How are anxiety disorders treated?
Many psychological treatments—such as relaxation training, meditation, biofeedback and stress management—can help with anxiety disorders. Many people with anxiety disorders also benefit from supportive counselling or couples or family therapy. However, experts agree that the most effective form of treatment for the anxiety disorders is cognitive-behavioural therapy (CBT). Medications have also been proven effective, and many people receive CBT and medication in combination.
CBT is a brief, problem-focused approach to treatment based on the cognitive and behavioural aspects of anxiety disorders. Typically, CBT consists of 12 to 15 weekly one-hour sessions. In the initial sessions, the person with the anxiety disorder works with the therapist to understand the person’s problems. The person’s symptoms of anxiety are assessed within a cognitive-behavioural framework, and the goals and tasks of therapy are established. As the therapy progresses, behavioural and cognitive tasks are assigned to help the person with the anxiety disorder learn skills to reduce anxiety symptoms. As the symptoms improve, the therapist also focuses on underlying issues that may pose a risk for “relapse,” a term used to describe the return of symptoms. Homework assignments between sessions can include facing a feared situation alone, recording thoughts and feelings in different anxiety-provoking situations, or reading relevant material. Following treatment, therapists often schedule less frequent “booster” sessions.
What does CBT involve?
A standard component of CBT treatment is exposure therapy, which involves gradually exposing the person, either directly or through the person’s imagination, to his or her feared situation that triggers anxiety. For instance, the person who fears dogs will be asked to spend time with dogs, the person who has panic attacks in the mall will be requested to go to malls, and the person who fears embarrassing himself or herself in social situations will be asked to attend gatherings and speak with others.
The rationale behind exposure therapy is that by practising exposure to their fears, people have the opportunity to learn that their fears are excessive and irrational, and that the anxiety decreases with more and more practice. This process is called habituation.
Because many people find it hard to face their fears, exposure therapy typically starts with exposing the person to situations that create only mild to moderate symptoms of anxiety, and gradually progresses to exposing the person to situations that create severe anxiety. In the case of someone who fears dogs, therapy may begin with the person discussing dogs, then progress to the person looking at photos of dogs, watching movies that showcase dogs and watching dogs from a distance, until eventually he or she can approach and pat different types of dogs.
Again, with repeated exposure, these situations begin to elicit less and less fear and anxiety for the person, and he or she feels less of an urge to avoid them. As the person makes progress in conducting exposures with the assistance of the therapist, he or she is increasingly requested to complete exposure tasks as part of homework between sessions. The time it takes for people to progress in treatment may depend on the severity of their fear and their ability to tolerate the discomfort associated with arousing their anxiety.
An important part of CBT is helping people with anxiety disorders to identify, question and correct their tendencies to overestimate danger and their perceived inability to cope with danger. Cognitive strategies are developed in combination with exposure therapy to help people recognize that their thoughts, attitudes, beliefs and appraisals can generate and maintain anxious states.
For example, people who fear dogs may have the mistaken belief that all dogs are dangerous, based on an earlier experience with a single dog bite, and people experiencing panic attacks are likely to overestimate the likelihood of, or the threat associated with, having another panic attack in the mall. People with social phobia tend to overestimate the degree to which they are going to make social blunders and subsequently be judged and ridiculed. People with contamination obsessions and washing compulsions exaggerate the perception of danger associated with benign objects, such as door handles, chairs, money or shoes.
With repeated practice in therapy and then as part of homework, people with anxiety disorders develop skills that enable them to identify anxiety-related thoughts and beliefs, identify common distortions in their thinking, examine the evidence that supports and does not support their fearful appraisals, and develop less-threatening alternative responses to the feared object or situation. Cognitive restructuring exercises are also introduced to help the person recognize why behavioural avoidance, reassurance-seeking behaviours and “safety” behaviours (e.g., the person experiencing panic who always carries a cell phone just in case he or she needs to call for help) are unhelpful long-term strategies.
CBT has been found to be effective for all the anxiety disorders. Most people experience a significant reduction in their symptoms and stay well after the treatment ends. Given the success of this therapy and its ability to reduce relapse, CBT is established as the first-choice psychological treatment for anxiety disorders. CBT should be offered to all people with anxiety disorders, except for those who have already completed a course of CBT and failed to improve, those who do not want to try CBT, or people who cannot access a well-trained CBT therapist. Step-by-step workbooks are available for each anxiety disorder.
Research has shown that people with anxiety disorders often benefit from medications that affect various neurotransmitters, particularly serotonin, norepinephrine and GABA. Medications can help reduce symptoms of anxiety, especially when combined with CBT.
The main medications used to treat anxiety are selective serotonin reuptake inhibitors (SSRIs), norepinephrine and serotonin reuptake inhibitors (NSRIs) and benzodiazepines (BZDs). SSRIs and NSRIs belong to a class of drugs called “antidepressants,” which are commonly prescribed to treat both anxiety disorders and depression. Benzodiazepines are classed as “sedatives” and are generally used to treat anxiety or insomnia.
Doctors treating anxiety disorders will usually prescribe an SSRI or an NSRI. Research indicates that these medications help reduce the symptoms of anxiety for about 70 per cent of the people who take them. For those who do not benefit from taking an SSRI or NSRI, other drug treatments can provide relief. In some cases, specific symptoms of anxiety may be addressed with other medications, such as “beta blockers” to reduce hand tremors or slow down the heart rate, or “anticholinergics” to reduce sweating. Such medications can be taken in addition to an SSRI or NSRI.
Antidepressants are usually the first medication prescribed to treat anxiety disorders. These medications are safe, effective and non-addictive, and have not been shown to have any long-term effects. The drawback of antidepressants is that they often have side-effects. For most people, the side-effects are mild and short-lived, an easy trade-off for the benefits of the medication. For others, the side-effects might be more troubling. People often experience the side-effects of an antidepressant within the first few weeks of treatment, before experiencing its benefits.
While SSRIs and NSRIs are the most commonly prescribed anti-depressants in the treatment of anxiety disorders, other classes of antidepressants are also effective. These include tricyclic and tetracyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs). Newer antidepressants are also available, but their effectiveness in treating anxiety disorders has not yet been established.
What’s involved in trying antidepressants?
For best results, antidepressants should be taken regularly, generally once or twice each day. These and all medications should be taken only as prescribed. Taking more or less than the prescribed amount can prevent medications from working, and may even worsen some symptoms. Most doctors recommend starting at a low dose and then, if the person tolerates the medication well, slowly increasing the dose until the ideal dose is found. The ideal dose is one that provides the greatest benefit with minimum side-effects.
Once a person has begun taking an antidepressant, he or she should continue for a trial period of at least three months. This allows time for the dosage to be adjusted correctly, for the initial side-effects to subside, and for the benefits of the drug to become clear. When these drugs work, the effects come on gradually. Usually several weeks pass before any change in symptoms is noticed. Then, the anxiety is reduced and it is easier for people to work on changing the way they behave in response to anxiety. It is important to realize that although these medications can be of great help to some people, not all symptoms of anxiety will be relieved.
If no benefits are derived from a particular antidepressant after a trial period of three months, doctors often recommend that another antidepressant be tried. Some people respond well to one drug and not at all to another. If a person does not benefit from the first medication (e.g., an SSRI), a second choice would be another SSRI or an NSRI, and the third choice would be a TCA. It is not uncommon for someone to try two or three antidepressant drugs before finding the one that works best.
The question of whether or not to take an antidepressant while pregnant or nursing should be discussed with your doctor. In some cases, the benefit of the drug clearly outweighs the possible risks.
How long should I take an antidepressant?
When the right antidepressant has been found, doctors usually advise taking the medication for at least six to 12 months. In some cases, the doctor may recommend taking the medication for several years, as there might be a greater risk of relapse if the medication is stopped. Even when taken for the long term, these medications are safe and non-addictive. No long-term side-effects have been associated with the use of antidepressants.
If a person begins to feel better and stops taking medication too soon or too quickly, the risk of relapse increases. The decision to stop taking medication should only be made in consultation with a doctor. The following guidelines can help lower the risk of relapse when a person wants to discontinue using medication:
• Lower the dosage gradually by “tapering,” or reducing, the medication over a period of time, possibly several weeks to months.
• Follow up regularly with a health care professional to help monitor the severity of any recurring symptoms of anxiety.
• Combine CBT with medication and use the skills learned to control any symptoms of anxiety that may arise when medication is discontinued.
Side-effects of antidepressants
People who take antidepressants are likely to experience side-effects. Side-effects often begin soon after the person starts treatment, and generally diminish over time. In the early stages of treatment, side-effects may resemble anxiety symptoms, causing some people with anxiety disorders to abandon the treatment before it has had a chance to take full effect. Such side-effects, however, usually only last a couple of weeks. Some side-effects may be reduced by adjusting the dose, or by taking the medication at a different time of the day. If this approach does not improve the side-effects, the doctor may prescribe another medication.
The side-effects of antidepressants are not permanent and will disappear completely when the medication is discontinued. When taking antidepressants or any medication, it is important to discuss with your doctor any side-effects that are troubling you. Each class of antidepressant and its common side-effects are discussed below.
Drug interactions with antidepressants
When taking an antidepressant, or any medication, it is important to check with your doctor or pharmacist for possible drug interactions before taking any other prescription or over-the-counter drugs, or any herbal products. Check also with your doctor before using alcohol or illicit drugs, as these may also interact with certain medications or reduce the effectiveness of treatment. Even on their own, alcohol and illicit drugs can create symptoms of anxiety.
Selective serotonin reuptake inhibitors
SSRIs are often the first medication prescribed to treat anxiety disorders. These medications are known to reduce symptoms of anxiety, to be safe, and to have milder side-effects than some other antidepressants. SSRIs have their primary effect on serotonin neurotransmitters.
The SSRIs currently available in Canada are: fluoxetine (Prozac), fluvoxamine (Luvox), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa) and escitalopram (Cipralex). Of these, citalopram (Celexa) and escitalopram (Cipralex) are the newest on the Canadian market and their effectiveness for all anxiety disorders has not yet been proven through research. These medications are considered to be equally effective, although each may work for some people and not for others. They work less rapidly than benzodiazepines, especially in panic disorder, but are better tolerated in the long term and do not cause dependence.
Common side-effects: sexual inhibition, gastrointestinal complaints, weight gain, headaches, anxiety, insomnia or sedation, vivid dreams or nightmares.
Norepinephrine and serotonin reuptake inhibitors
Venlafaxine (Effexor) is used to treat depression and generalized anxiety disorder, and also panic disorder, OCD and social phobia. The only other medication in this class currently available in Canada is duloxetine (Cymbalta), which has not yet been studied for effectiveness for anxiety disorders.
Common side-effects: nausea, drowsiness, dizziness, nervousness or anxiety, fatigue, loss of appetite and sexual dysfunction; in higher dosage, venlafaxine may increase blood pressure, and should only be taken on the doctor’s advice by people with hypertension or liver disease.
Tricyclic and Tetracyclic antidepressants
Although there are 10 TCAs available in Canada, not all of them have been shown to be effective for the treatment of anxiety disorders. Imipramine (Tofranil), desipramine (Norpramin) and clomipramine (Anafranil) have been the most studied for the treatment of panic disorder, generalized anxiety disorder and posttraumatic stress disorder. Clomipramine is most helpful for treating obsessive-compulsive disorder.
TCAs may interfere with certain medications, especially other mental health or heart medications. Review with your doctor the medications you are currently taking to check for possible interactions.
Common side-effects: dry mouth, tremors, constipation, sedation, blurred vision and change of blood pressure when moving from a sitting to a standing position (orthostatic hypotension). Because TCAs may cause heart rhythm abnormalities, ask your doctor for an electrocardiogram (ecg) before taking this medication.
Monoamine oxidase inhibitors
MAOIs are highly effective medications for the treatment of depression and anxiety. However, MAOIs are used less frequently than other antidepressants because people who take them must follow a diet that is low in tyramine, a protein found in, for example, foods that are aged, fermented or high in yeast. If tyramine is taken in a too large a quantity while taking an MAOI, it can cause severe high blood pressure, which may be life-threatening. If you are taking an MAOI, your doctor or pharmacist will provide you with a list of foods to avoid. Examples of MAOIs are phenelzine (Nardil) and tranylcypromine (Parnate).
MAOIs also interact with a number of medications. Some painkillers, for example, should be avoided. Ask your doctor or pharmacist for a list of medications to avoid. If you plan to have surgery, let your dentist or surgeon know you are taking an MAOI at least a few weeks before the scheduled date. You may be asked to discontinue the MAOI prior to the surgery to avoid possible drug interactions. If you require emergency surgery, your doctor will monitor and manage any possible drug interactions during and after the surgery.
Common side-effects: change of blood pressure when moving from a sitting to a standing position (orthostatic hypotension), insomnia, swelling and weight gain.
Moclobemide (Manerix) is an antidepressant related to the MAOIs, but which does not require diet restrictions and has fewer drug interactions, making it safer than MAOIs. It is used to treat social anxiety disorder. Mirtazapine (Remeron) and bupropion (Wellbutrin, Zyban) are newer antidepressants whose effectiveness in the treatment of anxiety disorders has not been established.
Benzodiazepines are a group of medications that increase the activity of the GABA neurotransmitter system. BZDs reduce anxiety and excessive excitement, and make people feel quiet and calm.
They also produce drowsiness, making it easier to fall asleep and to sleep through the night. For a long time, before SSRIs were available, BZDs were the drugs of choice for managing anxiety disorders. However, these drugs have potential for abuse and can be addictive, so the long-term use of BZDs is discouraged.
BZDs are often used to treat generalized anxiety disorder, panic disorder, social anxiety disorder, obsessive-compulsive disorder and posttraumatic stress disorder. They are usually prescribed in addition to an SSRI or other antidepressant for two to four weeks at the beginning of treatment, until the antidepressant becomes fully effective. The advantage of BZDs is that they can rapidly relieve and control anxiety.
The BZDs most commonly used to treat anxiety disorders are clonazepam (Rivotril), alprazolam (Xanax) and lorazepam (Ativan).
Common side-effects: drowsiness, sedation, dizziness and loss of balance; effects are most serious when BZDs are combined with alcohol or with other sedative medications.
Buspirone (Buspar) can be used to treat generalized anxiety disorder. It works mainly through the serotonin neurotransmitter system and usually takes two to three weeks to become effective. Antipsychotic medications are rarely used to treat anxiety disorders. When prescribed, they are generally given at a low dose in combination with antidepressants to people with severe anxiety who do not respond to antidepressants alone.
Over the years, many herbs have been thought to have some effect on mood and mental health. Although many plants may have active ingredients that can be somewhat effective in relieving various symptoms, their effectiveness has not been formally tested. In North America, the herbal industry is unregulated, meaning that the quality and effectiveness of herbal products is not consistent. Adverse effects are possible, as are toxic interactions with other drugs. If you are considering herbal medicines, you should discuss this with your doctor and review the medications you are already taking.
Some herbal products have sedative effects and are believed to reduce symptoms of anxiety. These include German chamomile, hops, kava kava, lemon balm, passion flower, skullcap and valerian. Other herbs without sedating effects, such as St. John’s wort, have also been suggested for treating anxiety disorders. The effectiveness of all of these medicines in the treatment of anxiety disorders, and their effectiveness in comparison to antidepressants, have not yet been studied.
What about recovery?
When someone begins treatment for an anxiety disorder, the first goal is to reduce and manage symptoms. The process of achieving this goal, known as “recovery,” often includes a combination of medication, cognitive-behavioural therapy (CBT) and supportive psychotherapy, and may also include other support such as occupational, recreation and nutrition therapy. Recovery also includes the way you apply the skills learned in treatment to real life situations. Your idea of what you hope to achieve through recovery is unique to you. Long-term goals may include improved relationships with others, a full and satisfying work life, increased self-esteem and improved overall quality of life.
Once recovery is underway, and you are ready to focus on getting your life back to normal, the next step is “relapse prevention.” Anxiety is not an illness with a “cure.” Medication and therapy can help to bring symptoms under control, but some of the symptoms of anxiety, such as worry and fear, can arise for anyone during everyday life. To prevent relapse, you need to be ready with a plan to manage symptoms as they appear. Moving through the process of recovery and relapse prevention depends on a combination of planning and attitude. Achieving and maintaining your goals is easier when you develop:
• awareness of warning signs and strategies to respond to setbacks
• a healthy lifestyle
• hope and optimism about the future
Adapted from Anxiety Disorders: An Information Guide © 2009, Centre for Addiction and Mental Health
* American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision). Washington, DC: Author.