Is Relief just a Swallow Away?
Guidelines for using drugs in anxiety treatment
by Margaret Wehrenberg
A blizzard of TV and magazine advertising has given millions of people the impression that anxiety is as easily relieved as heartburn--just take a pill! Primary-care physicians, and even many psychiatrists, tend to take this tack as well, automatically prescribing medications for anxiety without suggesting therapy. Why bother with therapy? Medications deliver peace of mind without the added hassle.
Anxiety is a catchall term applied to a host of conditions requiring different therapy approaches. Medications can be helpful, even necessary, for some cases--but certainly not for all. Therapy without medications is often a better option, and therapy combined with the judicious, tactical, and temporary use of medications may be the best alternative of all.
But how does a therapist decide whether to use therapy, medications, or a combination of both? How can a clinician determine whether the long-term use of medications might actually prevent a client from learning to conquer anxiety? The answer lies in recognizing the distinctions between different forms of anxiety and carefully assessing the client's own history to determine what kind or combination of anxieties he or she experiences. The following are keys to recognizing and treating some of the most typical types of anxiety disorder:
Of all the anxiety disorders, panic drives people into treatment the earliest. The fight-or-flight symptoms (rapid, shallow breathing, extremely fast heart rate, dizziness, nausea, etc.) are so disruptive and distressing that people can't tolerate them. They believe they're dying, going crazy, or losing control, and quickly seek medical help. They're usually given a prescription for an antianxiety medication (usually a benzodiazepine such as Xanax or Ativan) to see them through panic episodes, but symptoms come right back as soon as the medication is discontinued. Yet, of all the anxiety disorders, panic is the one that rarely requires prolonged medication for a full recovery.
People may experience their first panic attack "out of the blue." This might occur after a period of prolonged chronic stress, but may not feel related to it. Or the first panic attack might be triggered by serious, unexpected stress, such as a car accident. But once a person has one panic attack, "fear of fear" sets in. That sets up avoidance of places or situations that might create panic. The person becomes so watchful for the physical signs of panic that this hypervigilance may inadvertently trigger a panic attack.
Antianxiety drugs reliably prevent the fight-or-flight feelings, but don't cure the disorder. Sometimes, panic sufferers are given SSRIs (selective serotonin reuptake inhibitors) to balance the serotonin and norepinephrine levels that might be off after prolonged stress. However, learning to breathe away the physical arousal and control thoughts of going crazy or out of control can permanently eliminate panic without using drugs.
Generalized Anxiety Disorder
If the cognitive theme of panic is "Oh, no! I'm losing control!" then the theme of generalized anxiety disorder (GAD) is "Oh, no! I've made a mistake and someone is sure to find out." GAD is more common than panic, but also more often overlooked. People live with the worry of GAD for years before they seek help, and often come to psychotherapy for the depressed mood that results from ongoing worry. People with GAD may have a neurobiology that primes them to be worriers, but they also tend to be solemn, careful, or meticulous. Their worry feels appropriate, until it gets to be overwhelming.
People with GAD are likely to have physical problems such as headaches, ulcers, or colitis. When they finally get to psychotherapy, they can't describe their anxiety except to say, "I don't know, I just feel bad. …