A Comprehensive Overview of Treatment Options for Anxiety

Note that the title of this article is Treatment of Anxiety, not, Treatment of Anxiety Disorders. Anxiety is a fact of everyday life for the vast majority of people, including those who have no psychiatric diagnosis. In fact, anyone entirely devoid of anxiety would, quite probably, carry a diagnosis related to that absence. In that important sense, anxiety is normal, so why would we treat a "normal" response? The answer to that is not simple, but, for the most part, we should not. Unfortunately, it is not difficult to find providers who will, and that can lead to some long term problems of various types. I shall turn back to that knotty issue a bit later in this article. First, a brief definition of anxiety (given in greater detail in other articles) and then a look at the armamentarium of possible treatment options.

Anxiety is a response that has two somewhat separable components. One part of anxiety is the physical response of the nervous system that involves an imbalance in the autonomic nervous system such that the sympathetic branch is far more active than the parasympathetic branch. What this means is that the body is prepared for vigorous action (fight or flight). Blood is shunted into the muscles, sweating increases, the heart rate goes up, and respiration becomes more rapid; the body generally prepares for maximum physical activity. These changes are very similar to those in fear or rage responses.

Along with these physiological changes, anxiety is marked by an intense need to escape from the situation or the stimulus that provokes it. In acute anxiety attacks, there is often no identifiable stimulus to avoid, but the desire to avoid and escape is there, nevertheless. By definition, in all cases, the response is out of proportion to any objective threat. Mentally, anxiety is akin to the psychic analog of physical pain; you want it to stop. The range of anxious responses, though, is very broad, from mild discomfort to paralyzing panic. Previous articles discussed the various forms of pathological anxiety reactions, both chronic and acute. (put link here). How is this treated?

Psychological Treatments of Anxiety

By "psychological treatments," I am including all of the non pharmacologic options in use today. In a sense, these are all, 'behavioral', but that term, usually refers to a particular type of treatment, loosely related to learning theory, which is a subtype of the psychological approaches. Other psychological approaches include the various forms of psychotherapy from psychoanalytic or, more generally, insight based therapies, to the cognitive therapies that do not rely on analysis of underlying conflicts.

Behavioral approaches are often thought of as more modern than the various forms of psychotherapy, but the truth is that it predates all of them. In the early part of the twentieth century, John Watson demonstrated the induction and extinction (cure) of a phobia, using classical conditioning techniques, and these are still used today. In brief, the stimulus that causes the anxious reaction is 'extinguished' in some way, either by repeated exposure without ill consequences or by associating the stimulus with other, rewarding stimuli that provoke responses incompatible with anxiety. The techniques have become high tech over the years, but the basic effect is the same as in Watson's day. Does it work? Yes, if it's used for the right disorder, for example, a phobia limited to a specific stimulus, the diagnostic category for which is, Specific Phobia. Common fears such as animal phobias are especially amenable to this treatment, but in many anxiety disorders it is not as easy to find a stimulus that triggers the reactions and, therefore, there is no way to extinguish the response with simple conditioning techniques. Free floating anxiety, or chronic anxiety manifested by shifting worries about everything, does not respond well to simple extinction techniques of conditioning. However, related techniques, utilizing the learning of relaxation procedures have some efficacy for these more resistant forms of anxiety.

Relaxation Therapy and other counter conditioning techniques.

In 1929, a physician named Edmund Jacobson published a book that detailed a technique of what was called, Progressive Relaxation. This explained a method of identifying and creating tension in muscle groups in order to learn how to relax them. This original publication In German, was translated and republished In the United States in 1938 and was followed by a plethora of books and articles, all predicated on the concept of conscious and organized relaxation of voluntary muscles.

Subsequent to this technique, several other types of relaxation therapies have evolved. Some of these use similar kinds of procedures that focus on purely physical sensations Involved In muscle contraction and relaxation, but others use more global Imagery that Involve picturing or remembering very relaxed circumstances. Some are Indistinguishable from what is usually thought of as hypnosis. All are intended to produce responses that are incompatible with anxiety and can be thought of as forms of counter conditioning; that is conditioning responses to replace the troublesome anxiety.

Do these work? Arguably, yes; they are helpful. They are, however, highly dependent on the therapist. Some are much more comfortable and adept with these techniques than others. They are also more time consuming than prescribing medication, but less time consuming than some other forms of therapy. Some people are more suitable for this treatment than others. Trust and compliance are very important characteristics of the successful client, probably more so than in most other approaches.

Other 'Learning theory' based therapies

Other forms of treatment attempt to directly extinguish the anxiety reaction without depending on any relaxation training. For example, there are techniques that present the feared stimulus repeatedly under controlled conditions that 'force' the client to confront the stimulus and 'test the reality', which is that there is no really threatening event. Others involve an variation of this that presents the anxiety producing stimuli in excess, forcing the client to endure the presentation. This, rather frightening technique is called, flooding. These extinction techniques, of course, are suitable for specific phobias, but much less applicable to generalized anxiety disorders in which the threatening stimuli are vague or shifting, and difficult to identify.

There are also 'fad' therapies (usually from California, of course) that involve what are called conditioning techniques of specific types. For example, one of these that enjoyed some utterly undeserved popularity purported to condition "eye movements," predicated on some flawed theory of the connection of these to mental states. For the most part, people are well advised to ignore these 'miracle cure' techniques.

Psychotherapy

This is a general umbrella for a number of fairly different approaches. The common factor is that they all involve a form of intensive, usually (but not always) one on one talking sessions in which there is a therapist and a client. Sometimes there is a group of clients and one or more therapists, but this is not the rule for the treatment of anxiety.

In theory, there are several separable approaches that differ primarily in the degree to which they depend on 'unconscious', hidden emotional feelings, thoughts or memories, versus dealing with problems in the 'here and now' and attempting to help the client deal with situations by thinking of them differently or responding to them in different ways. "Cognitive restructuring," a somewhat pretentious phrase for insightful advice. (I expect to be lectured, sternly, by my colleagues for that crack, but not as much as for what I am going to say later.)

At the other end of the psychotherapy spectrum, we have psychoanalytic therapy, the pure form of which involves frequent (five times a week) contact between the therapist and the client, for fifty minutes each time. These sessions are aimed at stimulating memories, thoughts, and feelings that are not immediately accessible to the awareness of client. These 'unconscious' processes are 'interpreted', but little or no advice is ever given. The client gains insight into the meaning of the troublesome behaviors and can, then, choose more effective and mature responses, including the realization that the fears are not realistic, but stand for other conflicts in the clients' lives that can now be resolved. This tends to continue for an indefinite length of time, always measured in years. For a wide variety of reasons, this therapy is no longer common.

Between the purely cognitive and the psychoanalytic, lie a number of approaches that usually involve repeated contacts between the therapist and client, usually weekly, and for various lengths of time, depending (partly) on the type of therapy. Many of these variations are actually combinations of 'insight' based therapies and cognitive restructuring when the client becomes more aware of what actually needs to be restructured. Most of the insights, though involve more immediate responses rather than memories from long ago. For example, uncovering the immediate reaction and associations people have that are unrealistic, the assumptions that are made so automatically, that they are no longer 'conscious'. These thoughts can then be 'restructured' in more adaptive and realistic ways. In other words, the therapy is aimed at identifying and correcting irrational assumptions and reactions people have.

So, now for the big question: Do these approaches work? Yes, most of the time with a fairly select population of intelligent and verbal people, less well with others. However, the best treatment combines therapy with pharmacologic approaches. Perhaps even more than the non pharmacologic therapies, the drug treatments involve several different approaches.

Pharmacologic Treatments for Anxiety

This is a very brief overview of different approaches to drug treatment of anxiety. Each has its benefits and its costs. First, the most direct and obvious approach, anti-anxiety agents or tranquilizers.

Anxiolytics (Tranquilizers)

There are quite a few types of drugs that slow people down. These range from general anesthetics to true tranquilizers. For the most part, the differences are in degree, but there is a theoretical difference between what would be called a "true tranquilizer" and the rest of the drugs of this type. All of them reduce activity level to some degree. General anesthetics are used to induce a sleep with a vengeance, a sleep from which nothing but time (or other pharmacologic agents) will awaken you. One step 'down' from that are the hypnotics, which are what are commonly called 'sleeping pills. A step down in effect from hypnotics, are drugs that are commonly called, sedatives. Often, hypnotics and sedatives are the same drugs, just used in different doses. Sometimes they are different drugs. This is determined at least as much by marketing strategies of the pharmaceutical companies as by any real differences in the effects of the drugs.

Hypnotics and sedatives are drugs that reduce activity level "across the board"; that is they depress pleasurable activities to the same extent that they reduce anxiety, anger, or fear. Sometimes, though, this is a pretty good tradeoff. People suffering from anxiety disorders can be so anxious that their pleasurable activities are virtually ruined, anyway, so a little relief from the interfering anxiety can more than compensate for the slight attenuation of the enthusiasm over the activity. This effect explains a lot of the appeal of alcohol, for example. If we could reduce the bad responses without reducing the desirable ones, we would have an ideal drug for anxiety; we would have the perfect tranquilizer, little or no anger, fear, or anxiety but full enthusiasm.

Picture a rat in a cage. Richard has already learned that if he wants water, he can get a small bowl of it by pressing a lever. He has also learned that he can get a food pellet by pushing a different lever, but he had previously learned to fear this lever because it had shocked him, sometimes, when he pulled it. It doesn't do it anymore, but Richard had learned to fear the lever; it made him anxious. He won't go thirsty, but he'll have to get himself pretty hungry before he will overcome his fear and anxiety in order to get a little food. Let's give him a mild sedative What will happen is that he will hit the water lever a little less, but his aversion to the shock will be reduced and since he is already pretty hungry, he will probably get even more food than before. For the anxious rat, it will be a pretty good tradeoff. He won't care as much as he did before, but he will function a little better.

Now let's imagine a better drug, one that gets rid of all of his excess fear of a little shock but has no effect on the positive, pleasurable, approach behaviors. Now Richard would eat and drink as much as he wanted. A minor inconvenience wouldn't interfere with what he wanted to do. He would make decisions that were not interfered with by fear. That drug would be a perfect tranquilizer. That is the theoretical definition of a perfect tranquilizer. Does it exist in the real world? Well, almost. Some drugs have at least a greater effect on the avoidance behaviors than on the approach ones, but it's a matter of degree, and quite imperfect. There is, however, a drug on the market that is pretty close in that it has virtually no effect on general activity level and a significant but incomplete effect on reducing anxiety.

From the foregoing, it might be inferred that some or all of these drugs could be of use in anxiety disorders. That inference would be correct, but it would be far from the whole story. There are 'down sides' to these medications and limits to their usefulness. But they are definitely helpful. There are two other general classes of drugs that can help control anxiety symptoms. We shall discuss those briefly.

Beta Blockers

Recall that the sympathetic nervous system is overactive in anxiety states, particularly panic disorders. There is a class of drugs that interfere with the physical effects of this sympathetic discharge. Without going into the details, the sympathetic branch of the autonomic system is divided into sub-branches. One of these sub-branches is mediated by receptors that control a lot of the primary manifestations of anxiety, such as the heart rate and respiratory increases. The receptors involved in this are called beta receptors, which, in turn, are further subdivided depending on exactly where they are and what transmitters stimulate them.

Originally developed to control blood pressure, a class of drugs called beta blockers is available to prescribe. Some of these are helpful in the outward physical manifestations of anxiety, particularly the reactions in acute panic attacks. As a class, these drugs do not affect the way brain reacts, hence, they do not have any significant sedating or tranquilizing effects, but what they can do is to interfere with the outer signs of anxiety. While this does not sound too helpful, it actually is. In cases of acute panic attacks, it quickly becomes the attack itself that is feared and that controls the sufferers' behavior. What a general beta blocker can do is prevent this full blown panic response so that the attacks, in their most disruptive form, don't happen. This prevents the vicious cycle that is triggered by the attack.

The beta blockers have a role in the treatment of some anxiety conditions, particularly those associated with panic attacks, but they are never adequate themselves. They can contribute to the effectiveness of a treatment plan that includes therapy and, possibly, other medications. The fact that they are effective in lowering blood pressure is sometimes a handy ancillary action; anxiety is a risk factor for hypertension. However, at other times, this is an unwanted side effect. None of the drugs that have been alluded to, or will be mentioned, are devoid of possible adverse effects.

Antidepressants

Sometimes, anxiety is intertwined with depression. In fact, the relations between anxiety and depression are unclear, but they often occur together, and drugs designed for the treatment of depression can also be helpful for anxiety. This can be true even when the depression is not a prominent feature of the condition.

There is no 'magic bullet' for the treatment of anxiety. Even the best tranquilizers have partial effectiveness and enough possible adverse effects to limit their use. Tranquilizers and sedatives have abuse potential. They are almost all, to some extent, potentially addictive. The closest to a pure tranquilizer has limited abuse and addiction problems, but it is not usually effective enough by itself to completely eliminate symptoms, and it is ineffective or unsuitable for some people.

Conclusions

Anxiety disorders are treatable. They are not often 'curable' in any significant sense of that word, and they do not usually go away by themselves. It will probably not come as a great surprise that a combination of psychotherapy and drug treatments are considered the most effective way to deal with most anxiety conditions. However, as mentioned above, there are some specific phobias that can be very effectively treated, even 'cured' by relatively simple learning techniques, but most other acute or chronic anxiety syndromes are not so fortunate.

As a last word of caution: be sure of your diagnosis. Anxiety can be a result of other medical conditions (or even substances, including a lot of coffee). Sometimes, even the treatment of other medical conditions can provoke anxiety as a side effect. Lifestyle changes or the elimination of risk factors can, at times, be the best treatment.

Anxiety can be a virtually unendurable condition. The substantial majority of the time, however, it can be treated and improved.