● If another medical condition is present, the feelings of anxiety, fear, or avoidance are either clearly unrelated, or clearly excessive. Current evidence supports the use of CBT and pharmacotherapy for treating SAD (Rose & Tadi, 2021). SSRIs, particularly paroxetine and sertraline (which have FDA approval for treating SAD), are considered first-line pharmacologic agents. SNRIs also have solid evidence backing their use for managing SAD; venlafaxine has FDA approval for this use (Rose & Tadi, 2021). The beta blocker propranolol has utility for as-needed use in treating SAD without risk for dependence or abuse. Benzodiazepines also have utility for as-needed use but carry risk for dependence, tolerance, and misuse or abuse. Current evidence does not support the notion that combining psychological and pharmacological treatments are superior compared to monotherapy with either. Available literature suggests pharmacologic therapy is quicker for relieving symptoms, but CBT shows longer-lasting effects (Rose & Tadi, 2021). 5. Excessive, persistent reluctance about or fear regarding being alone or without the attachment figure. 6. Persistent refusal, concern, or reluctance to sleep away from home or in a setting where the attachment figure is not near. 7. Recurrent nightmares centered on separation. 8. Recurrent somatic complaints in the setting of anticipated or real separation from the attachment figure. Mild separation anxiety symptoms can typically be treated with patient education and support (Feriante & Bernstein, 2021). Moderate or severe symptoms often require psychologic and pharmacologic treatment, with CBT and SSRIs recognized by current evidence as first-line treatments (Feriante & Bernstein, 2021). Implicit Bias - Race and Anxiety Disorder Diagnoses Implicit biases refer to connections outside our conscious awareness and cause us to negatively assess an individual based on unrelated attributes, including ethnicity or gender. Studies have shown that factors beyond anxiety symptoms play a role in the diagnosis of anxiety disorders. One study by Vanderminden and Esala found that, regardless of the symptoms reported by the patient, Black respondents were less likely to receive an anxiety disorder diagnosis compared to White, Hispanic, and Native American respondents. This data suggests race plays an important role in whether one receives an anxiety disorder diagnosis. It represents a potential for underdiagnosis in Black patients and a potential for overdiagnosis in White, Hispanic, and Native American patients.
DSM-5 criteria for diagnosing SAD are as follows (Rose & Tadi, 2021): ● Notable anxiety or fear exists around one or more social situations, in which the individual is exposed to possible or perceived scrutiny by others. ● The anxiety or fear is out of proportion to any actual threat posed by the social situation. ● The social situation(s) almost always provokes anxiety or fear. ● The patient avoids the social situation(s) or endures it with intense anxiety or fear. ● The anxiety, avoidance, and/or fear must persist for 6 months or more. ● Feelings of anxiety, fear, and avoidance are not attributable to the physiologic effects of a substance or another medical condition. ● Feelings of anxiety, fear, and avoidance are not better explained as the symptoms of another disorder. Separation anxiety disorder Persons with separation anxiety disorder experience excessive fear and anxiety with separation from the person with whom they are attached. To qualify as separation anxiety disorder, the anxious feelings must be (1) beyond what is considered appropriate for the person’s age, (2) persistent for at least 6 months in adults and 4 weeks in children, and (3) interfere with activities of daily living (Muskin, 2021). A person with separation anxiety disorder often worries about losing the person closest to them. They may be reluctant to or avoid going out without the person, may refuse to sleep away from home without the person, and can experience nightmares about separation. Per DSM-5 criteria, to be diagnosed with separation anxiety, the patient must display at least three of the following eight symptoms; these symptoms must significantly impair functioning in social, academic, or occupational domains and must last longer than 4 weeks, with no other causes offering a better explanation for the symptoms (Feriante & Bernstein, 2021): 1. A pattern of recurrent, significant distress involving real or anticipated separation from an attachment figure or from home. 2. Excessive, persistent concern around loss of attachment figures, or harm coming to them. 3. Excessive, persistent concern about experiencing an unfortunate event will occur that separates the patient from the attachment figure. 4. A persistent refusal or reluctance to leave home, go to school or work or other places, due to fears of separation from the attachment figure.
PHARMACOLOGIC TREATMENTS
There are pharmacologic treatments for anxiety disorders. Selective serotonin reuptake inhibitors (SSRIs) Several selective serotonin reuptake inhibitors (SSRIs) have been approved by the U. S. Food and Drug Administration (FDA) for treating anxiety disorders. Despite the availability of FDA- approved medications in this class, SSRIs without FDA approval are commonly used off-label for treating anxiety disorders (Garakani et al., 2020). The mechanism of action for SSRIs is binding to the sodium- dependent serotonin transporter protein (SERT), also called 5-HTT, found in presynaptic neurons. This inhibits SERT- mediated serotonin reuptake from the synaptic cleft into the presynaptic neuron. The net effect is a potentiation of serotonin in the central nervous system (CNS). Serotonin (also called 5-hydroxytryptamine or 5-HT) is a modulator of numerous
behaviors, including mood, memory, stress response, appetite, anger, fear, sexuality, and addiction (Landy et al., 2022). SSRIs often require several weeks or months of therapy before symptom improvement is noted. However, adverse effects appear much sooner. Therefore, it is imperative to counsel patients on the importance of medication adherence and to not expect a sudden improvement in their mood or functioning at the start of treatment. SSRIs are currently available only in oral dosage formulations, including tablets, capsules, and liquid solutions/suspensions. SSRIs may be taken without regard to food, with the exception of vilazodone, which is not indicated for treatment of anxiety disorders (Chu & Wadhwa, 2022).
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