5 anxiety disorders

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34 BASICS OF PSYCHOPHARMACOLOGYClinical VignetteSue is 42 years old and experiencing her second episode of major depressivedisorder. She has never been on antidepressants before but this time wouldlike to try medication as part of her treatment. The initial assessment periodfor her will be a few days to a week after starting to make sure that themedication is not producing uncomfortable side effects. After 3–4 weeks,we expect to see some improvement in her mood; if there is no changewhatsoever, many physicians would change antidepressants after 4–5 weeks.Finally, when there has ceased to be any further improvement in mood, wewant to know, “Is she ‘well’ or is she only ‘better’?” If the answer is that shehas only gotten better, but not yet well, then we have more work to do.Going back to Figure 2.1, if we are stuck in the treatment, we should reconsiderthe pathophysiology of the disease state, asking ourselves which medications thatwe are perhaps not exploiting yet act on neurotransmitter systems. If the patient isnot yet participating in psychotherapy, we would bring it up again. Finally, if weremain stuck, it is often helpful to take a “blank slate” approach to the treatment,that is, confirm that what we are treating is what the patient really has.ADDITIONAL READINGArmstrong SC, Cozza KL, Sandson NB. Six patterns of drug–drug interactions. Psychosomatics2003; 44: 255–258.Black JE. Environment and development of the nervous system. In Gallagher M, Nelson RJ(eds), Handbook of Psychology: Biological Psychology, Volume 3. Hoboken, NJ: JohnWiley & Sons, 2003, pp 655–668.Cooper JR, Bloom FE, Roth RH. The Biochemical Basis of Neuropharmacology, 8th Edition.London: Oxford University Press, 2003.Hyman SE, Nestler EJ. Initiation and adaptation: a paradigm for understanding psychotropicdrug action. Am J Psychiatry 1996; 153: 151–162.Malhotra AK, Murphy GM, Kennedy JL. Pharmacogenetics of psychotropic drug response.Am J Psychiatry 2004; 161: 780–796.Nemeroff CB. New directions in the development of antidepressants: the interface of neurobiologyand psychiatry. Human Psychopharmacol 2002; 17(Supplement 1): S13–S16.Nemeroff CB, DeVane CL, Pollack BG. Newer antidepressants and the cytochrome P450system. Am J Psychiatry 1996; 153: 311–320.Nemeroff CB, Owens MJ. Contribution of modern neuroscience to developing new treatmentsfor psychiatric disorders. In Weissman M (ed), Treatment of Depression: Bridgingthe 21st Century. Washington DC: American Psychiatric Press, 2001, pp 61–81.Nemeroff CB, Musselman DL, Nathan KI, et al. Pathophysiological basis of psychiatricdisorders: focus on mood disorders and schizophrenia. In Tasman A, Kay J, LiebermanJA (eds), Psychiatry, Volume 1. Philadelphia: WB Saunders, 1997, pp 258–311.
ADDITIONAL READING 35Owens MJ, Mulcahey JJ, Stout SC, Plotsky PM. Molecular and neurobiological mechanismsin the treatment of psychiatric disorders. In Tasman A, Kay J, Lieberman JA (eds),Psychiatry, Volume 1. Philadelphia: WB Saunders, 1997, pp 210–257.Preskorn SH. The recommended dosage range: How is it established and why would it everbe exceeded? J Psychiatr Pract 2004; 10: 249–254.Stahl SM. Essential Psychopharmacology: Neuroscientifi c Basis and Practical Applications,2nd Edition. New York: Cambridge University Press, 2000.
Page 2 and 3: PRINCIPLES OFPSYCHOPHARMACOLOGYFOR
Page 4 and 5: Copyright © 2006 by John Wiley & S
Page 6 and 7: CONTENTSPrefaceFaculty Disclosurexv
Page 8: CONTENTSix5 ANXIETY DISORDERS 1275.
Page 13 and 14: xivCONTENTS13.2 Norepinephrine-Rela
Page 15 and 16: FACULTY DISCLOSUREJeffrey E. Kelsey
Page 17 and 18: FACULTY DISCLOSURExixBoard of Direc
Page 19 and 20: 2 INTRODUCTION AND OVERVIEWThe goal
Page 21 and 22: 4 INTRODUCTION AND OVERVIEWClinical
Page 23 and 24: 6 INTRODUCTION AND OVERVIEWClinical
Page 25 and 26: 2BASICS OFPSYCHOPHARMACOLOGY2.1 INT
Page 27 and 28: NORMAL HUMAN NERVOUS SYSTEM 11ture
Page 29 and 30: NORMAL HUMAN NERVOUS SYSTEM 13a kne
Page 31 and 32: NORMAL HUMAN NERVOUS SYSTEM 15This
Page 33 and 34: NORMAL HUMAN NERVOUS SYSTEM 17to du
Page 35 and 36: PATHOPHYSIOLOGY: STUDY OF WHAT GOES
Page 37 and 38: PATHOPHYSIOLOGY: STUDY OF WHAT GOES
Page 39 and 40: PHARMACOLOGY 23Only when we look at
Page 41 and 42: PHARMACOLOGY 25However, if an indiv
Page 43 and 44: PHARMACOLOGY 27soon see that for al
Page 45 and 46: PHARMACOLOGY 29mitter. When a molec
Page 47 and 48: PHARMACOLOGY 31the bacteria more ef
Page 49: PUTTING IT ALL TOGETHER 33Diagnose
Page 53 and 54: 38 MOOD DISORDERSMajor Depression (
Page 55 and 56: 40 MOOD DISORDERSMajor depression v
Page 57 and 58: 42 MOOD DISORDERSthe initial episod
Page 59 and 60: 44 MOOD DISORDERSTABLE 3.4. Medical
Page 61 and 62: 46 MOOD DISORDERSthese characterist
Page 63 and 64: 48 MOOD DISORDERSTABLE 3.7. Functio
Page 65 and 66: 50 MOOD DISORDERSlar, stimulants we
Page 67 and 68: 52 MOOD DISORDERSTABLE 3.8. Tricycl
Page 69 and 70: 54 MOOD DISORDERSIn the 1980s, deca
Page 71 and 72: 56 MOOD DISORDERSSertraline (Zoloft
Page 73 and 74: 58 MOOD DISORDERSand norepinephrine
Page 75 and 76: 60 MOOD DISORDERSThe cytochrome P 4
Page 77 and 78: 62 MOOD DISORDERSThere are several
Page 79 and 80: TABLE 3.11. Choosing an Antidepress
Page 81 and 82: 66 MOOD DISORDERSContinuation Phase
Page 83 and 84: 68 MOOD DISORDERSfor those with an
Page 85 and 86: 70 MOOD DISORDERStermed “endogeno
Page 87 and 88: 72 MOOD DISORDERSTABLE 3.13. Diagno
Page 89 and 90: 74 MOOD DISORDERSWhereas patients w
Page 91 and 92: 76 MOOD DISORDERSmania prior to the
Page 93 and 94: 78 MOOD DISORDERSreason, brain imag
Page 95 and 96: 80 MOOD DISORDERSLithium toxicity c
Page 97 and 98: 82 MOOD DISORDERSantidepressants (T
Page 99 and 100: 84 MOOD DISORDERSor the reticulocyt
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86 MOOD DISORDERScannot predict in
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88 MOOD DISORDERSand to provide pro
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90 MOOD DISORDERSagents. Carbamazep
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92 MOOD DISORDERSof other medicatio
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94 MOOD DISORDERSADDITIONAL READING
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4SCHIZOPHRENIA4.1 BRIEF DESCRIPTION
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BRIEF DESCRIPTION AND DIAGNOSTIC CR
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PRESENTATION AND CLINICAL COURSE 10
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INITIAL EVALUATION AND DIFFERENTIAL
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HISTORY OF TREATMENT 107fact that t
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HISTORY OF TREATMENT 109drugs. Even
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HISTORY OF TREATMENT 111As a group,
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HISTORY OF TREATMENT 113Chlorpromaz
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HISTORY OF TREATMENT 115physicians.
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HISTORY OF TREATMENT 117most effect
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HISTORY OF TREATMENT 119Olanzapine
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CURRENT APPROACH TO TREATMENT 121Th
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CURRENT APPROACH TO TREATMENT 123If
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ADDITIONAL READING 125tion combinat
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128 ANXIETY DISORDERSwith a single
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130 ANXIETY DISORDERSdisasters, or
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132 ANXIETY DISORDERSresult of thei
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134 ANXIETY DISORDERSTricyclic Anti
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136 ANXIETY DISORDERSdizziness, and
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138 ANXIETY DISORDERSintensely noxi
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140 ANXIETY DISORDERSIn particular,
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142 ANXIETY DISORDERSLike the MAOIs
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144 ANXIETY DISORDERSagoraphobic av
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146 ANXIETY DISORDERSrange from 4%
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148 ANXIETY DISORDERSAnxiety Disord
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150 ANXIETY DISORDERSA controlled t
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152 ANXIETY DISORDERSthree times ea
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154 ANXIETY DISORDERSunclear whethe
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156 ANXIETY DISORDERSTourette’s D
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158 ANXIETY DISORDERSStarted at 15-
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160 ANXIETY DISORDERSTABLE 5.9. Dia
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162 ANXIETY DISORDERSothers, as the
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164 ANXIETY DISORDERSlimitation is
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166 ANXIETY DISORDERSfor the effect
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168 ANXIETY DISORDERSTABLE 5.10. Di
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170 ANXIETY DISORDERSwarrants lifel
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172 ANXIETY DISORDERSTricyclic Anti
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174 ANXIETY DISORDERSof PTSD, it ca
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176 ANXIETY DISORDERSNemeroff CB. A
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178 SUBSTANCE USE DISORDERSregularl
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180 SUBSTANCE USE DISORDERSIn contr
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182 SUBSTANCE USE DISORDERSOne impo
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184 SUBSTANCE USE DISORDERSSocial f
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186 SUBSTANCE USE DISORDERSdevelop
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188 SUBSTANCE USE DISORDERScation i
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190 SUBSTANCE USE DISORDERSAversion
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192 SUBSTANCE USE DISORDERSStage Th
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194 SUBSTANCE USE DISORDERSexcessiv
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196 SUBSTANCE USE DISORDERSAcampros
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198 SUBSTANCE USE DISORDERSsame ben
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200 SUBSTANCE USE DISORDERS6.10 NIC
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202 SUBSTANCE USE DISORDERSTABLE 6.
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204 SUBSTANCE USE DISORDERSLAAM (Le
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206 SUBSTANCE USE DISORDERSADDITION
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208 EATING DISORDERSdisorder is war
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210 EATING DISORDERSTABLE 7.2. Diag
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212 EATING DISORDERSTABLE 7.3. Some
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214 EATING DISORDERSThe use of appe
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216 EATING DISORDERS7.2.6 Current A
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218 EATING DISORDERSpsychiatric nos
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220 EATING DISORDERSTABLE 7.7. Phys
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222 EATING DISORDERSFinally, althou
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224 EATING DISORDERSduring purging
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226 EATING DISORDERSsignificantly i
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228 EATING DISORDERSdoses. The typi
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230 EATING DISORDERSRoerig JL, Mitc
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232 ATTENTION DEFICIT-HYPERACTIVITY
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9SLEEP DISORDERS9.1 INTRODUCTIONPsy
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INTRODUCTION 259eye movement (REM)
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INSOMNIA 261falling asleep (initial
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INSOMNIA 263to professional attenti
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INSOMNIA 265worsen obstructive slee
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INSOMNIA 267TABLE 9.3. Medical Illn
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INSOMNIA 269(besides their many use
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INSOMNIA 271antipsychotics are safe
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INSOMNIA 273Magnesium. Recent resea
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NARCOLEPSY 275• Use the bed only
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NARCOLEPSY 277of complete remission
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NARCOLEPSY 279Pemoline (Cylert). Pe
Page 293 and 294:
ADDITIONAL READING 281regimen. The
Page 295 and 296:
10ALZHEIMER’S DISEASE ANDOTHER DE
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PREVALENCE AND RISK FACTORS 285•
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PREVALENCE AND RISK FACTORS 287solv
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Page 303 and 304:
Page 305 and 306:
HISTORY OF PHARMACOLOGICAL TREATMEN
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Page 309 and 310:
Page 311 and 312:
Page 313 and 314:
Page 315 and 316:
CURRENT APPROACH TO TREATMENT 303st
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CURRENT APPROACH TO TREATMENT 305us
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CURRENT APPROACH TO TREATMENT 307TA
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CURRENT APPROACH TO TREATMENT 309ch
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ADDITIONAL READING 311Bullock R. Tr
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314 PERSONALITY DISORDERSHow then h
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316 PERSONALITY DISORDERSnostic cri
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318 PERSONALITY DISORDERSis a repea
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320 PERSONALITY DISORDERScollateral
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322 PERSONALITY DISORDERSThe limite
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324 PERSONALITY DISORDERSthat child
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326 PERSONALITY DISORDERS11.3.4 His
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328 PERSONALITY DISORDERSin BPD. Th
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330 PERSONALITY DISORDERSaddress ea
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332 PERSONALITY DISORDERSDPD patien
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334 PERSONALITY DISORDERSand dopami
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336 PERSONALITY DISORDERSTrestman R
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338 TRAUMATIC BRAIN INJURYlong-term
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340 TRAUMATIC BRAIN INJURY12.1.4 In
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342 TRAUMATIC BRAIN INJURYescitalop
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344 TRAUMATIC BRAIN INJURYConsequen
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346 TRAUMATIC BRAIN INJURYwho exper
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348 TRAUMATIC BRAIN INJURYgeneral,
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350 TRAUMATIC BRAIN INJURYin TBI pa
Page 363 and 364:
352 TRAUMATIC BRAIN INJURYa control
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354 MANAGING SIDE EFFECTSmany of th
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356 MANAGING SIDE EFFECTSTABLE 13.1
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358 MANAGING SIDE EFFECTSalthough t
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360 MANAGING SIDE EFFECTSeffects of
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362 MANAGING SIDE EFFECTS13.2.2 Sid
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364 MANAGING SIDE EFFECTStreat Park
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366 MANAGING SIDE EFFECTSAntidepres
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368 MANAGING SIDE EFFECTSpatient a
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370 MANAGING SIDE EFFECTSdose. Once
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372 MANAGING SIDE EFFECTSPsychiatri
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374 MANAGING SIDE EFFECTSSexual Sid
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376 MANAGING SIDE EFFECTSdo produce
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378 MANAGING SIDE EFFECTSTABLE 13.7
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380 MANAGING SIDE EFFECTStricyclic
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INDEXAbecarnil, see β-carbolineAbi
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INDEX 385Disulfiram, 195, 198Donepe
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INDEX 387Obesity, 227Obsessive-comp
Page 399:
INDEX 389Valerian root, 272Valium,
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