Chapter 35: Management of Anxiety Disorders

Drugs used to treat PTSD

3 SSRIs- fluoxetine, paroxetine, and sertraline; and one serotonin/norepinephrine reuptake inhibitor (venlafaxine)

Obsessive-compulsive disorder (OCD)

an anxiety disorder characterized by unwanted repetitive thoughts (obsessions) and/or actions (compulsions)

First line drugs for panic disorder

benzodiazepines

busiprone (BuSpar) drug and food interactions

erythromycin and ketoconazole; also grapefruit juice

Characteristics of panic disorder

pounding pulse, chest pain or discomfort, feeling of choking, nausea or abdominal discomfort, fear of dying, flushes or chills, and fear of losing self control

Treatment plan for PTSD

psychotherapy and drugs

Treatment for social anxiety disorder (social phobia)

psychotherapy, SSRIs, paroxetine (Paxil, and sertraline (Zoloft)

Nondrug treatment approaches for generalized anxiety disorder

supportive therapy, cognitive behavioral therapy, biofeedback, and relaxation training

Anxiety

uncomfortable state with psychologic and physical components

First line antidepressant approved for generalized anxiety disorder

venlafaxine (Effexor XR)

How long does uncontrollable worrying occur before it is considered generalized anxiety disorder?

6 months or longer

The selective serotonin reuptake inhibitors (SSRIs) are recommended therapy for a number of psychologic disorders. The nurse identifies the SSRIs as effective for the treatment of patients with which psychologic disorders? (Select all that apply.) A. Depression B. Panic disorder C. Social anxiety disorder D. Post-traumatic stress disorder E. Obsessive-compulsive disorder

A, B, C, and E Rationale: Neither the SSRIs nor any other drugs, for that matter, have proved effective in the treatment of post-traumatic stress disorder. SSRIs are used to treat the other psychologic disorders listed.

A patient asks the nurse about treatments for post-traumatic stress disorder (PTSD). Which statement by the nurse is the most helpful? A. "The primary treatment is therapy, but there are some medications that have been somewhat effective." B. "The primary treatment is monotherapy with an SSRI." C. "The primary treatment is a combination of multiple medications." D. "The primary treatment is benzodiazepine for anxiety."

A. Rationale: Post-traumatic stress disorder can be treated with psychotherapy and with drugs. There are multiple therapy types and strategies. Regarding drugs, evidence of efficacy is strongest for three SSRIs (fluoxetine, paroxetine, and sertraline) and one SNRI (venlafaxine). Of these four drugs, only two—paroxetine [Paxil] and sertraline [Zoloft]—are FDA-approved for PTSD. If none of the first-line drugs are effective, the guidelines suggest several alternatives: mirtazapine, a TCA (amitriptyline or imipramine), or an MAOI (phenelzine). Current evidence does not support the use of monotherapy with either bupropion, buspirone, trazodone, or a benzodiazepine.

A distraught patient is admitted to the emergency department with symptoms of palpitations, tachycardia, chest pain, and shortness of breath. The physical examination reveals no physiologic basis for the symptoms. Which diagnosis, therefore, is most likely? A. Panic disorder B. Bipolar disorder C. Generalized anxiety disorder D. Clinical depression

A. panic disorder Rationale: Panic disorder is characterized by symptoms similar to those of a myocardial infarction (MI). Patients often fear losing control and dying and also may experience dizziness, nausea, depersonalization, and tingling or numbness in the hands. Generalized anxiety disorder is characterized by excessive worrying about events, but it also can include trembling, muscle tension, restlessness, palpitations, tachycardia, sweating, and clammy hands. Bipolar disorder is characterized by mood swings with periods of mania and depression.

buspirone (Buspar) tolerance, dependence, and abuse

no withdrawal symptoms have been observed,

busiprone (BuSpar)

not a CNS depressant, no abuse potential, doesn't intensify CNS depressant effects

The nurse identifies which antidepressant as effective in the treatment of generalized anxiety disorder (GAD)? (Select all that apply.) A. Fluoxetine [Prozac] B. Venlafaxine [Effexor XR] C. Paroxetine [Paxil] D. Escitalopram [Lexapro] E. Duloxetine [Cymbalta]

B, C, D, and E Rationale: Fluoxetine [Prozac] is not approved for the treatment of generalized anxiety disorder. All the other medications listed are approved for the treatment of GAD.

The nurse provides teaching for a pt with OCD who has been prescribed Sertraline (Zoloft). Which statement by the pt indicates that more teaching is necessary? A. "I may develop headaches and trouble sleeping." B. "I will feel better in 3 weeks." C. "I need to take this medication for at least a year." D. "I should watch my diet so that I don't gain weight."

B. Rationale: Beneficial effects of sertraline develop slowly over several months to become maximal. Common side effects include nausea, headache, insomnia, and sexual dysfunction. Weight gain can also occur. Tx lasts for at least a year.

The nurse is caring for a patient taking buspirone [BuSpar]. Which statement by the patient indicates a need for further teaching about this drug? A. "This medication should not make me feel drowsy." B. "This medication should help me feel less anxious." C. "I will drink grapefruit juice instead of coffee with breakfast." D. "I will take my medication three times per day."

C. Rationale: Grapefruit juice can greatly increase buspirone levels and should be avoided. The other statements are appropriate.

A pt is prescribed venlafaxine (Effexor XR) and requests information about the medication. Which response by the nurse is most appropriate? A. "You will need to talk with your doctor about that." B. "Call your pharmacist, because he/she will know the most about this drug." C. "Venlafaxine (Effexor XR) is used to treat anxiety and depression." D. "I will get you a pamphlet so that you can read about the drug."

C. Rationale: Venlafaxine (Effexor XR) is used to treat anxiety and depression.

The nurse is caring for a patient receiving buspirone [BuSpar] for the treatment of anxiety. Which symptom is most likely explained as an adverse effect of this drug? A. Diarrhea B. Risk for abuse C. Dizziness D. Weight gain

C. dizziness Rationale: Buspirone is an antianxiety medication with few side effects. The most common effects are dizziness, nausea, headache, nervousness, lightheadedness, and excitement. Buspirone does not cause drowsiness, risk for abuse, or weight gain.

The nurse is caring for a pt with social anxiety disorder. The pt is currently experiencing intense anxiety. The nurse should prepare to administer which medication for the immediate relief of anxiety? A. fluvoxamine (Luvox) B. paroxetine (Paxil) C. sertraline (Zoloft) D. clonazepam (Klonopin)

D. Rationale: Benzodiazepines provide immediate relief of anxiety and can be used as needed for intense anxiety. SSRIs are first line drugs for most pts with social anxiety disorder, and they are especially well suited for pts who fear multiple situations and face them on a regular basis.

The nurse is caring for a patient with severe generalized anxiety disorder. Which agent would be most effective for immediate stabilization? A. Venlafaxine [Effexor] B. Buspirone [BuSpar] C. Paroxetine [Paxil] D. Alprazolam [Xanax]

D. alprazolam (Xanax) Rationale: Alprazolam, a benzodiazepine, would provide the most rapid onset of relief. Buspirone, paroxetine, and venlafaxine are also first-line agents for the treatment of generalized anxiety disorder, but their onset is delayed. They are preferred for long-term management.

Drug therapy for OCD

SSRIs

Antidepressant classes used for treatment of panic disorder

SSRIs, TCAs, MAOIs

Anxiolytic

a drug that lessens anxiety

Generalized anxiety disorder

an anxiety disorder in which a person is continually tense, apprehensive, and in a state of autonomic nervous system arousal

Panic disorder

an anxiety disorder that consists of sudden, overwhelming attacks of terror

What is the most common psychiatric illness?

anxiety

Drug therapy for generalized anxiety disorder

benzodiazepines and buspirone (BuSpar)

What is the most common side effect of venlafaxine (Effexor XR)?

nausea

Adverse effects of buspirone (BuSpar)

dizziness, nausea, headache, nervousness, sedation, lightheadedness, and excitement

Other drugs used for generalized anxiety disorder

duloxetine (Cymbalta), paroxetine (Paxil), and escitalopram (Lexapro)

Social anxiety disorder (social phobia)

fear of interacting with others or being in social situations that might lead to a negative evaluation

Anxiety is characterized by

fear, apprehension, dread, and uneasiness

Other common reactions of venlafaxine (Effexor XR)

headache, anorexia, nervousness, sweating, daytime somnolence, insomnia, and hypertension