AETC-NMC
   

Treating Anxiety Disorders [NIMH Anxiety Disorders]

Anxiety disorders typically are treated with medication, psychotherapy, or a combination of the 2. [Hyman 2000] Treatment choices depend on the problem and the person’s preference. Before treatment begins, a doctor must conduct a careful diagnostic evaluation to determine whether a person’s symptoms are caused by an anxiety disorder or a physical problem. If an anxiety disorder is diagnosed, the type of disorder or the combination of disorders that are present must be identified, as well as any coexisting conditions, such as depression or substance abuse.

Sometimes alcoholism, depression, or other coexisting conditions have such a strong effect on the individual that treating the anxiety disorder must wait until the coexisting conditions are brought under control. Some patients need to try several different treatments or combinations of treatment before finding one that is most effective for them.

Pharmacotherapy

The principal medications used for treatment of anxiety disorders are antidepressants, anxiolytic agents, and beta-blockers to control some of the physical symptoms. When prescribed appropriately, such medications can enable patients with anxiety disorders to function socially and to experience normal quality of life. The anxiolytic effects of antidepressant medications typically require 4 to 6 weeks of administration until anxiety symptoms are alleviated.

SSRIs. Selective serotonin reuptake inhibitors (SSRIs) alter the levels of the neurotransmitter serotonin and are associated with both antidepressant and anti-anxiety effects. Fluoxetine, sertraline, escitalopram, paroxetine, and citalopram are commonly prescribed to treat panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. Venlafaxine, a serotonin/norepinephrine reuptake inhibitor (SNRI) is used to treat GAD.

Tricyclics. Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD. They are also started at low doses that are gradually increased. They sometimes cause dizziness, drowsiness, dry mouth, and weight gain, which can usually be corrected by changing the dosage or switching to another tricyclic medication. Tricyclics include imipramine, which is prescribed for panic disorder and GAD, and clomipramine, which is the only tricyclic antidepressant useful for treating OCD.

MAOIs. Monoamine oxidase inhibitors (MAOIs), the oldest class of antidepressants, are sometimes used in the treatment of anxiety disorders, the most frequently prescribed being phenelzine, tranylcypromine, and isocarboxazid, which are useful in treating panic disorder and social phobia. MAOIs require restrictions on certain types of foods, beverages, and medications. MAOIs can interact with SSRIs to produce “serotonin syndrome,” leading to confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions.

Anxiolytics. Benzodiazepines can be effective in the treatment of anxiety and have relatively few adverse events other than drowsiness. Typically, benzodiazepines are prescribed for short periods of time, due to the risk of dependence, particularly in patients who have abused drugs or alcohol and who become dependent on medication easily. However, patients receiving benzodiazepines for treatment of panic disorder may be prescribed them for up to a year. Specific agents include:

  • Clonazepam for social phobia and GAD
  • Lorazepam for panic disorder
  • Alprazolam for both panic disorder and GAD

Abrupt discontinuation of benzodiazepines, rather than tapering off, may be associated with withdrawal symptoms and potential return of anxiety symptoms.

The more recently introduced anxiolytic buspirone is used to treat GAD. Unlike benzodiazepines, it must be taken consistently for ≥ 2 weeks to achieve an anti-anxiety effect.

Beta-Blockers. Beta-blockers, such as the heart medication propranolol can prevent the physical symptoms that accompany certain anxiety disorders, particularly social phobia.

Psychotherapy

Cognitive-behavioral therapy (CBT) is the most frequently used psychotherapy for treatment of anxiety disorders, aiding patients in changing the thinking patterns that support their fears and how they react to anxiety-provoking situations. For example, patients with panic disorder can learn that their panic attacks are not heart attacks and those with social phobia can learn how to overcome the belief that others are always watching and judging them.

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