Despite the lack of guidance available for practitioners, extensive polypharmacy has become the primary method of treating patients with severe and chronic mood, anxiety, psychotic or behavioral disorders. This ground-breaking new book provides an overview of psychopharmacology knowledge and decision-making strategies, integrating findings from evidence-based trials with real-world clinical presentations. It adopts the approach and mind-set of a clinical investigator and reveals how prescribers can practice 'bespoke psychopharmacology', tailoring care to the individualized needs of patients.
Present fears are less than horrible imaginings.
▢ Appreciate that anxiety symptoms and disorders are often less benign and more insidious than one might initially think
▢ Distinguish preventative from abortive pharmacotherapy strategies for management of anxiety and their relative appropriateness for a given patient
▢ Understand the demonstrated anxiolytic properties of specific antidepressants, benzodiazepines, anticonvulsants, and antipsychotics, as well as antihistamines, β-blockers, α agonists, and cannabidiol
Ostensibly innocuous, yet deceptively so, like Monty Python’s fabled Killer Rabbit of Caerbannog (but with no Holy Hand Grenade of Antioch to lob as a countermeasure), anxiety often stands underappreciated for its pernicious and often devastating ill effects. Less profound and baffling than the perceptual and ideational anomalies of psychosis, less emotionally wrenching or blatantly lethal than suicidal melancholy, and less relentlessly haunting than the psychic sequelae of trauma, anxiety may be the prime example of a normal human emotion gone awry. While “normal” anxiety cues vigilance to environmental threats, demands, and rewards, aberrant anxiety paralyzes cognitive function, over-rides judgment, subverts harm appraisal, drives impulsive action, and generally worsens the prognosis and treatment responsiveness of any coexisting psychiatric problem. It is also easily mistaken for other forms of psychopathology that involve autonomic hyperarousal and psychomotor activation, potentially driving wrong pharmacotherapy decisions.
Anxiety follows an inverted U-shaped curve, sometimes known as the Yerkes–Dodson law; a minimum threshold of anxiety is necessary for arousal, vigilance and motivation, but beyond an optimum point leads to disorganization and impaired performance.
Collectively, anxiety disorders are the most common psychiatric condition in the United States, annually afflicting about 18% of adults. They are also among the most heterogeneous of disorders, cutting across virtually all forms of psychopathology, with implications for likely shared underlying neural circuitry. Their diverse phenomenology can involve psychomotor hyperactivity, somatization, disruption to the sleep–wake cycle and sleep architecture, eating dysregulation (restriction; comfort/binge eating), relief-based addiction behaviors, cognitive/executive dysfunction (“Can you consider the possibility that there may be alternative explanations for how you are interpreting events?”), rumination, and harm appraisal.
It is useful to differentiate anxiety symptoms from formal disorders, and the extent to which they may be comorbidities versus artifacts of other free-standing conditions. Anxiety is often (but not always) linked with affective disorders. Asking patients if they perceive a chronology (does anxiety precede depression or vice-versa? Or are they entirely coincidental?) may help gauge whether one of the two represents the more driving force, with possible pharmacological implications. Subthreshold anxiety symptoms often color the presentation of virtually all other psychiatric disorders. It is also, therefore, especially useful to clarify what exact problems patients are actually referring to when they invoke language involving the concept of “anxiety.”
Because the term “anxiety” can encompass many diverse emotional states, and in the spirit of defining the goals of treatment, clinicians should aim to delineate specific target signs and symptoms of anxiety before embarking on its pharmacotherapy. Box 17.1 provides a kind of informal glossary that may help to “translate” patients’ subjective complaints about anxiety into more definable and tangible symptoms that become targets of treatment.
|The Term …||… Really Means …|
|“Activation”||Medications that can induce a state of psychomotor acceleration or hyperarousal (such as stimulants or some antidepressants) may cause patients to complain of “anxiety”|
|“Agitation”||A state of feeling keyed-up and restless; motor hyperactivity tends not to be goal-directed|
|“Akathisia”||Subjective and/or objective restlessness caused by dopamine antagonists|
|“Delirium”||Delirious patients, with an acutely altered sensorium with waxing and waning consciousness, may identify themselves as feeling “anxious” when they actually mean “grossly cognitively disorganized” and “unable to process basic information due to unalertness”|
|“Dementia”||Dementia patients may use the term “anxiety” to capture subjective feelings of distress associated with confusion, disorientation, memory loss, or other aspects of cognitive disorganization|
|“Depression”||Clinically depressed patients may misidentify anxiety as a predominant emotional state when sadness or despair may be more accurate descriptors of their internal experience|
|“Hyperactivity”||In ADHD, hyperactivity is a hyperkinetic phenomenon involving fidgetiness or squirminess, impatience, difficulty taking turns, and a sense of urgency|
|“Mania”||The psychomotor activation of (hypo)mania is purposeful and goal-directed, in contrast to the more diffuse sense of tension and distress associated with agitation|
|“Obsession”||The repetition of a(n often senseless) thought that intrudes into one’s awareness, from which it is difficult to redirect sustained attention elsewhere|
|“Panic”||A brief, time-limited autonomic hyperarousal state that involves tachypnea, tachycardia, and feelings of dread; “anxiety” may pertain to an anticipatory state of recurrences|
|“Paranoia”||Someone who expects harm or mistreatment by others may identify their apprehension as “anxiety” without necessarily registering the nefarious intent they attribute to others|
|“Racing thoughts”||The phenomenon in which one thought follows another at an accelerated rate, often making it difficult to discern their specific content, usually associated with the psychomotor acceleration of mania/hypomania|
|“Ruminations”||Excessive and repeated focusing on thoughts and feelings related to distress|
Anxiety features can be captured and quantified based on their frequency and intensity using formal rating scales such as those used in RCTs (see Table 17.1 at the end of this chapter) – or by simply having patients self-rate symptoms using a 0 to 10 Likert-type scale. Formal anxiety rating scales used in clinical trials vary in the phenomena they measure (e.g., psychic worry, somatic symptoms, panic attacks). It is helpful for clinicians to choose some metric that patients will find user-friendly enough to objectify and track anxiety symptoms over time – particularly in the case of a symptom that, by definition, can be prone to embellishment or overdramatization by its inherent nature.
|Measure||Description with strengths and weaknesses|
|HAM-A (Hamilton, 1959)||The HAM-A is a 14-item clinician-administered scale, with each item scored individually from 0 (“absence”) to 4 (“very severe”). Total scores <17 are considered to reflect mild anxiety, 18–24 equate to moderate anxiety, and scores >25 are considered severe. Subscales capture psychic anxiety (e.g., anxious mood, tensions, fears) and somatic anxiety (e.g., musculoskeletal, cardiovascular, respiratory, gastrointestinal, and genitourinary complaints). Some experts feel the overall scale may be unduly weighted toward somatic components|
|Beck Anxiety Inventory (Beck et al., 1988)||21-item self-report tool thought to have less “contamination” from content related to depression. Scores of 0–7 reflect minimal anxiety, 8–15 = mild anxiety, 16–25 = moderate anxiety, and 26–63 = severe anxiety|
|STAI (State–Trait Anxiety Inventory)||40 self-report questions (20 capturing state- (“S-anxiety”) and 20 identifying trait- (“T-anxiety”) features), each on a four-point Likert scale. Total scores for each scale range from 20 to 80 with higher scores reflecting greater severity|
|Zung Anxiety Scale (Zung, 1971)||20-item self-report measure that taps cognitive, autonomic, motor and central nervous system aspects of anxiety, with each item scored from 1 (“a little of the time”) to 4 (“most of the time”). Total raw scores can range from 20 to 80; ≤44 is considered normal, 45–59 reflects mild to moderate anxiety, 60–74 indicates marked to severe anxiety, and ≥75 reflects extreme anxiety|
|Liebowitz Social Anxiety Scale (LSAS) (Liebowitz, 1987)||24-item self-report or clinician-rated index; contains 13 questions regarding performance anxiety and 11 related to concerns involving social interactions. Each item is rated from 0 to 3; higher scores reflect greater severity. Total scores <30 reflect an absence of clinically significant symptoms, scores from 31–60 are considered “probable,” scores from 61–90 are considered “very probable,” and scores ≥90 are “highly probable” of SAD|
|Brief Social Phobia Scale (BSPS) (Davidson et al., 1991; Wilson, 1993)||11-item checklist designed to capture changes in the frequency and severity of symptoms (each rated from 0 to 4) over time. A total score as well as subscores reflecting fear, avoidance, and physiology can be calculated|
|Marks Fear Questionnaire (Marks and Mathews, 1979)||17-item self-rated measure; each item scored from “0” (“would not avoid it”) to “8” (“always avoid it”). The sum of items 2–6 gives a range from 0 to 120. Scores ≥30 are clinically significant|
|Penn State Worry Questionnaire (Meyer et al., 1990)||16-item self-report questionnaire capturing trait worry. Questions rated from “1” (“not at all typical of me”) to “5” (“very typical of me”). Total scores range from 16 to 80. Scores of 26–39 reflect “low worry,” 50–59 indicates “moderate worry,” and 60–80 reflect “high worry”|
|Social Phobia and Anxiety Inventory (SPAI) (Turner et al., 1989)||45-item self-report form that captures social-situational anxiety, somatic symptoms, and phobic cognitions. Individual items are rated on seven-point scales. Scores ≥60 = clinically significant social phobia|
|Social Phobia Inventory (SPIN) (Connor et al., 2000)||17-item self-rated form capturing fear, avoidance, and physiological/somatic dimensions of social anxiety. Each item is rated from “0” (“not at all”) to “4” (“extremely”), range from 0 to 68; scores ≥19 taken as a cut-off for casehood|
|Panic and Agoraphobia Scale (PAS) (Bandelow, 1995)||13-item inventory measuring panic attacks, agoraphobic avoidance, anticipatory anxiety, disability, and health-related worries, clinician- or self-rated|
Abbreviations: HAM-A = Hamilton Ratings Scale for Anxiety; SAD = social anxiety disorder