Treating Anxiety Disorders In Adults

By | March 23, 2015

Anxiety is an emotional and physiological state that all people feel and that can be either normal or pathological. Anxiety can be defined as a feeling of unpleasant apprehension typically accompanied by bodily sensations such as a tightness in the chest, a feeling of choking, perspiring, and trembling or shaking. Often, anxious individuals feel restless or confused or think they are not in control or even that they are dying (APA, 2000). Normal anxiety serves an adaptive function if it motivates the individual to behave in a way that forestalls danger. Anxiety is pathological when, due to its intensity or duration, it impedes the client’s ability to function. More than 16 million Americans between the ages of 15 and 24 have anxiety disorders (National Institute of Mental Health [NIMH], 1999), and an estimated 80% of persons diagnosed with anxiety disorders experience panic attacks.

Several theories have been generated to explain the causes of pathological anxiety. Cognitive-behavioral theorists believe that when a stimulus is observed, perceived, or otherwise experienced as frightening, future threats of that stimulus are also perceived with apprehension or avoidance (Seligman, 1998). Psychoanalytic theory suggests that anxiety is a warning to the ego that unacceptable unconscious material is pressing for expression and that the ego must take action, usually in the form of a defense mechanism to cope. Existential theory is useful in explaining “free-floating” anxiety, often associated with generalized anxiety disorder. This form of anxiety is thought to stem from an individual’s sense of purposelessness and mean-inglessness in life. Finally, biological theories suggest that the autonomic nervous system, limbic system, and regions of the cerebral cortex may have dysfunctions in relation to pathological anxiety. Specific neurotransmitters, such as norepinephrin, gamma-aminobutyric acid (GABA), and serotonin, have been linked to anxiety.

The Diagnostic and Statistical Manual, fourth edition, text revised (DSM-IV-TR), of the American Psychiatric Association (APA, 2000) names the following under the heading of anxiety disorders: Panic Disorder with and without Agoraphobia, Specific Phobia, Social Phobia, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder, Acute Stress Disorder, Generalized Anxiety Disorder, Anxiety Disorder Due to a Medical Condition, Substance-Induced Anxiety Disorder, and Anxiety Disorder NOS. These disorders are classified together because anxiety is a significant presenting symptom in all of them. However, each disorder responds differently to pharmacological interventions, leading researchers to suspect that they are really a heterogeneous group of disorders.

General Treatment Approach

Although the treatment for the various types of anxiety disorders differs, there are some generalized treatment approaches that have been found to be successful across the spectrum of anxiety disorders. In their landmark meta-analysis, Smith, Glass, and Miller () found effect sizes for the treatment of anxiety disorders to be 1.78 for cognitive-behavioral approaches, 1.67 for cognitive approaches alone, and 1.12 for behavioral approaches alone. Unlike the null hypothesis, which simply measures whether or not a relationship exists, effect sizes measure the strength of a relationship, with higher numbers indicating greater strength. All of these effect sizes are considered large (). Subsequent research has supported the meta-analytic results on the treatment of anxiety disorders (). There is growing support in the research for the use of pharmacological interventions as an adjunct to psychosocial treatments, particularly for severe cases when debilitating anxiety limits the initial success of psychosocial interventions (NIMH, 1999). For all the anxiety disorders, a medical referral is strongly encouraged to rule out a medical condition that might mimic the symptoms of anxiety ().

Treating Panic Disorder with and without Agoraphobia

Panic Disorder is one of the most common mental disorders for which people seek treatment, with up to 4 million people, or 1.5% of the U.S. population, meeting the criteria for this disorder. Panic Disorder is characterized by the existence of panic attacks that are not cued by external stimuli. These panic attacks can lead to the development of agoraphobia, and thus panic disorder can occur without (PD) or with agoraphobia (PDA). There is high comorbidity with mood disorders (50% to 65%) and substance abuse disorders (15%), and up to 20% of individuals with panic disorder attempt suicide.

Pharmacological interventions

• Tricyclic antidepressants, MAOIs, benzodiazepines, and SSRIs have all been used in conjunction with psychological interventions, but overreliance on medication can limit the success of psychotherapy by artificially lowering anxiety levels, which rebound when medication is withdrawn.

Treating Specific Phobia and Social Phobia

Lifetime prevalence for specific phobias is 11%, with significant gender differences (females = 16%, males = 7%). Specific phobias, although very common overall, tend to be distinct. That is, when a client presents with a specific phobia, it is unlikely that other Axis I or Axis II diagnoses will be comorbid. Social phobia is very common and is the third most prevalent of all mental disorders, exceeded only by Major Depressive Disorder and alcohol dependence. Comorbidity of social phobia and Axis I disorders is common, most often with Agoraphobia (45%), alcohol abuse (19%), major depression (17%), drug abuse (13%), Dysthymia (13%), and Obsessive-Compulsive Disorder (11%). Additionally, up to 70% of persons who meet the criteria for social phobia also meet the criteria for Avoidant Personality Disorder.

Pharmacological interventions

• Pharmacological treatments have not been proven effective for the treatment of specific phobias.

• For the treatment of social phobia, there has been support for MAOIs and SSRIs. Benzodiazepines also have demonstrated some success, but their use is complicated by high rates of substance abuse comorbidity with social phobia.

Treating Obsessive-Compulsive Disorder (OCD)

The prevalence rate for Obsessive-compulsive disorder is 2.5% in adults, and it appears that this disorder occurs at approximately that rate in children and adolescents. Because of the nature of this disorder, clients with severe obsessive-compulsive disorder often have difficulty maintaining employment and have extreme dysfunctions in their marital and interpersonal relationships.

Pharmacological interventions

• Drugs may be an important adjunct to treatment, particularly for clients for whom psychotherapy or behavioral therapy alone has been ineffective. Pharmacological interventions appear to be more successful in treating the compulsions than the obsessions. With obsessive-compulsive disorder, there is often a medication lag of up to two months before any noticeable improvement, and thus medication trials should last 6 to 12 months before attempts are made to taper off the medication.

• The tricyclic antidepressant clomipramine (Anafranil) has become the standard medication for obsessive-compulsive disorder. Recent research has supported the efficacy of SSRIs, although these have not been as extensively studied with this population, and no research exists to suggest that they are more effective for obsessive-compulsive disorder than clomipramine.

Treating Posttraumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD)

Prevalence rates for posttraumatic stress disorder and acute stress disorder range from 1% to 14% in various studies. This broad range can be accounted for by fluctuations in the occurrences and nature of disasters that affect large populations (e.g., bombings, earthquakes) and traumatic events that affect individuals (e.g., rapes, assaults). posttraumatic stress disorder has significant comorbidity with other Axis I disorders, particularly alcohol abuse (70%) and depression (68%), as well as Axis II disorders (26%). acute stress disorder is diagnosed when the symptoms last for less than one month; posttraumatic stress disorder is diagnosed when the symptoms last for more than one month.

Pharmacological interventions

• No specific class of medications has been demonstrated to be the treatment of choice, although SSRIs, particularly fluoxetine, are gaining in popularity and have demonstrated significant treatment success. Other pharmacological interventions that have received empirical support include tricyclic antidepressants, MAOIs, and benzodiazepines (these should be used with caution, given the high rates of comorbidity with substance abuse).

Treating Generalized Anxiety Disorder (GAD)

generalized anxiety disorder is characterized by excessive worry about several circumstances on more days than not for a period of more than six months (APA, 2000). generalized anxiety disorder is a chronic disorder that may have biological and characterological bases that are not completely amenable to psychotherapy. generalized anxiety disorder has a prevalence of 5.1% in the general population and is twice as common in women as men. More than 90% of clients with generalized anxiety disorder have a lifetime history of the disorder. Although research to date has not uncovered a treatment that is effective in eliminating the symptoms of generalized anxiety disorder, several interventions have shown moderate success in reducing the severity of the symptoms.

Pharmacological interventions

• Some success has been shown with the following medications, all used in conjunction with psychological interventions: benzodiazepines; buspirone (reduces the cognitive anxiety symptoms to a greater extent than the physical symptoms); and antidepressants (imipramine or SSRIs).

Treating Anxiety Disorders: Summary

Anxiety disorders are some of the most common clinical mental health diagnoses, and there is a substantial body of research relating to their treatment. In general, the research supports a cognitive-behavioral approach to treatment, although this is less supported for Generalized Anxiety Disorder. Many different types of pharmacological interventions also have been demonstrated to be effective in the treatment of anxiety, and the mental health practitioner should work closely with the client’s physician in the treatment of these cases.