Innovations in the Management of Anxiety

Vernon M Neppe MD, PhD

Educational Objectives

1. To educate in the area of anxiety.
2. To discuss the clinical implications with regard to management options and problems.
3. To discuss the uses and abuses of benzodiazepines, azapirones, beta-adrenergic blocking agents.

Abstract

The current classification of anxiety of a separation of panic and generalized anxiety disorder has historical and epidemiologic limitations. We review alternative perspectives of anxiety viewed along the normal - abnormal continuum, as well as the frameworks of somatic and psychic anxiety. Similarly, subdivisions into adjustment disorder, anxiety states, mixed anxiety / depression and organic anxiety disorder lead to a more fruitful approach as to the patient’s pharmacologic needs.

Future innovative approaches to anxiety paradoxically imply a re-evaluation of management over the last century to eliminate side-effects and develop customized treatment. Alcohol, bromides, barbiturates and meprobamate have all had their problems. The benzodiazepines, an apparent major advance, have turned out to have benefits with selected but limited indications. This is so because of their significant problems.

Legitimate alternatives such as antidepressant, beta-adrenergic blockers and azapirones are examined. Specialized groups such as addicts, medically ill and geriatric patients, have their own particular problems. Psychopharmacology is rapidly approaching the age of specialized receptorology and serotonin subtypes play a major role in management of both anxiety and depression. The advent of the azapirones has been a significant advance and may exemplify the neuromodulating roles played by varying doses of drug impinging on a specific receptor, in this instance serotonin 1A.

Animal models of aggression suggest the azapirones are potent anti-aggressive agents. This should be via components of their specific serotonin 1A partial agonist effects. Irritability is an early target symptom of response with buspirone in generalized anxiety disorder possibly implying persistent low-dose effects.

Preliminary open experience by the author suggests low doses of buspirone (15-25 mg per day) were effective after a few days in alleviating irritability, anger and hostility with or without associated significant anxiety.