Anxiety is a part of life, but some people are stuck in this state, unable to calm down. It is a state of physical symptoms, feelings of paralyzing fear and loss of control. How can drug and non-drug therapy help?
Anxiety is a part of life. It may even be beneficial in an evolutionary sense – the heightened awareness of surroundings and the anticipation of sudden reaction. The stalking lion and the Olympic sprinter both share a focused, whole body concentration and readiness. If the prey never materializes or the Starter’s pistol never fires, there is a short period of recovery while the mind and body relax back into a more normal state.
In contrast, consider the person who cannot turn the switch off, or for whom the switch is thrown inappropriately – there is no race to run, no prey to chase after. Now, what evolution has programmed into us becomes a disability. And the physical symptoms of anxiety disorder appear.
- Rapid heart rate and palpitations – for some, the feeling that they are about to have a heart attack.
- Sweating – as in the ‘sweaty palms’ of nervousness, only to an excessive degree.
- Increased blood pressure, flushing, headaches, and trembling.
Along with the physical symptoms, feelings of paralyzing fear, anxiety and a loss of control predominate. The important difference between the common incidents we all feel and anxiety that requires treatment is the frequency and duration of the attacks and how much they interfere with daily life. Sometimes, even generalized anxiety in the form of chronic, diffuse worry is treated as an anxiety disorder, especially in older adults.
Conditions that fall under the umbrella of anxiety disorders include: panic attacks, obsessive-compulsive disorder, post traumatic stress disorder and others, including mixed types that overlap with depression. Depression often appears in patients with anxiety disorders (as high as 60%).
The historical treatment of a shot of brandy and a slap on the face is the movie version of emergency care for those paralyzed by overwhelming stress. The idea is to induce a kind of ‘reset’, as one might do for a computer acting badly. Unfortunately, long-term, the results of such treatments are more likely to be alcoholism and a severely bruised face.
Patients do self-treat. For anxiety that causes insomnia (sometimes called ‘racing thoughts’) patients may try alcohol, over the counter sleep aids (usually antihistamines) or even illegal opioids. For anxiety that has a specific trigger, patients may adjust their lifestyle to avoid certain situations – for example, an agoraphobic who is careful to avoid elevators, bridges or exposure to heights.
Non-pharmacological medical treatments that have shown benefits include cognitive behavior therapy (CBT), hypnotherapy or interpersonal therapy. These methods attempt to train the patient in a stepwise fashion until previous stressors no longer induce anxiety (or at least not crippling anxiety). Of these, CBT has been shown to have excellent results for those patients for whom triggers can be determined. The method relies on exposure to the trigger situations in graduated degrees with relaxation training used to combat anxiety as it arises. The obvious benefit of CBT is the limiting aspect. Unlike medications, after a successful treatment regimen (which may be a dozen sessions) patients are free to fend for themselves and, in a real sense, are cured.
The benefits of anxiolytics alone, when contrasted with therapy alone, are that they are easier to administer (no special training is required and patients are expected to monitor their own usage) and often give quick results. They are less expensive initially (as opposed to psychiatric office visits) and the side-effect profile for many is quite good – this makes them an attractive choice for general practitioners who want to ‘try something out’ and insurance companies which are happy with the diagnosis + prescription model of reimbursement.
The rationale for chemical agents is also ‘more scientific’. It is more difficult to duplicate and measure what a talented therapist does and much easier to produce convincing statistical metrics with chemical entities (blood levels, pharmacokinetics, receptor sites). Once a patient is stabilized on a medication regimen that reduces symptoms, they can be largely ignored for months at a time, unless or until they need a dosage adjustment. These cost/benefit advantages allow for more care at a lower overall price.
The disadvantages are a lack of real ‘customization’ and the statistical filtering of the patient population. Statistical filtering means that a large patient population is prescribed a medication (perhaps overprescribed) and those that are not helped ‘fall through’. This smaller pool is then administered the next medication on the list and another portion is filtered out. The cycle can continue until only the most difficult cases remain, and those are then referred to psychiatric care.
At first, this system seems rational. But because many of the anti-anxiety drugs are prescribed by non-specialists (often based on the results of an in-the-office test) the filtering shunts many patients out of the system too soon. Without the expertise to evaluate often complex diagnoses, patients are treated in a ‘one size fits all manner’ by general practitioners who simply want to help.
Anxiolytics are classified by their mechanism of action:
- SSRIs (Selective Serotonin Reuptake Inhibitors) interfere with serotonin removal from synapses in the brain. They are called ‘selective’ to contrast them with less specific drugs which also affect other neurotransmitters (norepinephrine and even dopamine). These represent first-line therapy for anxiety disorders and include fluoxetine, paroxetine and sertraline. These agents are also prescribed for depression.
- Benzodiazepines, such as diazepam, clonazepam and alprazolam, are prescribed for short-term or ‘as needed’ relief of symptoms. They are habit forming and cause sedation. They can be prescribed for chronic use in patients who suffer from anxiety induced insomnia as a sleep aid. Some studies show that benzodiazepines may actually cause depression in some situations, either from higher doses or long-term use. (Example from Medscape.) Patients also commonly complain of cognitive impairment (memory loss) on benzodiazepines, which can restrict their use.
- Azapirones – these include buspirone and tandospirone. These drugs act directly on serotonin receptors (5HT-1A) as partial agonists. They are not habit forming like the benzodiazepines, and in naïve patients, provide the same level of relief from symptoms. They also do not cause sedation and for this reason, patients who have used benzodiazepines may feel they are not working, because they do not get the drowsiness or mental impairment they have come to associate with their medication. This class is also not useful for as-needed relief – the effects can take several weeks to appear.
- Barbituates have been used in the past to treat anxiety (acute), but are discouraged because of the high addiction potential and the danger of death in combination with alcohol. Currently, they only find use in sleep-onset insomnia.
- Other drugs, such as beta blockers or hydroxyzine (anti-histamine) have been used effectively as anxiolytics because they address the physical symptoms, especially in performance anxiety situations. Inderal (propranolol) has seen amateur application by college students who suffer from test anxiety. The lower heart rate and blood pressure drop caused by the drug can stop what would otherwise be a downward spiral of nervousness during stressful exams. The effect is not spurious; students actually score higher with the correct dose.
Best practices will probably continue to be some combination of both drug and non-drug therapy. The gap between what psychiatry sees as physical (best treated with a physical agent) and mental (best treated with cognitive therapy) will continue to close as neuro-anatomy and neuro-physiology advance.
While the hope is that anxiolytics will become as specific as antibiotics are now, it is unlikely that skilled psychiatric care will be replaced by a short list of standard pharmaceuticals. Diagnosis remains an art. Patients are diverse enough that clear categorization into simplistic classes is unlikely. The overlap of conditions (i.e. depression paired with anxiety paired with failing health) makes single issue patients a rarity and agents that are helpful theoretically may interfere with other medications.
One caveat remains – the advent of each new drug leads to increased usage of drugs. The old saying is true: “When all you have is a hammer, the whole world starts to look like a nail.” In a sense, new drugs create new diseases. We must rely on psychiatrists to keep the process rational and realistic. They must resist pressure from other medical personnel to take over their profession with ‘quick fixes’.