A Disturbing Trend in the Treatment of Anxiety

A summary of treatment options — pros and cons

Anxiety disorders are some of the most common problems that clients report as they come to my office for services. Many have been suffering for years from nervousness and worry.

They are not alone. Statistics suggest that 40 million people suffer from a diagnosable anxiety disorder in the United States.

Clinical anxiety versus normal anxiety

It’s important to mention that anxiety is a normal human experience. It even has a function. Not ALL anxiety is a bad thing and not all people with anxiety should be considered to have a diagnosis and/or require treatment.

Biologically anxiety is part of the fight or flight response. Our survival (especially in the caveman era) depended on us being aware of our surroundings and when danger might be more or less likely. That nervous feeling heightened our awareness of our surroundings so that we could scan for the saber-toothed tiger that might be wanting us for dinner and maximized the chances that we would notice him before it was too late.

I personally have not been worried about being eaten by a tiger, but there are plenty of other things that cause ‘normal’ worry in our modern life: traffic, kids being past curfew, physical symptoms that might be a sign of serious health problems. Most of the time this is fleeting in nature and in response to specific circumstances or events.

Anxiety becomes more of a problem when it is out of proportion to the event/circumstance. It is one thing, for instance, to worry about traffic when I’m in the middle of it or the car in front of me is swerving erratically and another altogether to worry about traffic from the moment I wake up to the point that I no longer am willing to commute to work.

When anxiety takes on that intrusive nature and causes distress in daily living (rather than promoting survival) then we can say it’s diagnosable anxiety.

Anxiety disorders in clinical practice

While I’m going to talk about anxiety in general terms in this article, it is important to be aware that there are actually several anxiety disorders. As clinicians, we use the Diagnostic and Statistical Manual of Mental Disorders to classify psychological problems. In the 5th edition, we include:

• Separation Anxiety — This is when a person feels extreme discomfort when they need to be away from another “safe” person. This is probably more common in children with a parental figure but can happen in adults as well.
• Specific Phobia — when a client is afraid of a specific thing such as a snake or spider. This one is a little different than the others since it related specifically to one thing. Not all specific phobias require treatment. Many people are afraid of snakes, for instance, but it doesn’t disrupt their normal daily lives since snakes are (for most people) easily avoided.
• Social Anxiety Disorder/Social Phobia — when the focus of the anxiety is centered around situations when they feel they are the center of attention from others and worry about negative judgment and/or criticism.
• Panic Disorder — Panic disorder occurs when someone experiences episodes of panic (which can be so severe that people present at times to the ER thinking they are having a heart attack or other serious physical health problem).
• Agoraphobia — Contrary to the literal translation, this is not the fear of open spaces but of the fear that one might be trapped somewhere and be unable to get to safety. Often this starts with panic disorder and agoraphobia develops over time as people try to avoid places they have panicked (or thought they might) in the past. However, it can also occur on its own.
• Generalized Anxiety Disorder — Clients with GAD suffer excessive worry about a variety of things almost all of the time. These feelings can even be like intense restlessness and discomfort on a daily basis.
• Selective Mutism — As the name implies, this is voluntarily refusing to talk due to heightened anxiety
• Substance or Medication Induced Anxiety Disorder — certain substances can result in feelings of panic or anxiety
• Anxiety Disorder due to another medical condition — some medical conditions can cause anxiety disorders as well

Anxiety Disorder Treatments

Treatment for Anxiety disorder is varied but might include:

Cognitive Behavioral Therapy (CBT)

One of the most well-researched and efficacious treatments for anxiety disorders is cognitive-behavioral therapy (CBT). At its core, CBT refers to a family of interventions and techniques that promote more adaptive thinking and behaviors in an effort to ameliorate distressing emotional experiences (2). CBT differs from other therapeutic orientations in that it is highly structured and often manualized. CBT sessions often occur weekly for a limited period (e.g., 12–16 weeks), and a small number of booster sessions are sometimes offered subsequently to reinforce independent use of skills. A cognitive-behavioral conceptualization of anxiety disorders includes identification of dysfunctional thinking patterns, distressing feelings or physiological experiences, and unproductive behaviors. When each of these three components interact and mutually reinforce one another, distressing and impairing levels of anxiety can be maintained over time.

In general, CBT is going to include one or more of the following interventions (depending on the precise diagnosis):

• Cognitive Restructuring — Changing the way we are thinking about something (i.e. that it’s not the end of the world to be criticized or symptoms of panic might not be desirable but they aren’t life-threatening) can change the perceived threat and allow us to relax. Cognitive distortions often are at the root of the anxiety and with some interventions, life can feel much more do-able for clients.
• Relaxation Training — I’ve written about several of these and they can be effective ways of teaching ourselves to lower our arousal level
• Exposure Therapy — One of the difficulties with anxiety is that it maintains itself. If you have ever had a panic attack, you can probably understand how one might over time not want to leave the house. The fear of the fear itself and subsequent escape (i.e. not going places or other avoidance activity) is reinforcing. Exposure therapy does just what it says — puts the client in the situation where they have to face their fear AND learn that their anxiety about it has been overblown.

Psychopharmacology

Medication to alleviate the symptoms is the other type of treatment— various possible prescriptions are available and include:

• Benzodiazepines — these medications (including valium, klonopin, xanax among others) were once the most common types of prescription for anxiety. However, they have several disadvantages including a high abuse/dependence risk (which means yes, you will have withdrawal even if you aren’t abusing them when you try to stop taking them with higher anxiety than ever), cognitive problems, increased fall risk, etc.
• Beta-blockers — All Beta-blockers (including acebutolol, bisoprolol, carvedilol, propranolol, metoprolol, and atenolol) are used off-label for anxiety. According to Healthline:

Beta-blockers are also called beta-adrenergic blocking agents. They prevent adrenaline — a stress-related hormone — from making contact with your heart’s beta receptors. This prevents adrenaline from making your heart pump harder or faster.

In addition to relaxing your heart, some beta-blockers also relax your blood vessels, which can help to reduce blood pressure.

• Antipsychotics — Antipsychotics are sometimes used for anxiety. Common medications include Zyprexa and Risperdal and side effects are generally related to fatigue and low energy.
• Anticonvulsants —

The basis for the use of anticonvulsant drugs in treating anxiety disorders can be found in the main cerebral structures involved in fear circuits. Although numerous brain regions are likely to be involved, the amygdala and the hippocampus play a key role. The amygdala is im­portant in experiencing fear and its autonomic and endocrine response through the output to the hypothalamus, while the output to periaqueductal gray matter is mainly implicated in avoidance behavior, which is also typical of fear response.4 In addition, the hippocampus is important in the re-experiencing of fear and the cognitive aspects of fear and anxiety. — https://www.psychiatrictimes.com/view/can-anticonvulsants-help-patients-anxiety-disorders

Trends

What got me thinking about all of this and deciding to write about it was a news story I saw last month about how medication is being prescribed more and more for patients reporting anxiety especially in young adults. I apologize for losing the exact article right now, but here is a link to a similar story.

Basically it suggests (and to be honest this data was from the UK but I would expect it to be essentially the same for US data, but I want to be clear that I’m extrapolating here) that there has been a two-fold increase in the prescribing rates for all of these medications and, in particular:

There were some differences in prescribing trends depending on the class of drug. New prescriptions for beta-blockers increased over the study period. However, prescriptions for benzodiazepines decreased.

Among young adults though, the researchers found an increase in new prescriptions for drugs in every class. This includes prescriptions of antidepressants (most notably among people under 25) and benzodiazepines.

The authors say there are several possible reasons for the increase in prescribing for this age group, including increasing rates of anxiety, better detection of anxiety, and greater acceptance of medication.

To read the original research, you can do so here.

The concerning part is that for younger people benzodiazepines were being prescribed at higher rates despite the known risks!

AND, I haven’t said this specifically yet so I probably need to point it out — Remember when I said avoidance behaviors (escape) reinforce the anxiety? Think about that for a moment and then think about the effect of that pill… Not ONLY is there no wisdom in the drug so no one is learning new behaviors with a pill alone, but the pill itself is being reinforced as the solution when they feel relief so there is little chance that the people taking these medications will be motivated to go out and try the uncomfortable work of facing their challenges head-on and making real change.

Of course, that isn’t true if someone is using a combination of CBT and medication. Sometimes the combo is the most effective since it allows them to function while addressing behavior and cognitive changes.

If you or a loved one are experiencing distress associated with anxiety, seek out a CBT-trained therapist to assist. While asking your general practitioner for medication might be the easiest route, don’t you really want the best route and freedom from anxiety in the long run?