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Instructors can request access to the Casebook Instructor's Guide on AccessPharmacy: Pharmacotherapy Principles and Practice. Email User Services (userservices@mhprofessional.com) for more information.

Content Update

April 4, 2019

Transcranial Magnetic Stimulation (TMS) for Obsessive-Compulsive Disorder (OCD): In August 2018, the U.S. Food and Drug Administration (FDA) cleared BrainsWay deep TMS (dTMS) system for treatment of OCD. Despite the FDA permitting first-time marketing of a dTMS device for OCD based on one unpublished study by the device manufacturer, the significant heterogeneity across published study designs and outcomes exploring the use of TMS in OCD requires careful interpretation and application. Neuromodulatory approaches including TMS augmentation should continue to be reserved for patients with severe, debilitating OCD who have not achieved a sustained response with standard of care therapies.

LEARNING OBJECTIVES

LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Explain the pathophysiologic mechanisms underlying anxiety disorders.

  2. Recognize common presenting symptoms of generalized anxiety, panic, and social anxiety disorder (SAD).

  3. List treatment goals for patients with generalized anxiety, panic, and SAD.

  4. Identify appropriate lifestyle modifications and over-the-counter medication use in these patients.

  5. Compare the efficacy and tolerability profiles of psychotherapy and pharmacotherapy interventions for anxiety disorders.

  6. Design a patient-specific pharmacotherapy treatment plan for patients with generalized anxiety, panic, and SAD.

  7. Develop a monitoring plan for patients with anxiety placed on specific medications.

  8. Formulate appropriate educational information to be provided to a patient receiving pharmacotherapy for generalized anxiety, panic, and SAD.

INTRODUCTION

Anxiety disorders are among the most frequent mental disorders encountered by clinicians.1-3 All anxiety disorders are highly comorbid and share features of fear and anxiety that differ from developmentally normative fear or anxiety by being excessive, persistent, and resulting in behavioral disturbances.1 Anxiety disorders are associated with significant patient and family burden, functional impairment, and increased risk of developing comorbid major depressive disorder (MDD).1-4

Initial detection and diagnosis generally falls to primary care clinicians, to whom most patients present in the context of other complaints.4 Anxiety disorders are often missed or attributed incorrectly to other medical illnesses, and most patients are treated inadequately.4 Untreated anxiety disorders are associated with increased health care utilization, morbidity and mortality, and a poorer quality of life.1-4

EPIDEMIOLOGY AND ETIOLOGY

Epidemiology

Prevalence

The lifetime prevalence of anxiety disorders collectively is 28.8% with specific phobia (12.5%) and social anxiety disorder (SAD; 12.1%) being the most common.2,3 Data from the National Comorbidity Survey, Revised (NCS-R) estimate the lifetime prevalence of generalized anxiety disorder (GAD) for those 18 years of age and older to be 5.7%, closely followed by panic disorder (PD) at 4.7%.2,3

Anxiety disorders are more prevalent among women than men (2:1).2 Prevalence rates across the anxiety spectrum increase from ...

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