Day # 65: Treatment of Anxiety Disorders

Today we will discuss an overview of the treatment of anxiety disorders. We will summarize pharmacological and non-pharmacological options and provide a framework for when to consider specific treatments. Later we will discuss each anxiety disorder and provide detailed treatment information.

Today's Content Level: Beginner, Intermediate

INTRODUCTION

•Treatment options for all anxiety spectrum disorders include psychotherapy, pharmacotherapy, and other alternative treatments. Therapy and medications are both effective separately and together in anxiety disorders. The most effective treatment is probably a combination of these approaches.

•Discuss patient’s preference for psychotherapy and/or pharmacotherapy, as studies show that there is no significant difference in efficacy of psychotherapy vs medications in GAD.

•It is important to understand that anxiety spectrum disorders tend to be chronic and treatment is often only partially successful.

•Medications can reduce symptoms enough so that a patient can participate in therapy and address the core psychosocial origins of the anxiety and reduce avoidance behavior. Therapy can help prevent relapse if medications are no longer prescribed.

•We will discuss an overview of treatment today, but see specific posts on the various disorders (GAD, panic, phobia's, etc...) for more detail summary of treatment considerations.

PSYCHOTHERAPY

There are a number of different modalities of psychotherapy that are helpful for patients suffering from anxiety disorders. This post will describe some of the most commonly used techniques.

Cognitive Behavioral Therapy (CBT) 1

• Strong evidence for effectiveness for anxiety disorders. Has the most evidence of any form of psychotherapy. First-line for GAD, panic disorder, and others.

• CBT has both short-term and long-term efficacy.

• Due to methodological issues, the exact magnitude of the effect is currently difficult to estimate.

• Examines relationship between anxiety-driven thoughts, emotions, and behaviors. The general approach is exposure (not reassurance) and cognitive restructuring.

• If poor response after course of CBT then add pharmacotherapy.

Psychodynamic Psychotherapy 2

• Less studies overall when compared to CBT but existing evidence supports its efficacy.

• Head-to-head study with CBT-> both modalities showed significant overall improvements. CBT was more effective on a few measures, including worrying.

• Focuses on unconscious conflicts associated with anxious symptoms, identifying ego strengths, and emphasizes a positive patient-therapist relationship to help encourage new behaviors.

• Facilitates understanding and insight into the development of anxiety and ultimately increases anxiety tolerance.

Other

• Dialectical Behavioral Therapy (DBT) 3: Originally designed for treatment of borderline personality disorder, but now has evidence in the treatment of depression, anxiety, trauma, and more.

• Family Therapy: All mental health disorders, including anxiety, have a significant impact on family and damaged relationships can be a source of additional anxiety. Family therapy addresses effective communication, addresses past issues, and develops an action plan for future situations.

• Applied Relaxation 4: Focused on learning to recognize early anxiety signals and learning to cope with the situation through various relaxation techniques.

• Emotional Regulation Therapy: Incorporates components of CBT such as psychoeducation and self-monitoring while also adding interventions that address emotional regulation, emotional avoidance, and interpersonal difficulties.

• Mindfulness Therapy: Mindfulness based stress reduction programs involves the nonjudgmental observation of moment to moment experiences. Evidence supports lowered anxiety symptoms in response to a stressful challenge.

• Acceptance and Commitment Therapy: ACT combines mindfulness with the acceptance of internal states and orientation of actions towards valued goals. It does not involve any form of cognitive restructuring or specific relaxation training.

Non-Pharm / Non-Therapy

• Encourage patients to engage in regular physical exercise. Exercise has been shown to significantly reduce anxiety and is comparable to our treatment options. 5

• Evaluate for "stimulants" such as caffeine (coffee, tea, energy drinks), workout supplements ("pre-workout), or herbal remedies with stimulant properties. Recommend significant reduction or elimination.

MEDICATIONS

There are a number of medications that can be helpful in anxiety disorders. SSRIs/SNRIs are typically first-line treatment of primary anxiety disorders, but other medications are also frequently used as augmentation or as second-line options. Additionally, symptomatic management of severe anxiety with benzodiazepines or other short-term anxiolytics (pregabalin, gabapentin, hydroxyzine, SGAs) can be used as needed. These are typically used short-term.

Selective Serotonin Reuptake Inhibitors (SSRIs) 5

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

• First-line medications for anxiety spectrum disorders.

• Effective but takes weeks to see treatment effect.

• May initially exacerbate symptoms during early treatment, so recommended a lower starting dose (half of typical starting dose).

• Often requires ultimately titrating to the higher dose range to achieve symptom remission when compared to treating depression.

• Most effective when combined with psychotherapy.

• No specific drug has been shown to have significantly higher efficacy than any other. The choice is often based on the side effect profile, drug-drug interactions, patient preference, or providers clinical experience.

TCAs or MAOIs

• May be considered if first-line agents are not effective.

• Typically considered in mixed anxiety and depressive states.

• Higher side effect profile makes them less tolerable. See earlier posts on TCAs and MAOIs for details.

Benzodiazepines 6

• Highly effective and has rapid treatment effect.

• More effective at treating the physical/somatic symptoms of anxiety as well.

• Major downsides include 1) They can be addictive. 2) Can develop tolerance and dependence. 3) Dangerous when combined with alcohol. 4) Dangerous withdrawals (similar to alcohol withdrawal). 5) PRN use can limit psychotherapeutic focus on not avoiding the anxious stimulus.

• Normally for short-term use only. Ideally maximum is 2-4 weeks while initiating SSRI/SNRI. Minimize the use, duration, and dose.

• Some are of the opinion that risks are overstated.

• Should be avoided in pts with a history of substance use disorders, particularly alcohol.

• Provide CBT if tapering benzodiazepines.

• Benzodiazepines will be covered in detail in a later post.

Buspirone

• Partial agonist of serotonin receptors.

• Has delayed onset of action. Takes up to 6 weeks to show equal efficacy with benzodiazepines.

• Not as commonly used and often only prescribed as augmentation to SSRI/SNRI.

• Buspirone will be covered in detail in a later post.

Pregabalin or Gabapentin

• These anticonvulsants are most commonly used to treat neuropathic pain.

• Pregabalin is approved for GAD in europe. Pregabalin and gabapentin often used off-label in the US for treatment or augmentation of anxiety disorders. Studies demonstrate mixed results.

• Relatively quick onset of action and response may be seen in the first week of treatment.

• Pregabalin is often well-tolerated, and has low abuse potential. Gabapentin is a cheaper, more accessible alternative for many, but has some abuse potential.

• These medications will be covered in detail in a later post.

Beta-Blockers (Propranolol)

• May be used to help control autonomic symptoms (eg, palpitations, tachycardia, sweating) with panic attacks or performance anxiety.

Antipsychotics (SGAs) 7

• Quetiapine has been recommended as monotherapy for anxiety, but some evidence that it is not effective as adjunctive therapy to SSRI/SNRI in treatment resistant cases.

• Quetiapine, olanzapine, and risperidone have the best evidence among SGA's.

Mirtazapine 8

• Only FDA approved for depressive disorders, however review of the literature found mirtatzapine to perform significantly better than placebo at controlling symptoms of anxiety with comorbid depression, PTSD, GAD, panic disorder, and social anxiety disorder.

• Studies show comparable efficacy to SSRIs and TCAs and in some cases with significantly better response rates.

• One meta‐analysis suggests that mirtazapine does not help with panic symptoms but with the anxiety associated with panic disorder.

Diphyhydramine or Hydroxyzine

• It is unclear whether efficacy is due to an anxiolytic effect or a sedative effect.

• Can be used as PRN alternative to benzodiazepines.

Alpha-2 Agonists (Clonidine and Guanfacine)

• These are sometimes termed "sympatholytics" because they decrease sympathetic outflow from the CNS.

• Indicated to lower blood pressure and heart rate. Also approved to treat ADHD in children.

• Due to its anxiolytic properties is also sometimes used off-label to treat GAD, panic disorder, or PTSD.

Experimental

• There are a number of other medications and alternative treatments for anxiety. These either have initial positive data or mixed results for anxiety.

• Options include lamotrigine, valproic acid, lavender oil, chamomile, gingko biloba, and kava kava.

CONCLUSION

I hope you enjoyed this overview of the treatment of anxiety disorders. Feel free to comment below if there is something I missed or if there was anything in particular that you learned. During our next lesson we will discuss generalized anxiety disorder (GAD).

Resources for today's post include the Maudsley Prescribers Guide and Stahl's Essentials for Psychopharmacology. These are my two favorite resources for psychopharmacology. Maudsley is great reading material when you want to really study and improve your psychopharm. I use Stahl's as a reference and frequently look up meds in Stahl's before I prescribe them.

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