctance among clinicians to utilize benzodiazepines, especially in longer-term treatment of SAD, despite evidence suggesting long-term effectiveness and safety of agents such as clonazepam. Generally speaking, β-adrenergic blockers (eg, propranolol) should be reserved for treating the prominent physiological arousal characteristic of discrete public performance situations. Recent interest in the use of novel anticonvulsants as antianxiety agents has prompted investigation of these medications in the treatment of generalized SAD.
SAD and social-evaluative anxiety states have been treated with a variety of behavioral, cognitive, and combined cognitive-behavioral therapies (CBT). Behavior therapies used for SAD have been relatively problem focused, addressing the most prominent features associated with the disorder. Physiological retraining, or applied relaxation, involves teaching patients to use breathing techniques and progressive muscle relaxation when anxiety-provoking social situations are encountered.
Systematic exposure, either real or imagined, to a hierarchy of progressively more anxiety-provoking stimuli has been found to be a powerful component of treatment for several anxiety disorders.
The authors of this article use CBT treatment protocol in their clinic, which combines psychoeducation, cognitive therapy, and in-session systematic exposures to feared social situations using planned and structure role-play techniques. Briefly, individuals with SAD are educated about social anxiety in both its normal and pathological manifestations. Clients are taught to employ cognitive restructuring techniques, as discussed above, which help them to cope with anxiety experienced during in-session role-plays with the therapist.
SAD has clearly evolved from a once neglected anxiety disorder to an increasingly recognized, highly prevalent, and impairing psychiatric condition with considerable public health significance. Indication and important safety information for fortical (calcitonin-salmon rdna origin) nasal spray for intranasal use. The two main treatments for generalized anxiety disorder are psychotherapy and medications. Other medications may also be used to treat anxiety disorders, including maois (monoamine oxidase inhibitors), anticonvulsants, beta blockers, and atypical. Social anxiety disorder also known as social phobia is commonly treated by either psychotherapy or certain types of psychiatric medications.
A relatively small number of outcome investigations on late-life anxiety have focused on the impact of pharmacological and psychotherapeutic treatments. Benzodiazepines are the most commonly used anxiety management medication, followed by serotonergic antidepressants, buspirone (BuSpar), and venlafaxine (Effexor) (Mamdani et al., 2005). All pharmacological interventions reviewed are approved treatment options for anxiety disorders.
Only three randomized controlled trials have investigated the efficacy of benzodiazepines for anxiety disorders in later life. Five pharmacotherapy studies of late-life anxiety disorders have tested antidepressant medications.
It is intended for general informational purposes only and does not address individual circumstances. The purpose of this article is to provide a clinically relevant overview of some of the more substantive issues concerning the diagnosis and treatment of SAD. Public speaking may be an unpleasant and somewhat distressing prospect for a significant proportion of the general population. However, clinicians should be mindful of cultural variations in the presentation of SAD, or of social anxiety phenomena more generally. One plausible hypothesis is that there may be a common underlying core trait of social anxiety, the expression of which varies as a function of cultural idioms.


Onsets later in life, after a peak between the second and third decades, are relatively rare and are more likely to be cases of SAD occurring secondarily to, or as sequellae of, another mental disorder (eg, depression, psychotic disorders, eating disorders).34 Though onset is characteristically early, individuals with SAD may not recognize the fears and anxieties they experience in social situations as legitimate emotional problems in need of treatment. Clinical observations, focused interviewing, and the use of appropriate measures can help to facilitate accurate diagnosis and effective treatment planning.
In this regard, clinicians should be particularly vigilant for the presence of other anxiety disorders, substance use or abuse, depressive symptoms, and possible suicidal ideation.
The Structured Clinical Interview for DSM-IV (SCID-IV) is a comprehensive clinician-administered diagnostic interview, with both clinical and research versions available.48 It has been designed to be consistent with the classification of psychiatric diagnoses published in DSM-IV,24 and is organized into separate modules which evaluate classes of disorders (eg, psychotic, affective, anxiety, etc). Positive results were reported in two open clinical trials of tranylcypromine.68,69 In a study by Versiani and colleagues,68 patients were followed openly for 52 weeks with 62% of patients showing marked improvement, and another 17% showing moderate improvement. SSRIs are easily managed compared to other drug classes, and have therefore been investigated extensively in the treatment of SAD and its generalized subtype. Moreover, only 2 months after drug discontinuation, most patients reported a return to baseline levels of social anxiety symptoms. These skills include developing topics for conversation and maintaining appropriate eye contact and bodily orientation. Patients are taught to identify the earliest physiological cues of anxious arousal upon entering socially anxious situations, and then to counter these sensations via rapid deployment of learned anxiety reduction skills. These distorted cognitions generate significant anxiety and form the psychological core of the disorder.
Cognitive restructuring exercises and in vivo exposures are assigned for between session homework, as well.
This approach provides a therapeutic context in which members of the group enact and replicate some of the problematic or anxiety-provoking social situations that individuals encounter in daily life.
Studies by Kobak and colleagues86 and Clark and colleagues87 demonstrated that both combinations of active treatments and monotherapy are superior to placebo-controlled conditions. The distinguishing of a generalized subtype, which bears close resemblance to APD, has had important implications for assessment and treatment of SAD. The benzodiazepines are the other treatment that i commonly see being used in kids with anxiety disorders. Recent research has also examined the impact of psychotherapy, typically cognitive-behavioral therapy (CBT), for late-life anxiety. It is not a substitute for professional medical advice, diagnosis or treatment and should not be relied on to make decisions about your health.
In contrast, early pharmacologic treatment approaches may have been somewhat hindered, as SAD had yet to be formally recognized as an autonomous syndrome requiring independent investigation. Exposure to these phobic situations consistently evokes an anxiety response, which in some cases may be in the form of a panic attack (Criterion B). Individuals with SAD experience such incapacitating anxiety that it can actually have the untoward effect of undermining their public speaking performance, consequently reinforcing many of the fearful and maladaptive core beliefs driving the anxiety. People with SAD often fear that their symptoms of anxiety, (eg, blushing, perspiration, trembling, or a quivering voice) will be noticeable to others. A notable example of a culturally dependent manifestation of social anxiety is a condition known as taijin kyofusho, which has been reported in some Asian cultures including Japan and Korea, and is categorized as a culturally bound syndrome in the DSM-IV-TR.10 Whereas the primary focus of fear and anxiety in SAD is the prospect of embarrassing or humiliating oneself, in taijin kyofusho the individual is exquisitely sensitive to interpersonal relations, and may be preoccupied with concerns over doing something, or presenting oneself in a manner, that would be embarrassing or offensive to others in a social context (the offensive subtype). Several comprehensive reviews of the methodological issues and available assessment instruments for SAD have been presented elsewhere.45-47 The authors of this article provide a brief summary of strategies and tools that have been particularly useful in the assessment of SAD and social anxiety.
Likewise, when these frequently co-occurring conditions are the presenting complaint, accompanying symptoms of social anxiety should be carefully probed for.
The LSAS is both valid and reliable, and has become the standard primary outcome measure for social anxiety symptoms in clinical trials research. The scale has been found to be reliable and valid in nonclinical samples, and was recently validated in a sample of clinically anxious individuals.53 The BFNE has also been found to be a sensitive measure of change over the course of treatment.
Foremost among these was the recognition of SAD as a formal diagnosis, one that is both highly prevalent and substantially impairing. Virtually all SSRIs, including citalopram,77-79 escitalopram,80-81 fluoxetine,82-88 fluvoxamine,89-91 paroxetine,92-98 paroxetine controlled release,99 and sertraline100-104 have been subjected to randomized, double-blind, placebo-controlled clinical trials, typically demonstrating superior treatment efficacy to placebo control conditions on primary efficacy parameters (Table 1). In contrast, the efficacy of the longer acting benzodiazepine, clonazepam, was tested in a 10-week, double-blind, placebo-controlled trial, revealing a treatment response rate of 78% compared to only 20% of patients receiving placebo.112 The effectiveness of clonazepam in treating SAD has also been supported by several open clinical trials, and has recently been examined in a placebo-controlled clinical trial as augmentation for partial and nonresponse to SSRI therapy. In such a situation, the benzodiazepine would be used for several days before the event, and the β-blockers would be taken approximately 1 hour before the speech or performance.
The authors of this article focus on the CBT protocol developed by Heimberg and colleagues, which is currently being used in conjunction with pharmacotherapy in a collaborative research program between the Anxiety Disorders Clinic of New York State Psychiatric Institute and the Adult Anxiety Clinic of Temple University. In systematic exposure for SAD, patients engage in a feared social activity such as making small talk, public speaking, and dating, and remain in the feared situation until the anxious arousal subsides. A rating of fear is established for each item in the hierarchy using the Subjective Units of Distress Scale, a 0–100 rating scale in which higher numbers indicate increasing levels of distress and anxiety. For example, patients can practice presentations or public speaking in front of the group, role-play social encounters with members of either sex, and receive constructive feedback from co-members.
However, thus far there is little evidence suggesting superiority of the combined treatments over either individual treatment. Social anxiety disorder and the risk of depression: a prospective community study of adolescents and young adults. The treatment of social failure: A comparison of anxiety-reduction and skills acquisition procedures on two social problems. Relative effectiveness of rational restructuring and self-control desensitization in the reduction of interpersonal anxiety. The offensive subtype of Taijin-kyofu-sho in New York City: The phenomenology and treatment of a social anxiety disorder. The impairments caused by social phobia in the general population: Implications for intervention.
Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample.
Social anxiety disorder and the risk of depression: A prospective community study of adolescents and young adults. Comorbidity of anxiety and depressive disorders: issues in conceptualization, assessment and treatment. The efficacy of selective serotonin reuptake inhibitors for social anxiety disorder (social phobia): A meta-analysis of randomized controlled trials. Symposium presented at the 25th Annual Meeting of the Anxiety Disorders Association of America. Cognitive behavioral group therapy vs phenelzine therapy for social phobia: 12-week outcome.
Psychopharmacological treatment of social phobia: clinical and biochemical effects of brofaromine, a selective MAO-A inhibitor. Psychopharmacological treatment of social phobia; a double blind placebo controlled study with fluvoxamine. Fluvoxamine treatment of social phobia (social anxiety disorder): a double-blind, placebo-controlled study. Fluvoxamine CR in the long-term treatment of social anxiety disorder: the 12- to 24-week extension phase of a multicentre, randomized, placebo-controlled trial. Paroxetine treatment of generalized social phobia (social anxiety disorder): a randomized controlled trial.
A double-blind placebo-controlled trial of paroxetine in the management of social phobia (social anxiety disorder) in South Africa.


Efficacy of paroxetine for relapse prevention in social anxiety disorder: a 24-week study.
A multicenter, randomized, double-blind, placebo-controlled trial of paroxetine in children and adolescents with social anxiety disorder.
Randomised controlled general practice trial of sertraline, exposure therapy and combined treatment in generalised social phobia. Generalized anxiety disorder (gad) is a mood disorder that is characterized by multiple andor nonspecific worries that interfere with the persons life in some way. The data from these trials suggest the utility of benzodiazepines for anxiety disorders in older adults. Never ignore professional medical advice in seeking treatment because of something you have read on the WebMD Site. An overview of assessment and treatment via pharmacotherapy and cognitive-behavioral therapy, with a focus on practical clinical applications, is also presented. Issues concerning the assessment of SAD in the clinical and research settings are reviewed, and an overview of current empirically supported psychopharmacologic and psychotherapeutic treatments is provided.
Public speaking situations may be avoided to the extent that one’s social success and occupational advancement are compromised, (eg, turning down a promotion for fear of conducting presentations, or speaking to and managing subordinates). Equally problematic, the very nature of the core pathology in SAD, fear and avoidance of embarrassment and humiliation, leads to reduced treatment seeking. Much like the SCID-IV, the ADIS-IV requires training and is more typically employed in clinical research settings and anxiety disorder specialty clinics. Because of their common usage in the pharmacotherapy literature, these instruments provide useful metrics for inter-study comparisons. Whether MAOIs, SSRIs, or SNRIs used on a maintenance basis are helpful in patients who only suffer performance anxiety is not clear. In the continued presence of the anxiety-provoking social stimulus, the central nervous system gradually habituates, so that the stimulus situation no longer has the capacity to evoke anxious arousal. The therapist and patient gradually work through the hierarchy beginning with situations that prompt moderate amounts of anxiety, and working up to more distressing situations as therapy progresses. If this were determined to be the case, it would only serve to bolster support for the conduct of sequencing and augmentation studies. Definition of social anxiety disorder social anxiety disorder is a condition that causes you to fear social situations. For example, panic attacks, but not necessarily DSM-diagnosable panic disorder, are common in chronic obstructive pulmonary disease (COPD). A follow-up investigation demonstrated improvement in anxiety symptoms in patients with PD using sertraline (Zoloft) (Sheikh et al., 2004). Finally, the article underscores the necessity of integrating biologically based and psychosocial therapies to maximize long-term treatment effectiveness of SAD.
For example, Schneier and colleagues24 have cogently argued for the recognition and study of a social anxiety spectrum, which would encompass clinical social phobic states, as well as subsyndromal manifestations, associated symptoms, behaviors, and underlying variations in temperament and personality traits, (eg, shyness, behavioral inhibition).
There must also be prominent avoidance of the phobic performance or situation and, if not, it is typically endured with great anxiety or distress (Criterion D). Thus, clinicians (especially those serving diverse populations) should be cognizant of this and other potential culturally variable expressions of social anxiety.
For example, historically, men have been more likely to enter the workforce and to be the initiators of romantic relationships.
Total scores in the range of 30–60 are more typical of those with social anxiety in a specific circumstance, such as public speaking, eating in front of others, or other performance anxiety.
There is also greater abuse potential, discontinuation difficulties, adverse interactions with alcohol and other substances of abuse, and ineffectiveness for comorbid conditions, particularly depression.114 At present, there are no established guidelines suggesting the use of clonazepam over SSRIs as a first-line treatment for SAD. However, they do seem to help the performance anxiety that is a component of generalized SAD.
Patients are trained to internalize and utilize this dialogue when working to challenge maladaptive anxiety-provoking thoughts on their own between sessions.
A sample with mixed anxiety disorders showed high response rates to fluvoxamine (Luvox) (Wylie et al., 2000).
Among the advantages of a dimensional approach, Schneier and colleagues24 suggest that a social anxiety spectrum has utility in understanding the associations among SAD and diverse comorbid clinical syndromes, identifying underlying trait-like psychological constructs, and candidate neurobiological and neurochemical substrates. Difficulties in these significant roles presumably lead to greater salience and recognition of personal functional impairment in men, and to subsequent treatment seeking. A physician is your primary source for anxiety disorder treatment, but sometimes you just need to hear from someone who has walked in your shoes. The content on this site is presented in a summary fashion, and is intended to be used for educational and entertainment purposes only.
GAD: Emotional SymptomsThe main symptom of GAD is a constant and exaggerated sense of tension and anxiety.
Similarly, McNeil25 has proposed a continuum model of social anxiety and its disorders in which these anxieties and fears exist along a continuum, normally distributed in the general population.
Total scores of ≥90 occur in those patients with the generalized subtype of SAD experiencing very severe social anxiety and avoidance in a variety of situations. Some types of anxiety drugs can be habit-forming and are usually prescribed on a short-term or as-needed basis. Katz and colleagues (2002) conducted a secondary analysis of data from patients age 60 years and older who participated in five randomized clinical trials of venlafaxine for GAD. Sometimes it can be positive, for example, if it helps you deal with a tense situation in the. In the only prospective, randomized trial to date of a serotonergic antidepressant, Lenze and colleagues (2005), found citalopram (Celexa) superior to placebo, and these gains were maintained at 32-week follow-up for patients who continued taking the medication (Blank et al., in press). Diagnosing GADThere's no lab test for GAD, so the diagnosis is made based on your description of symptoms.
You may have GAD if you have been feeling anxious or worrying too much for at least six months. Self-Care for GADYou can support your treatment for GAD by making a few simple changes in your habits. Avoid caffeine, street drugs, and even some cold medicines, which can boost anxiety symptoms. Complementary Remedies for GADIt hard to know whether any non-traditional remedies for GAD work because they have not been well researched. Herbal Remedies for GADAmong herbal remedies, there is some evidence that kava may help ease mild to moderate anxiety.
Panic disorder affects about six million American adults, and it's one of the most treatable of all anxiety disorders. Rape, abuse, physical assaults, accidents, or a natural disaster can lead to this type of anxiety. Social Anxiety DisorderPeople with social phobia feel overly panicky and self-conscious in ordinary social situations.
If an anxiety disorder seems likely, your doctor may recommend medication and refer you to a mental health professional.



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