Anxiety Disorders

At Health Psych Maine, we provide focused, empirically-validated treatment for a number of anxiety disorders -- cognitive-behavioral therapy (CBT).

Noted below is general information about common anxiety disorders and generally-established treatments. This web page is not intended to substitute as a self-treatment manual. Individuals should see an appropriately trained professional for an assessment and an individualized treatment plan.

How common are anxiety disorders?

The data below are from a 2005 study. These numbers indicate how many people experience the disorder at least once during their lifetime (also known as lifetime prevalence).

Anxiety disorders (any): 28.8%
Social phobia: 12.1%
Specific phobia: 12.5%
Posttraumatic Stress Disorder (PTSD): 6.8%
Generalized Anxiety Disorder (GAD): 5.7%
Separation Anxiety Disorder: 5.2%
Panic disorder (with or without agoraphobia): 4.7%
Obsessive-Compulsive Disorder (OCD): 1.6%
 
This data was collected in face-to-face interviews of 9,282 people interviewed 2001-2003. Source: Kessler et al. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62 (June), 593-602.
 
In terms of seeking treatment, the most common anxiety disorders are:
  1. Panic Disorder.
  2. Social Anxiety Disorder or Social Phobia.
  3. Obsessive-Compulsive Disorder (OCD).
  4. Posttraumatic Stress Disorder (PTSD).
  5. Generalized Anxiety Disorder (GAD).
Individuals with anxiety disorders also commonly have another ''comorbid'' disorder such as depression. Often, the depression is secondary to the anxiety disorder. The disruption in someone's life caused by the anxiety disorder can trigger depression.

Overview of Typical Treatment

 The first step is an assessment which includes an interview, questionnaires, and possibly psychophysiological assessment. Treatment usually lasts 6-20 sessions and often involves the following components:

  • Relaxation training.
  • Cognitive strategies.
  • Exposure-based or desensitization treatment.
At Health Psych Maine, individuals are often trained in relaxation skills so that they have the ability to slow down their body's reaction to a perceived trigger or stress. Because we have biofeedback equipment for other problems, we sometimes will use biofeedback in order to help a person learn the relaxation skills. The next step often involves training an individual in cognitive skills to help defuse reactions to situations. For example, for an individual with panic disorder, when that person experiences the first sensations that might signal that a panic attack is on the way, the typical reaction on a cognitive level is something like: "Oh my gosh! Hear comes another one!" This cognitive reaction, while natural and understandable, will simply add fuel to the fire by further activating the fight-or-flight or sympathetic nervous system. Hence, an individual can be trained to use different cognitive reactions to lessen the activation of the nervous system. Then, depending on the problem, a hierarchy may be developed for use in systematic desensitization. A hierarchy is simply a list of situations or activities that would go in order from mildly distressing to very distressing. At the individual's own pace, the individual is helped to gradually "de-sensitize" himself/herself to whatever is triggering the anxiety, whether it is open spaces, being in a car, being in a small place, being in a crowded place, hearing certain noises, or simply perceiving one's own heart rate increase:
  • In panic disorder, the individual learns to become less sensitive or desensitized to internal sensations themselves such as noticing one's heart rate.
  • In other disorders, it may be something external, such as driving after an automobile accident or speaking in front of others.
  • With Obsessive-Compulsive Disorder (OCD), treatment at this phase may involve gradually learning to break the cycle of rituals or compulsions.
  • With excessive worry or Generalized Anxiety Disorder (GAD), treatment involves worry exposure & desensitization, training the brain to slow down the worry.
Typically, a person will start at a level on the hierarchy that is challenging but not overwhelming. So, for example, if someone has a fear of traveling, when we get to the desensitization part of treatment, we might start by having the person travel a couple of miles and do that until being 2 miles from home no longer triggers significant anxiety. Then, we would move up the hierarchy, let's say, to traveling 4 miles from home. There are variations on this that might be appropriate for an individual case, such as starting higher up on the hierarchy. Pace is determined by the individual client. Treatment progresses at the individual's pace; the individual remains in control.
As is indicated in the box below, the information here is general. Do not make any abrupt medication changes without checking with your prescriber; stopping some medications abruptly can cause medical problems.
 
In general, depending on the specific disorder, cognitive-behavioral methods are either more effective or as effective as medications, especially when one factors in relapse rates. In some situations, it may be helpful to use a combination of medications and therapy. For some medications there is a problem of tolerance and dependence. For many anxiety disorders, treatment with medications alone creates a relapse problem in that as soon as a person stops the medication, the anxiety problem tends to return.

For anxiety disorders, if medications are going to be used, the first-line choice is generally from a group of medications referred to as selective serotonin reuptake inhibitors or SSRIs: fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro). Other medications frequently utilized in contemporary practice include venlafaxine (Effexor; SNRI/Selective Serotonin-Norepinephrine Reuptake Inhibitor), duloxetine (Cymbalta, also an SNRI) or a drug called clomipramine (Anafranil). All of these drugs are referred to as antidepressants but have established some level of efficacy in treating certain anxiety disorders, even if a person is not depressed. It is not uncommon for someone with an anxiety disorder to also be depressed; hence, use of these medications may also be helpful for any depression that is present.

Another class of medications that is used though less frequently than in the past is the benzodiazepines. This class includes drugs such as alprazolam (Xanax). Although there are situations where use of a benzodiazepine may be required for short-term management, they create tolerance and dependence and may simply create another problem. With panic disorder, there is evidence that use of benzodiazepines actually interferes with successful cognitive-behavioral treatment (see medication section on panic disorder page).

Medications versus therapy versus both for anxiety:
  1. Most of what we know comparing medications to therapy to the combination comes from research on panic disorder.
  2. Both medications and CBT (cognitive-behavioral therapy) provide clear relief in the time frame of approximately 3 months.
  3. However, there is a significant relapse problem with medications in that once the individual stops the medications, the anxiety typically returns. This occurs with both the benzodiazepines (e.g., Xanax, Klonopin) and antidepressants (e.g., Paxil).
  4. CBT has stronger longer-term outcome.
  5. Medications actually interfere with CBT outcome in some areas such as panic.
  6. CBT has demonstrated usefulness in helping individuals to taper or get off of medications.
  7. Patients not responding to 1 treatment may respond to the other.
  8. CBT provides benefits beyond the end of treatment, which is not the case with medications.
  9. Since CBT is a learning, skills-oriented approach, patients continue to consolidate skills as time goes on.
  10. Different mechanisms are at work with medications versus CBT: Attenuation vs. Skills
    • Whereas medications have their effect by attenuating and muffling the anxiety response...
    • CBT has its effect by extinguishing the fear response. Patients are gradually and repeatedly exposed to relevant stimuli -- habituation and desensitization. The individual learns to feel safe in presence of stimuli.
    • Medicated state = learned safety state. With medications, the individual learns to feel safe when medicated. When the medication is gone, he/she no longer feel safe. With CBT, the individual learns to gradually feel safe in the presence of the feared situation.

 

What if you are already on a medication?
 
If you are already on a medication, do not make any abrupt changes. Each individual's situation is different. Abruptly stopping some medications can cause medical problems. Usually at Health Psych Maine, we proceed through the treatment steps noted above and then as a last stage of treatment, in consultation with your prescriber and depending on your individual situation, one option might be to taper from medications in a slow gradual fashion.

 

Above is general information about common anxiety disorders and generally-accepted treatments. This web page is not intended to substitute as a self-treatment manual. Individuals should see an appropriately trained professional for an assessment and an individualized treatment plan. If you are a client or prospective client, be sure to ask your physician and psychologist about medication questions so that you have enough information to make an informed choice in collaboration with your providers. If you are taking one of these medications presently, be sure to consult with your prescriber before stopping that medication since abrupt stopping of some medications can cause medical problems.
 
For workbook suggestions and references click here
 

Please contact the Health Psych Maine office if you would like more information or to schedule an appointment (207-872-5800) or .