Treating Anxiety
Treatment of anxiety does not always require medication. The use of antianxiety drugs depends in part on whether the patient can tolerate his or her symptoms while learning to manage them through such measures as education on the causes of anxiety; psychotherapy; or techniques including progressive muscle relaxation, biofeedback, or, less commonly, yoga, self-hypnosis, or meditation. In general, these approaches are designed to give people with anxiety a feeling of control over their symptoms.
Patients can also help themselves by getting enough sleep, exercising (which aids sleep and improves self-esteem), and avoiding caffeine and alcohol. Patients often have more than one anxiety disorder; determining exactly which disorders are present can lead to better treatment. Depending on the severity of anxiety symptoms, treatment can be managed by a primary care physician or specialist.
This section has more on general medication treatment. Also, because the various disorders respond differently to the available types of treatment, there is more information on treating:
- Panic disorder
- Generalized anxiety disorder
- Obsessive-compulsive disorder
- Post-traumatic stress disorder
- Phobic disorders
Although benzodiazepines are still commonly used to treat anxiety, two classes of antidepressant drugs—SSRIs and tricyclics—have become the first line of treatment for anxiety in many people. The serotonin and norepinephrine reuptake inhibitors and tetracyclics are also used to treat these conditions. These drugs are not habit forming and can be effective in low doses. Clearly, antidepressants are indicated when a person with anxiety is also depressed. Tricyclics and SSRIs take at least two to three weeks to act, making them slower acting than benzodiazepines, but they do bring an early benefit to patients with anxiety by promoting better sleep, which quickly improves daily functioning.
It is thought that benzodiazepines relieve anxiety by enhancing the effects of the inhibitory neurotransmitter GABA. However, their mechanisms of action are not completely understood. The side effects of benzodiazepines are generally minor. They include mild disturbances of thinking and, in rare instances, slowed breathing. Two side effects of benzodiazepines, drowsiness and clumsiness, may lead to an increased risk of accidents while driving.
The most troublesome features of the benzodiazepines are the development of tolerance (decreased effectiveness of a given dose with continued use) and both physical and psychological dependence, especially with long-term use of high doses. Tolerance may cause a person to request, and at times receive, increasingly larger doses to maintain benefits. Such patients may be switched to an SSRI or a tricyclic drug instead of higher doses of a benzodiazepine.
Physical dependence is defined by the development of a specific set of physical symptoms upon withdrawal of a drug. Psychological dependence refers to a persistent desire for the drug after it has been discontinued. Physical and psychological dependence can lead to serious manifestations (including irritability, agitation, restlessness, insomnia, loss of appetite, tremor, muscle aches, and, in some patients, confusion or seizures) upon withdrawal of benzodiazepines. The danger of severe withdrawal symptoms can be diminished by using the smallest effective dose of a benzodiazepine for the shortest possible time and by slowly tapering the drug dose as it is discontinued.
A newer drug, buspirone (BuSpar), has fewer adverse effects than benzodiazepines, but it may be less effective, in particular for panic disorder. Common side effects of buspirone are dizziness, headache, nervousness, and nausea. However, buspirone does not produce drowsiness, and abuse is unlikely because it does not cause tolerance or dependence. In switching from benzodiazepines to buspirone, patients may be able to minimize anxiety symptoms by starting immediately on buspirone while tapering the dose of a benzodiazepine.
Panic disorder may require more long-term drug therapy than other anxiety disorders, such as GAD. Treatment of panic disorder often involves both psychotherapy and pharmacologic measures. Referral to a therapist experienced in treating panic disorder is often necessary. Growing evidence supports the effectiveness of cognitive behavioral psychotherapy that involves graded exposure to situations that induce symptoms of anxiety.
The mainstay of drug treatment had been the tricyclic antidepressants or MAO inhibitors; both are 80 percent to 90 percent effective in blocking panic attacks but require six to 12 weeks to take effect. High doses of alprazolam (Xanax), one of the newer benzodiazepines, can be effective within a few days and cause fewer side effects than the antidepressants. A relapse of symptoms occurs in 30 percent to 60 percent of patients six to 12 months after drugs are discontinued. In addition to these drugs, the SSRIs fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) have been approved by the FDA for the treatment of panic disorder. The tricyclics desipramine (Norpramin), imipramine (Tofranil), and nortriptyline (Aventyl, Pamelor) are also used, although they do not have FDA approval for this use. Beta blockers, such as propranolol (Inderal) or atenolol (Tenormin), can halt the physical symptoms of panic attacks but do not prevent the fear or panic itself.
Treating generalized anxiety disorder
Despite its more chronic course, GAD responds better to treatment than panic disorder. Psychotherapy benefits many people, either by itself or in combination with medication. In addition, relaxation techniques, such as deep breathing exercises or meditation, may relieve symptoms of GAD.
Venlafaxine (Effexor) and paroxetine have both received FDA approval for the treatment of GAD, but other serotonin and norepinephrine reuptake inhibitors, SSRIs, tricyclics, buspirone, and benzodiazepines, such as alprazolam and diazepam (Valium), are also used. A 2003 study from the American Journal of Psychiatry found that significantly more patients with GAD who took 40 mg of paroxetine for eight weeks experienced a significant reduction in symptoms than those who took a placebo (68 percent vs. 46 percent).
Persistent GAD symptoms can lead to depression and abuse of alcohol and drugs—especially of benzodiazepines. Treatment with benzodiazepines should be limited to short (five to seven days) courses to avoid dependence. Buspirone may be a better option because it does not cause dependence or withdrawal symptoms. Cutting back on caffeine may also help ease the symptoms of GAD.
Treating obsessive-compulsive disorder
As with panic disorder, OCD may improve with a combination of medication and cognitive behavioral psychotherapy. An important recent pharmacologic advance is the effective use of SSRIs, such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine, fluvoxamine also has received approval.
Treating post-traumatic stress disorder
Successful treatment requires a combination of psychotherapy—aimed at desensitizing the individual to the traumatic experience—and medication. A recent study in Behaviour Research and Therapy found that eight to 12 sessions of a combination of cognitive and behavioral therapy (involving desensitization and progressive muscle relaxation) was better at reducing post-traumatic stress disorder symptoms than supportive therapy. Two SSRIs have been approved by the FDA for treatment of post-traumatic stress disorder: sertraline and paroxetine. The tricyclics amitriptyline (Elavil, Vanatrip) and desipramine (Norpramin) are commonly used to treat the mood disturbances and anxiety that accompany the disorder.
When treatment is needed, cognitive and behavioral therapy may help desensitize the person to the thing or situation that causes the fear by gradually exposing the person to the feared situation. The therapist can teach the patient to use relaxation techniques when confronted by fear.
Recent studies have shown that the SSRIs paroxetine and fluvoxamine can successfully relieve social phobia. MAO inhibitors and benzodiazepines are also used. Beta blockers, such as propranolol, may reduce the physical symptoms of performance anxiety but are not recommended for ongoing treatment.
Content excerpted from the Johns Hopkins White Paper on Depression and Anxiety.
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