Anxiolytics

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]

Overview

An anxiolytic is a drug prescribed for the treatment of symptoms of anxiety. Some anxiolytics have been shown to be useful in the treatment of anxiety disorders as have antidepressants such as the class of selective serotonin reuptake inhibitors (SSRIs).

Though not anxiolytics, beta-receptor blockers such as propranolol and oxprenolol can be used to combat the somatic symptoms of anxiety.

Types of Anxiolytics

Anxiolytics are generally divided into two groups of medication, benzodiazepines and non-benzodiazepines.

Benzodiazepines

Benzodiazepines are prescribed for short-term relief of severe and disabling anxiety. Common medications are lorazepam (Ativan), clonazepam (Klonopin), alprazolam (Xanax), and diazepam (Valium). Benzodiazepines may also be indicated to cover the latent periods associated with the medications prescribed to treat an underlying anxiety disorder. They are used to treat a wide variety of conditions and symptoms and are usually a first choice when short-term CNS sedation is needed. Longer term uses include treatment for severe anxiety and psychosis. There is a risk of withdrawal symptoms and rebound syndrome after continuous usage past two weeks. There is also the added problem of the accumulation of drug metabolites and adverse effects.

Non-Benzodiazepines

See also: Nonbenzodiazepine

Buspirone (Buspar) is a serotonin 1A agonist. It lacks the sedation and the dependence associated with benzodiazepines and causes much less cognitive impairment. It may be less effective than benzodiazepines in patients who have been previously treated with benzodiazepines as the medication does not provide the sedation that these patients may expect or equate with anxiety relief.

Barbiturates

Barbiturates and meprobamate exert an anxiolytic effect linked to the sedation they cause. The risk of abuse and addiction is high. Many experts consider these drugs as obsolete for treating anxiety, although they may be valuable for the short term treatment of severe insomnia.

Herbal Treatments

Certain herbs, such as St. John's wort, kava (kava kava), chamomile, bacopa monniera and Valerian are reputed to have anxiolytic properties. With the exception of kava kava, only limited evidence exists for their efficacy.[1][2]

Use of marijuana as an anxiolytic has seen promising results in regions where its practical study is possible, but its status as a controlled substance in many countries make its study as such difficult.

Alternatives to Medication

Psychotherapy (e.g. cognitive or behavior therapy) is often useful as an adjunct to pharmacotherapy or as an alternative to medication.

Anxiolytic Withdrawal

Differential Diagnosis

DSM-V Diagnostic Criteria for Sedative, Hypnotic, or Anxiolytic Withdrawal[3]

  • A. Cessation of (or reduction in) sedative, hypnotic, or anxiolytic use that has been prolonged.

AND

  • B. Two (or more) of the following, developing within several hours to a few days after the cessation of (or reduction in) sedative, hypnotic, or anxiolytic use described in Criterion A:
  • 1. Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 bpm).
  • 3. Insomnia.
  • 4. Nausea or vomiting.
  • 6. Psychomotor agitation.
  • 7. Anxiety.

AND

C. The signs or symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

AND

D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

Specify if:

  • With perceptual disturbances: This specifier may be noted when hallucinations with intact reality testing or auditory, visual, or tactile illusions occur in the absence of a delirium.

Anxiolytic Intoxication

Differential Diagnosis

DSM-V Diagnostic Criteria for Sedative, Hypnotic, or Anxiolytic Intoxication[3]

  • A. Recent use of a sedative, hypnotic, or anxiolytic.

AND

  • B. Clinically significant maladaptive behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment) that developed during, or shortly after, sedative, hypnotic, or anxiolytic use.

AND

  • C. One (or more) of the following signs or symptoms developing during, or shortly after,sedative, hypnotic, or anxiolytic use:

1. Slurred speech.

2. Incoordination.

3. Unsteady gait.

4. Nystagmus.

5. Impairment in cognition (e.g., attention, memory).

6. Stupor or coma.

AND

  • D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance.

Anxiolytic Use Disorder

Differential Diagnosis

Epidemiology and Demographics of Sedative, Hypnotic, or Anxiolytic Use Disorder

Prevalence

The 12 month prevalence of hypnotic or anxiolytic use disorder is:

  • 300 per 100,000 (0.3%) among adults 12-17 years old
  • 200 per 100,000 among adults 18 years and older[3]

Risk Factors

  • Availability of the substances
  • Alcohol use disorder
  • Environmental factors
  • Early onset of use
  • Genetic predisposition
  • Peer use of the substance[3]

DSM-V Diagnostic Criteria for Sedative, Hypnotic, or Anxiolytic Use Disorder[3]

  • A. A problematic pattern of sedative, hypnotic, or anxiolytic use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
  • 1. Sedatives, hypnotics, or anxiolytics are often taken in larger amounts or over a longer period than was intended.
  • 2. There is a persistent desire or unsuccessful efforts to cut down or control sedative, hypnotic, or anxiolytic use.
  • 3. A great deal of time is spent in activities necessary to obtain the sedative, hypnotic,or anxiolytic; use the sedative, hypnotic, or anxiolytic; or recover from its effects.
  • 4. Craving, or a strong desire or urge to use the sedative, hypnotic, or anxiolytic.
  • 5. Recurrent sedative, hypnotic, or anxiolytic use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences from work or poor work performance related to sedative, hypnotic, or anxiolytic use; sedative-,hypnotic-, or anxiolytic-related absences, suspensions, or expulsions from school;neglect of children or household).
  • 6. Continued sedative, hypnotic, or anxiolytic use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of sedatives, hypnotics, or anxiolytics (e.g., arguments with a spouse about consequences of intoxication; physical fights).
  • 7. Important social, occupational, or recreational activities are given up or reduced because of sedative, hypnotic, or anxiolytic use.
  • 8. Recurrent sedative, hypnotic, or anxiolytic use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by sedative, hypnotic, or anxiolytic use).
  • 9. Sedative, hypnotic, or anxiolytic use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the sedative, hypnotic, or anxiolytic.
  • 10. Tolerance, as defined by either of the following;
  • a. A need for markedly increased amounts of the sedative, hypnotic, or anxiolytic to achieve intoxication or desired effect.
  • b. A markedly diminished effect with continued use of the same amount of the sedative,hypnotic, or anxiolytic.

Note: This criterion is not considered to be met for individuals taking sedatives, hypnotics, or anxiolytics under medical supervision.

  • 11. Withdrawal, as manifested by either of the following:
  • a. The characteristic withdrawal syndrome for sedatives, hypnotics, or anxiolytics.
  • b. Sedatives, hypnotics, or anxiolytics (or a closely related substance, such as alcohol)are taken to relieve or avoid withdrawal symptoms.

Note: This criterion is not considered to be met for individuals taking sedatives, hypnotics, or anxiolytics under medical supervision.


Specify if:

  • In early remission: After full criteria for sedative, hypnotic, or anxiolytic use disorder were previously met, none of the criteria for sedative, hypnotic, or anxiolytic use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use the sedative, hypnotic, or anxiolytic,” may be met).
  • In sustained remission: After full criteria for sedative, hypnotic, or anxiolytic use disorder were previously met, none of the criteria for sedative, hypnotic, or anxiolytic use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use the sedative, hypnotic, or anxiolytic,” may be met).

Specify if:

  • In a controlled environment: This additional specifier is used if the individual is in an environment where access to sedatives, hypnotics, or anxiolytics is restricted.

References


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