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Themenschwerpunkt, Theme Articles

Pharmakotherapie bei Angsterkrankungen

Published Online:February 28, 2015https://doi.org/10.1024/1661-4747.57.3.185

Abstract

Die moderne Psychopharmakotherapie von Angsterkrankungen begann mit der Beobachtung von Donald Klein und Max Fink, dass Imipramin antipanisch wirksam ist. Darauf aufbauend wurde die heute gebräuchliche Klassifikation von Angsterkrankungen entwickelt. Die akut anxiolytisch wirksamen Benzodiazepine sollten aufgrund von Nebenwirkungen und dem Missbrauchs- und Abhängigkeitspotenzials nur in Ausnahmenfällen angewendet werden. Derzeit werden selektive Serotonin- bzw. Serotonin- und Noradrenalin-Rückaufnahme-Inhibitoren als Mittel der ersten Wahl in der Psychopharmakotherapie von Angsterkrankungen angesehen. Daneben sind Pregabalin und Buspiron zur Behandlung der generalisierten Angststörung und Moclobemid zur Behandlung der sozialen Phobie zugelassen. Auch wenn einzelne Studien eine kurz- bis mittelfristige Überlegenheit der Kombination von Psychopharmakotherapie und Psychotherapie beschreiben, scheint diese langfristig, insbesondere nach Beendigung der Pharmakotherapie keine eindeutigen Vorteile zu besitzen. Ein neuer Ansatz zur Kombination von Pharmakotherapie und Psychotherapie wurde ausgehend von präklinischen Befunden entwickelt, die die molekularen Mechanismen von Konditionierung und Extinktion näher charakterisiert haben. Als partieller Agonist an der Glycin-Bindungsstelle des NMDA-Rezeptors verstärkt D-Cycloserin expositionsassoziierte Extinktion. Erste klinische Studien bestätigen die extinktionsfördernde Wirkung von D-Cycloserin bei Patienten mit Höhenangst, sozialer Phobie aber auch bei Zwangsstörungen.

Bereits heute sind gut wirksame und verträgliche Substanzen zur Psychopharmakotherapie von Angsterkrankungen verfügbar. Die Anwendung neuerer, aus präklinischen Befunden abgeleiteten Therapiestrategien im klinischen Alltag muss noch weiter untersucht werden.


Pharmacotherapy of Anxiety Disorders

The modern pharmacotherapy of anxiety disorders is based on the observation of Donald Klein and Max Fink that the tricyclic antidepressant imipramine has antipanic properties. Subsequently, different anxiety disorders were delineated of the former diagnostic category «anxiety neurosis». Although benzodiazepines have an acute anxiolytic activity, they are not first line treatment of anxiety disorders because of side effects and the risk of abuse and dependency. At the moment, selective serotonin or serotonin and norepinephrine reuptake inhibiting antidepressants are first choice treatment for patients with anxiety disorders which need a pharmacological treatment. In addition, pregabaline and buspirone are approved for the treatment of generalized anxiety disorder and moclobemid for the treatment of social anxiety disorder. Although some studies suggest a short-term beneficial effect of the combination of antidepressants and cognitive behavioural therapy on the long run this advantage is not perpetuated. A new approach for the combination of drug and psychotherapy has been developed from preclinical findings on the neurobiology of fear conditioning and extinction. D-Cycloserine is a partial agonist at the NMDA receptor and preclinical studies could demonstrate that this drug enhances the long-term effects of extinction training. In line, first clinical studies suggest that this drug, given 1 h before exposure therapy improves the clinical efficacy of CBT in patients with acrophobia, social phobia and obsessive compulsive disorder.

In addition to cognitive behavioural therapy, pharmacological treatment of anxiety disorders is effective and safe. New treatment approaches which have been generated from clinical studies have to be further characterized in the everyday clinical setting.

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