Generalised Anxiety Disorder
When treating anxiety with medication, Selective Serotonin Reuptake Inhibitor antidepressants (SSRIs) are helpful e.g. Sertraline, commencing at 50 mg daily and increasing up to 150-200 mg daily over 3-4 weeks. Venlafaxine is an appropriate alternative if there is no response to an SSRI. Pregabalin may also be effective, initially at 150 mg daily in 2-3 divided doses (increased as per BNF guidelines). The use of regular benzodiazepines should be avoided as tolerance/dependence may develop and they are associated with other unhelpful side effects.
Cognitive Behavioural Therapy (CBT) may be effective if the person is able to engage, but can be more challenging if there are significant cognitive or communication difficulties.
Phobic Anxiety Disorder
Phobic anxiety disorders can be treated with antidepressant medication and/or by a graded exposure programme to the anxiety provoking stimulus under the supervision of a Clinical Psychologist/Neuropsychologist.
A graded exposure programme for social phobia (social anxiety disorder) may involve a structured programme of gradual exposure to brief and non-threatening social situations, building up to the more anxiety provoking social situations (e.g. visit to a supermarket).
Obsessive Compulsive Disorder (OCD)
Obsessive compulsive traits are commonly observed following brain injury and may contribute to significant levels of anxiety and distress. Treatment with Sertraline may be helpful as a first line. If treatment with Sertraline is ineffective, then Clomipramine (tricyclic antidepressant) may be considered. Clomipramine may be associated with anticholinergic side effects including dry mouth, blurred vision, drowsiness and postural hypotension. It may reduce seizure threshold and therefore should be used with caution where there is a diagnosis of epilepsy.
Where the diagnosis of an obsessive compulsive disorder has been made, the mainstay of treatment is a psychological approach (i.e. Exposure and Response Prevention and Cognitive Behavioural Therapy). It may be helpful to prescribe antidepressant medication as an adjunct to psychological treatment.
Post-Traumatic Stress Disorder (PTSD)
Post-trauma symptoms may occur following brain injury. Where they remain problematic 2-3 months after the traumatic event, specific treatment should be considered. Psychological therapy may be effective. Trauma focussed Cognitive Behavioural Therapy (CBT) or Eye Movement Desensitisation and Reprocessing therapy (EMDR) may be helpful. EMDR aims to support the person to re-process the traumatic memory in a more normal way. A Selective Serotonin Reuptake Inhibitor (SSRI) antidepressant drug may be considered as an adjunct to psychological treatment (e.g Sertraline, Fluoxetine). Venlafaxine or Mirtazapine may be considered second line treatments where there is no improvement after a satisfactory trial of an SSRI (over 4 weeks at adequate dose).
Please refer to the British National Formulary (BNF) for contraindications and adverse effects before prescribing.