Anxiety Therapy Treatments

Pharmacologic therapy & Social Phobia Cognitive therapy

Nonpharmacologic modalities should be the initial treatment for people with mild anxiety to address the three categories of symptoms of generalized anxiety disorder. Relaxation techniques and biofeedback are used to decrease arousal.

Cognitive therapy helps patients to limit cognitive distortions by viewing their worries more realistically, enabling them to make better plans to manage their anxiety.

In cognitive therapy, patients may be taught to record their worries, listing evidence that justifies or contradicts the extent of their concerns. Patients also learn that "worrying about worry" maintains anxiety and that avoidance and procrastination are not effective ways to solve problems.

A small number of studies have found that cognitive therapy is more effective than behavior therapy, psychodynamic psychotherapy and pharmacotherapy, but more research needs to be conducted before the superiority of cognitive therapy is firmly established.

Patients with personality disorders, those with chronic social stressors and those who expect little benefit from psychologic treatments do not respond well to psychotherapeutic techniques for the treatment of anxiety. Often, psychotherapy and pharmacotherapy are necessary.

Family members should participate in the treatment plan of patients with generalized anxiety disorder. Initially they can provide additional historical information and contribute to the formulation of the treatment plan.

Because patients with this disorder tend to be vigilant for signs of danger and may misinterpret information, family members can provide another perspective on the patient's problems.

In addition, family members should be included in efforts to help the patient develop problem-solving skills and can also help decrease the social isolation of patients with GAD by providing structured activities to promote interaction with others and lessen rumination about problems.

Another source of structured activity includes day programs provided by community mental health centers. If substance abuse is prominent, the patient should be referred to a rehabilitation facility.

Pharmacologic Treatment

Pharmacologic therapy should be considered for patients whose anxiety results in significant impairment in daily functioning. Study results have not revealed an optimal duration of pharmacologic treatment for patients with GAD. While 25 percent of patients relapse within one month of discontinuing drug therapy and 60 to 80 percent relapse within one year, patients treated for at least six months have a lower relapse rate than those treated for shorter time periods.

Benzodiazepines. The anxiolytics most frequently used are the benzodiazepines. All of the benzodiazepines are of equal efficacy and all act on the g-aminobutyric acid (GABA)/benzodiazepine (BZ) receptor complex, causing sedation, problems in concentrating and anterograde amnesia. Benzodiazepines do not decrease worrying per se, but act to lower anxiety by decreasing vigilance and by eliminating somatic symptoms such as muscle tension. Tolerance to the sedation, impaired concentration and amnesia effects of these drugs develop within several weeks, although tolerance to the anxiolytic effects occurs much more slowly--if at all. Benzodiazepine therapy can begin with 2 mg of diazepam, or its equivalent, three times daily. The dosage can be increased by 2 mg per day every two to three days until the symptoms abate, side effects develop4 or a daily dose of 40 mg is reached. Diazepam does not have to be used as the initial agent; several alternatives are available. In the elderly patient, benzodiazepine therapy should begin at the lowest possible dosage and increased slowly.

Agents with short half-lives, such as oxazepam (Serax), are easily metabolized and do not cause excessive sedation. These agents should be used in the elderly and in patients with liver disease. They are also suitable for use on an "as-needed" basis. Agents with long half-lives, such as clonazepam (Klonopin), should be used in younger patients who do not have concomitant medical problems. In addition to improved compliance, the longer acting agents offer several advantages: they can be taken less frequently during the day, patients are less likely to experience anxiety between doses and withdrawal symptoms are less severe when the medication is discontinued. When a benzodiazepine is prescribed, the patient should be warned about driving and operating heavy machinery while taking this medication.

Use of benzodiazepines in therapeutic dosages does not lead to abuse, and addiction is rare. The benzodiazepines most likely to be abused are those that are rapidly absorbed such as diazepam, lorazepam (Ativan) and alprazolam (Xanax). Alprazolam should be prescribed only for patients with panic disorder. When abused, benzodiazepines are usually abused with other substances, particularly opiates. The patients most likely to abuse benzodiazepines are those who have a previous history of alcohol or drug abuse, and those with a personality disorder.

All benzodiazepine therapy can lead to dependence; that is, withdrawal symptoms occur once the medications are discontinued. Withdrawal symptoms include anxiety, irritability and insomnia, and it can be difficult to differentiate between withdrawal symptoms and the recurrence of anxiety. Seizures occur rarely during withdrawal. Withdrawal symptoms tend to be more severe with higher dosages, with agents that have short half-lives, with rapidly tapered dosages, and in patients with current tobacco use or with a history of illegal drug use. The risk of dependence increases as the dosage and the duration of treatment increases, but it can occur even when appropriate dosages are used continuously for three months.

Withdrawal symptoms begin six to 12 hours after the last dose of an agent with a short half-life and 24 to 48 hours after the last dose of an agent with a longer half-life. In patients who have taken a benzodiazepine for more than six weeks, the dosage should be decreased by 25 percent or less per week to prevent withdrawal symptoms. Patients may experience rebound anxiety (akin to the rebound hypertension that occurs when some antihypertensives are discontinued) once the tapering process is completed, but this is transient and ends within 48 to 72 hours. Once the rebound anxiety ends, a patient may re-experience the original symptoms of anxiety, referred to as recurrent anxiety.