Nervenheilkunde 2019; 38(08): 565-569
DOI: 10.1055/a-0961-2589
Schwerpunkt
© Georg Thieme Verlag KG Stuttgart · New York

Angsterkrankungen und Therapieresistenz

Klinische Empfehlungen und PerspektivenAnxiety disorders and therapy resistance
Peter Zwanzger
1   Fachbereich Psychosomatik und Allgemeinpsychiatrie, kbo-Inn-Salzach-Klinikum, Therapieschwerpunkt Angst und Depression, Wasserburg am Inn
2   Klinik für Psychiatrie und Psychotherapie der Ludwig-Maximilians-Universität, München
,
Julia Diemer
1   Fachbereich Psychosomatik und Allgemeinpsychiatrie, kbo-Inn-Salzach-Klinikum, Therapieschwerpunkt Angst und Depression, Wasserburg am Inn
3   Fachbereich Psychologie, Ludwig-Maximilians-Universität, München
› Author Affiliations
Further Information

Publication History

Publication Date:
01 August 2019 (online)

ZUSAMMENFASSUNG

Epidemiologischen Studien zufolge gehören Angsterkrankungen zu den häufigsten seelischen Störungen. Dabei stellen insbesondere diejenigen Verläufe die größte Herausforderung dar, die anamnestisch bereits zahlreiche erfolglose Behandlungsversuche aufweisen. Die in Anlehnung an die Depressionsbehandlung als therapieresistente Angsterkrankungen bezeichnete Gruppe von Störungen ist im Hinblick auf therapeutische Ansätze weit weniger untersucht als die therapieresistente Depression. Im Rahmen der Übersicht werden Studien zur Behandlung therapieresistenter Angsterkrankungen referiert. Der Fokus liegt dabei auf der Panikstörung, der generalisierten Angststörung sowie der sozialen Phobie. Die Behandlungsansätze umfassen pharmakologische Ansätze mit atypischen Antipsychotika und Antikonvulsiva, Kombinationstherapien, den psychotherapeutischen Ansatz der Acceptance and Commitment Therapy (ACT) sowie den experimentell pharmakologischen Einsatz von D-Cycloserin (DCS). Auf die Problematik von Pseudotherapieresistenz und die Notwendigkeit einer sorgfältigen Diagnostik und Differenzialdiagnostik wird ebenso eingegangen.

ABSTRACT

According to epidemiological studies, anxiety disorders are among the most frequent psychiatric disorders. In particular, nonresponse and treatment resistance represent a relevant challenge in daily clinical practice. However, prevalence and clinical management of treatment resistant anxiety disorders are far less investigated in comparison to treatment resistant major depression.

Within the scope of this overview, studies on the treatment of therapy-resistant anxiety disorders are presented. The focus is on panic disorder, generalized anxiety disorder and social phobia. Potential treatment approaches include pharmacological approaches with atypical antipsychotics and anticonvulsants, combination therapies, the psychotherapeutic approach of acceptance and commitment therapy (ACT) and the experimental pharmacological use of D-cycloserine (DCS). The problem of pseudo-treatment-resistance, and the necessity of careful diagnostics and differential diagnostics are also discussed.

 
  • Literatur

  • 1 Wittchen HU. et al The size and burden of mental disorders and other disorders of the brain in Europe 2010. European Neuropsychopharmacology 2011; 21: 655-679
  • 2 Bandelow B. et al World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-cpmpulsive and post-traumatic stress disorders – first revision. World J Biol Psychiatry 2008; 9 (04) 248-312 doi: 10.1080/15622970802465807
  • 3 Bandelow B. et al S3-Leitlinie Behandlung von Angststörungen. (Stand: 15.04.2014) www.awmf.org/leitlinien.html
  • 4 Zwanzger P. Pharmakotherapie bei Angsterkrankungen. Fortschr Neurol Psychiatr 2016; 84: 306-314
  • 5 Zwanzger P. Psychopharmakotherapie. In: Angst – Medizin. Psychologie. Gesellschaft.. Berlin: Medizinisch Wissenschaftliche Verlagsgesellschaft; 2019
  • 6 Bystritsky A. Treatment-resistant anxiety disorders. Molecular Psychiatry 2006; 11: 814
  • 7 Simon NM. Generalized anxiety disorder and psychiatric comorbidities such as depression, bipolar disorder, and substance abuse. J Clin Psychiatry 2009; 70 (Suppl. 02) 10-4
  • 8 Schüle C. Chronische Depression – Epidemiologische Daten und therapeutische Möglichkeiten. Fortschr Neurol Psychiatr 2014; 82 (03) 155-173
  • 9 Brawman-Mintzer O. et al Adjunctive risperidone in generalized anxiety disorder: a double-blind, placebo-controlled study. J Clin Psychiatry 2005; 66 (10) 1321-5
  • 10 Pollack MH. et al Olanzapine augmentation of fluoxetine for refractory generalized anxiety disorder: a placebo controlled study. Biol Psychiatry 2006; 59 (03) 211-5
  • 11 Simon NM. et al Quetiapine augmentation of paroxetine CR for the treatment of refractory generalized anxiety disorder: preliminary findings. Psychopharmacology 2008; 197: 675-81
  • 12 Hirschmann S. et al Pindolol augmentation in patients with treatment-resistant panic disorder: A double-blind, placebo-controlled trial. J Clin Psychopharmacol 2000; 20 (50) 556-9
  • 13 Stein MB. et al Pindolol potentiation of paroxetine for generalized social phobia: a double-blind, placebo-controlled, crossover study. Am J Psychiatry 2001; 158 (10) 1725-7
  • 14 Schoretsanitis G. et al TDM in psychiatry and neurology: A comprehensive summary of the consensus guidelines for therapeutic drug monitoring in neuropsychopharmacology, update 2017 a tool for clinicians. World J Biol Psychiatry 2018; 19: 162-174
  • 15 Roy-Burne P. Treatment-refractory anxiety; definition, risk factors, and treatment challenges. Dialogues in Clinical Neuroscience 2015; 17 (02) 191-206
  • 16 Goddard AW. et al A controlled trial of quetiapine XR coadministration treatment of SSRI-resistant panic disorder. Ann Gen Psychiatry 2015; 14: 26
  • 17 Wang HR. et al The potential role of atypical antipsychotics in the treatment of panic disorder. Hum Psychopharmacol 2014; 29 (05) 405-413
  • 18 Simon NM. et al Next-Step Strategies for Panic Disorder Refractory to Initial Pharmacotherapy. J Clin Psychiatry 2009; 70 (11) 1563-1570 doi:10.4088/JCP.08m04485blu
  • 19 Keck PE. et al Valproate treatment of panic disorder and lactate-induced panic attacks. Biological Psychiatry 1993; 33 (07) 542-546
  • 20 Zwanzger P, Rupprecht R. Selective GABAergic treatment for panic? Investigations in experimental panic induction and panic disorder. J Psychiatry Neurosci 2005; 30 (03) 167-175
  • 21 Rupprecht R, Zwanzger P. Die Bedeutung von GABAA-Rezeptoren für Pathophysiologie und Therapie der Panikstörung. Nervenarzt 2003; 74: 543 https://doi.org/10.1007/s00115-002-1433-x
  • 22 Gloster AT. et al Treating Treatment-Resistant Patients with Panic Disorder and Agoraphobia Using Psychotherapy: A Randomized Controlled Switching Trial. Psychother Psychosom 2015; 84: 100-109 https://doi.org/10.1159/000370162
  • 23 Kreys T-JM, Phan SV. A Literature Review of Quetiapine for Generalized Anxiety Disorder. Pharmacotherapy 2015; 35 (02) 175-188
  • 24 Lalonde CD, Van Lieshout RJ. Treating generalized anxiety disorder with second generation antipsychotics: a systematic review and meta-analysis. J Clin Psychopharmacol 2011; 31 (03) 326-33 doi: 10.1097/JCP.0b013e 31821b2b3f
  • 25 Rickels K. Adjunctive therapy with pregabalin in generalized anxiety disorder patients with partial response to SSRI or SNRI treatment. Int Clin Psychopharmacol 2012; 27 (03) 142-50 doi: 10.1097/YIC.0b013e 328350b133
  • 26 Samuel M. et al Efficacy and safety of treatments for refractory generalized anxiety disorder: a systematic review. Int Clin Psychopharmacol 2011; 26 (02) 63-68 doi: 10.1097/YIC.0b013e328341bb4a
  • 27 Baldwin DS. et al Pregabalin for the treatment of generalized anxiety disorder: an update. Neuropsychiatr Dis Treat 2013; 9: 883-892 doi: 10.2147/NDT.S36453
  • 28 Pollack MH. et al A double-blind randomized controlled trial of augmentation and switch strategies for refractory social anxiety disorder. Am J Psychiatry 2014; 171 (01) 44-53 doi: 10.1176/appi.ajp. 2013.12101353
  • 29 Roy-Burne P. Treatment in Nonresponsive Patients With Social Anxiety: Back to the Future With Benzodiazepines. Am J Psychiatry 2014; 171 (01) 1-4 doi.org/10.1176/appi.ajp.2013.13101304
  • 30 Blanco C. et al A placebo-controlled trial of phenelzine, cognitive behavioral group therapy, and their combination for social anxiety disorder. Arch Gen Psychiatry 2010; 67 (03) 286-95 doi: 10.1001/archgenpsychiatry.2010.11
  • 31 Yoshinaga N. et al Cognitive Behavioral Therapy for Patients with Social Anxiety Disorder Who Remain Symptomatic following Antidepressant Treatment: A Randomized, Assessor-Blinded, Controlled Trial. Psychother Psychosom 2016; 85 (04) 208-217 doi: 10.1159/000444221
  • 32 Hofmann SG. et al D-Cycloserine as an augmentation strategy with cognitive-behavioral therapy for social anxiety disorder. Am J Psychiatry 2013; 170 (07) 751-8 doi: 10.1176/appi.ajp.2013.12070974
  • 33 Rodrigues H. et al Does D-cycloserine enhance exposure therapy for anxiety disorders in humans? A meta-analysis. PLoS One 2014; 9 (07) e93519 doi: 10.1371/journal.pone.0093519. eCollection 2014
  • 34 McGuire JF. et al A Meta-Analysis of D-Cycloserine in Exposure-Based Treatment: Moderators of Treatment Efficacy, Response, and Diagnostic Remission. J Clin Psychiatry 2017; 78 (02) 196-206 doi: 10.4088/JCP.15r10334