Ask Dr. Pat

Dr. Pat Consults: Treatment Options for Anxiety

There are a number of treatment options for anxiety. I commend you for wanting to try something other than medication to start with. The non-pharmacological treatment with the most evidence is cognitive behavioral therapy (CBT).  CBT for GAD focuses on the anxious person’s tendency to focus on the negative and catastrophize. If you’re an anxious person, when your boss walks by your office without saying hello you immediately jump to, “I did something terrible and will be fired and not be able to pay rent and end up homeless on the streets,” rather than the more likely, “Maybe she is having a bad day or maybe she is busy/preoccupied/etc.”  Life throws you turbulence and, while part of you recognizes it’s just a bit of turbulence, another part of you knows for sure the plane will crash.  With catastrophizing, even very benign things take on a threatening hue when viewed through the lens of anxiety.  Further, these beliefs tend to be perpetuated by avoidance and procrastination — you mention you’ve been avoiding going out because it makes you more anxious. This is a very common phenomenon. The problem is, by not going out, you don’t get the opportunity to prove to yourself that going out is fine; in fact, you may even enjoy it.  CBT works on these various cognitive distortions, helping you to acquire tools to address your anxiety and begin to change the self-perpetuating thought process around these issues.  On average, over half of those who try CBT notice significant improvement that persists even a year later.  There are many books available to help guide you through CBT for anxiety and worry, which is a great way to start.  If you are able to, working with a therapist experienced in CBT is the most likely to bring success.

Other treatment options that have shown success in some studies include yoga, tai chi, and regular physical exercise.  Mindfulness, with its focus on attending to the present in a nonjudgmental way, has also been shown to be moderately effective against anxiety. Similarly transcendental and qigong meditation have been shown to reduce anxiety. All of these approaches require regular practice for them to have their anxiety reducing effect, so it is important to find a method that works well with your own preferences. Further, you are more likely to be successful if you find someone experienced to help you get started and guide you along the way.

Medications can be very helpful in the treatment of anxiety, particularly if other interventions don’t bring sufficient relief.  Also, sometimes people are too anxious to really focus on therapy, and medication can help tone down the worry until they learn skills to help manage anxiety, at which point they may be able to taper down or off medications. While we often think of benzodiazepines (lorazepam, clonazepam, alprazolam) for the treatment of anxiety, the best first-line medications are actually antidepressants called selective serotonin reuptake inhibitors (SSRIs), including paroxetine, citalopram, and escitalopram, and serotonin and norepinephrine inhibitors (SNRIs), including venlafaxine and duloxetine.  About two thirds of people taking SSRIs experience a significant reduction in anxiety. While anxiety and depression often coexist, SSRIs are helpful in treating anxiety even in those not suffering from depression. However, it takes an average of four weeks for SSRIs to begin to be helpful and, paradoxically, some people feel slightly more anxious when they start using the medication.  During this initial period, it may be helpful for some to add a benzodiazepine. While benzodiazepines (like the drug suggested by your GP) can be very effective in the short term, they do not work as well for chronic anxiety and, as you mention, can be addictive. Thus the goal is often, but not always, to be eventually tapered off the benzodiazepine.

It will be important for you to work closely with your primary care doctor or a psychiatrist to find the right combination of medications and therapy to help manage your anxiety.  There are many ways to help decrease anxiety and, with persistence, you can find the right mix that works for you. You clearly have been successful in many areas of your life and are motivated to deal with this problem so that you can look forward to a more joyful life.

 

References

Bromberger JT, Kravitz HM, Chang Y, Randolph JF Jr, Avis NE, Gold EB, Matthews KA.

Does risk for anxiety increase during the menopausal transition? Study of women’s health across the nation. Menopause. 2013 May;20(5):488-95.

Bryant C, Judd FK, Hickey M. Anxiety during the menopausal transition: a systematic review.

J Affect Disord. 2012 Jul;139(2):141-8.

Bystritsky, A. Pharmacotherapy for generalized anxiety disorder. Oct 2015.

Bystritsky, A. Complementary and alternative treatments for anxiety symptoms and disorders: Physical, cognitive, and spiritual interventions. Oct 2015.

Faravelli C, Alessandra Scarpato M, Castellini G, Lo Sauro C. Gender differences in depression and anxiety: the role of age. Psychiatry Res. 2013 Dec 30;210(3):1301-3.

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  • Megan Riddle November 23, 2015 at 11:58 pm

    Thank you for your comments! Anxiety can be truly debilitating. It can be easy for others to say “It’s all in your head – you have nothing to worry about.” For those with anxiety, however, it is absolutely real. Thankfully, there are lots of way to work with anxiety that can really help – the trick is to keep trying until you find what is right for you.

    Best,
    Megan

    Reply
  • Rebecca Foust November 19, 2015 at 2:02 am

    Helpful article, thank you. My son’s anxiety, before it was treated, was more crippling than his autism. Of all the remedies mentioned, regular exercise has been most helpful to me; that and a regular dose of activities–even just lying on my back for a few minutes on the grass in sunlight–that bring joy.

    Reply
  • Diane Dettmann November 16, 2015 at 9:27 pm

    Very helpful insights. Thanks for sharing them.

    Reply
  • Roz Warren November 16, 2015 at 1:01 pm

    Great information! Thanks.

    Reply