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Edited by
David Kingdon, University of Southampton,Paul Rowlands, Derbyshire Healthcare NHS foundation Trust,George Stein, Emeritus of the Princess Royal University Hospital
Anxiety symptoms and anxiety disorders are common in community settings and primary and secondary medical care. Anxiety symptoms are often mild and only transient, but many people are troubled by severe symptoms that cause both considerable personal distress and a marked impairment in social and occupational function. The principal anxiety disorders are currently considered to comprise panic disorder, generalised anxiety disorder, social anxiety disorder, agoraphobia, specific phobias, separation anxiety disorder and selective mutism. Additional conditions (not considered further here) include substance/medication-induced anxiety disorder, anxiety disorder due to another medical condition, other specified anxiety disorder and unspecified anxiety disorder. Together, anxiety disorders constitute the most frequent mental disorders, with an estimated 12-month prevalence of approximately 10–14 per cent.
Although the societal impact of anxiety disorders is substantial, many of those who could benefit from psychological or pharmacological treatment are neither recognised nor treated. Recognition relies on maintaining a keen awareness of the psychological and physical symptoms of anxiety disorders, and accurate diagnosis rests on identifying the pathognomonic features of specific conditions.
This chapter outlines the best current therapy of post-herpetic neuralgia (PHN) and herpes zoster (HZ) and the exciting promise of the zoster prevention vaccine. The clinical findings, on examining a patient with PHN, demonstrate three main features to the pain. There is a constant, steady burning pain, electric shock-like pains reminiscent of trigeminal neuralgia, and the skin is often very sensitive or painful to summating touch stimuli such as skin stroking. There are three possible approaches to managing PHN: the treatment of established PHN, the prevention of PHN by early and aggressive treatment of HZ, and the prevention of HZ and PHN by vaccination. Drugs such as Tricyclic antidepressants (TCAs), gabapentinoids, and opioids affect all features of the pain. An important question for clinicians is how satisfactory these drugs are for PHN patients in ordinary practice in terms of pain relief and disability, tolerability of side effects, and long-term benefit.
Tricyclic antidepressants (TCAs) and serotonin norepinephrine reuptake inhibitors (SNRIs) (venlafaxine, duloxetine) are recommended as the first-line agents for peripheral neuropathic pain, especially for painful polyneuropathy, the other first-line options being gabapentinoids and topical lidocaine. Tricyclic antidepressants became a mainstay in the management of neuropathic pain before their mechanisms were elucidated and before the advent of systematic ways to evaluate their efficacy. Venlafaxine and duloxetine should be used with caution in patients with a history of mania, seizures, or bleeding tendency. Due to risk of excessive serotoninergic effect, they should be used with caution in patients receiving concomitant selective serotonin reuptake inhibitor (SSRI) or tramadol treatment. When selecting the treatment for an individual patient, comorbid conditions and their medications need to be taken into account. More detailed information of the effects of pharmacological agents on various symptoms of neuropathic pain and sensory profiles may guide drug selection in the future.
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