Is Relief Just a Swallow Away?: Guidelines for Using Drugs in Anxiety Treatment

Article excerpt

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:

Panic

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." Feeling bad is a red flag for the dread that characterizes GAD. The anxiety may not be acute, but it's persistent.

GAD hides behind a workaholic lifestyle, chronic pain, or restless sleep. The worrying finally gets so pervasive and acute that it's very hard to get rid of. When that happens, clients may be helped by SSRIs to diminish the cycle of worry and to help them sleep. An atypical antianxiety medication like Buspar, which can be taken over a long period because it's not addictive or mood altering in the way benzodiazepines are, can also "take the edge off" their worry while they practice cognitive-behavioral techniques. But medications are rarely a lifelong need. People with GAD need to change their lifestyle and benefit enormously from therapy to learn relaxation and thought-stopping techniques. But even with creative and persistently applied cognitive-behavioral therapy, it may take clients months to stop worrying. It helps if they are told that the lifestyle of worry takes years to develop, so it takes time to eliminate, too.

Obsessive-Compulsive Disorder

While obsessive-compulsive disorder (OCD) is less common than GAD, it's a good idea to screen for it. In OCD, the rumination is obsessive and clients perform compulsive actions (rituals) to get free of the obsession. They have a specific right-sided brain structure problem that causes the thought process to "get stuck." For most, medications are required to manage OCD while the client learns to overcome the "I doubt it" thinking. (Did I lock the door? I doubt it. Do it again. ) A client with GAD may worry that she didn't turn off the iron, and she may go back to check, in that way acting like someone with OCD. To determine if OCD is a factor, I apply what I call the "repetition-reassurance" test. If a client makes sure that the iron is off, paying attention to the fact that she's doing it, and this reassures her that she has really turned it off, she doesn't have OCD. Someone with OCD is driven to repeat actions over and over, and isn't reassured by repetition.

Social Phobia

Anyone watching late-night TV commercials may become convinced that his shyness is likely to be "social anxiety disorder." The DSM IV-TR has caught up to the advertisers, and now includes social anxiety as well as social phobia.

Social phobia describes clients who have an intense fear of being observed in social situations and of being rejected or humiliated. Their theme is "Oh no! I'm being watched and I'm bound to make a mistake!" The condition has neurobiological roots. Slightly enlarged right-sided limbic structures cause an individual to be very sensitive to faces and emotional tones in interpersonal interactions. This is the experience of shyness. Children with this neurobiology do tend to be very shy, and exposure to observation is painful. They can usually adapt to this and develop successful interpersonal relationships with parenting that encourages without pushing. But when these children are exposed to humiliating experiences in school or family life, or don't develop sufficient social skills, they learn to cope by avoidance behavior: avoiding notice in school by remaining mediocre students; avoiding restaurants or parties, where they might be noticed; or avoiding failure. They usually maintain a small number of close friendships so they feel safe, and they prefer work that doesn't require much personal interaction.

When physical flushing and rapid heart-rate are obvious symptoms, treatment can include medications, such as the new anticonvulsants (like Neurontin), or beta blockers (like Inderol), which stop the physical symptoms. Too often, however, these clients receive antianxiety medications to use "as needed," i.e., whenever they feel anxious. They may also be prescribed an SSRI or SNRI (serotonin norepinephrine reuptake inhibitor). The medications regulate and calm clients, which helps them better tolerate social situations. But clients never learn to overcome their anxiety through their own efforts and, consequently, they don't gain the confidence and competence that come with an ability to regulate themselves.

Many therapists try to avoid using antianxiety medication on an as-needed basis, but it may be very helpful with social anxiety clients immediately before an exposure to a social situation. The client won't get as anxious and will be able to use his new skills to calm himself down. The next time out, he won't need to use medication. A cautionary note: antianxiety medications shouldn't be taken once anxiety has set in.

Specific Phobias

Phobias originate from many causes, and typical phobias include fear of public speaking, fear of flying, and fear of animals or insects. It's uncommon to see specific phobias presented in therapy as the only issue a client has, because people don't feel distress when they're not in the situation they fear. Unless the phobia interferes seriously with some aspect of their lives, as fear of flying sometimes does, people most often just avoid what they fear.

Phobias can be successfully treated without medication at all. The best therapy tools for a specific phobia are those that eliminate symptoms rapidly and also eliminate any connection to the original cause, if that's necessary. Earlier types of treatment included desensitization, but in the last decade, two forms of treatment--EMDR and the "energy therapies"--have become widely used for most phobic clients. EMDR is extremely effective when the phobia is intense and when it originated in trauma. For uncomplicated phobias, an energy therapy like Thought Field Therapy is fast and effective. It works by eliminating the sensation of fear when the client thinks about the phobic subject. Both of these methods have numerous other applications, but they work well with phobia.

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Anxiety can have a life of its own. Many who suffer anxiety describe the experience as being like having a voice in their ear that's creative and continually finds new worries and new reasons to feel fear. The relief of finding medication to calm down that sensation is profound. Therapists can help their clients get the courage to eliminate, rather than mask, the voice of anxiety when they explain to them how medication helps and inform them of what they can't do. Using medications can make therapy work better, but ultimately, it's the therapy that will eliminate anxiety from a client's life.

Margaret Wehrenberg, Psy.D., maintains a private practice in Lisle, Illinois. She was a cofounder of the Anxiety Treatment Network, and she lectures nationally on topics related to psychotherapy, neurobiology, addiction, and anxiety. Address: 4513 Lincoln Avenue, Suite 110, Lisle, IL 60532. E-mails to the author may be sent to drmw116@aol.com.  Letters to the Editor about this article may be sent to Letters@psychnetworker.org.

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