MENTAL HEALTH & ADDICTION
Anxiety treatment is an important dual diagnosis need for many people. These people may have been struggling with anxiety for many years, and this likely impacts their overall recovery efforts. One of the primary problems with anxiety treatment is that it often fails to be specific and evidence-based. People put into a general symptomatic pool are mainly prescribed forms of sedative medication to soften the anxiety.
The discussion is far too short for many people diagnosed with anxiety. They meet with a psychiatrist, primary care physician, or therapist and talk about tension, nervousness, panic attacks, avoidance behaviors, and general discomfort. This often leads to that physician saying something like this:
“It looks like you have anxiety. I’d like you to take these meds when you need them. This will help your anxiety settle down.”
These meds often refer to benzodiazepines. Benzodiazepines are a class of medication which trigger the GABA receptor in the brain and associated with calming and some sedation. Activating this receptor often lifts anxiety and the person can continue on with their day. While providing some temporary comfort, there are potential problems with a treatment approach such as this. Some of the common problems include the following:
- We don’t have a great explanation for the source of the anxiety
- Tolerance builds up via benzos, requiring increasing doses over time
- The benzodiazepines carry a significant risk for addiction
- As they tend to be slower and ‘less effective’ than the benzos, coping skills often underutilized
- The person has no capacity to ever discontinue the benzodiazepines. Any discussion of this often can precipitate a crisis for the patient as they feel unable to cope without the benzos.
Band-Aid for Surgery
An analogy for this form of anxiety treatment is to just use indefinite Band-Aids for wounds, even the wounds that require sutures or full surgery. The bandage will prevent loss of blood, and this is all that we need for many cuts but does not get to the root of the problem for most forms of anxiety.
We can do better and you deserve better as a patient. Let’s look at some of the specific anxiety disorders, how they are different or similar, and some of the specific medication evidence that can target the conditions.
Social Anxiety Disorder
Social anxiety disorder, also called social phobia, involves a significant fear of embarrassment or rejection in group or public settings. It often develops during teenage years and can lead to sever avoidance patterns and social isolation.
This condition involves a history of having panic attacks and the associated fear of experiencing a panic attack such that the person avoids many potentially triggering panic situations. Those panic situations do not need to be actual crises and often are during mundane situations. Examples include waiting in line at the store or driving down an empty road. For some reason, the panic attack occurs and the person associates the anxiety with that situation. They may then live for many years with a conscious effort to avoid such a setting, as exposure could trigger another miserable panic attack.
Generalized Anxiety Disorder
Excessive worry about real-life fears such as bills, poor work or school performance, loss of relationships, or potential death of loved ones are the core symptoms of generalized anxiety or GAD. The excessive worry from this condition is very debilitating, as the person lives with a baseline level of distraction from everyday life. It is also important to acknowledge that the fears attached to GAD often are everyday fears such as getting laid off from a job or falling behind on bills.
Post-Traumatic Stress Disorder
PTSD involves a person experiencing a history of one or multiple severe traumatic events. As years go by after those events, the person lives in a constant ‘fight or flight’ position with life. It is possible for people to acute flairs of PTSD or more of a chronic picture. The experts for treating PTSD are the clinicians through the Department of Veterans’ Affairs, as combat trauma is strongly associated with PTSD. I often look to their algorithms for treating PTSD to guide my clinical choices. An emphasis on safety is key for PTSD. Benzodiazepines are often very harmful to a person with PTSD, even though they may offer brief relief.
Adjustment Disorder with Anxious Mood
This is the clinical name for ‘situational anxiety’ and often occurs during significant life disruption or changes (loss of job, divorce, death in the family). Adjustment disorders are very common and are important to identify, as this will influence treatment recommendations. Because the anxiety has heavy relational and psychological components, we try to avoid prescribing medications to treat an adjustment disorder. Instead, supportive therapy is the treatment of choice. It will emphasize healthy coping, avoiding substance abuse, and bolstering resiliency through a few training options.
Differentiating the Anxiety Disorders
When I teach this lecture in our treatment program, I build a grid to list the differences and similarities between the anxiety disorders. Each condition is connected to a fear, a conditioned response to counter that fear, appropriate med options, and therapy tools. There are some themes across the different anxiety conditions. For instance, a common thread is that of avoidance patterns to deal with the perceived threats. Another common theme is that SSRI medications (such as Prozac, Zoloft, or Lexapro) are the first-line treatment for the conditions.
It is important to acknowledge the inherent disability present with an anxiety disorder is actually that of the conditioned response. Having fear is normal in line, but excessive avoidance, worries, or fight/flight positions set a person up to function less than optimally. Much of the psychotherapy used for anxiety disorders targets the conditioned response instead of the fear itself.
My basic recommendation to people is to give more weight on your psychotherapy than on your meds. People often do just the reverse – they want to find the ideal medication to alleviate their symptoms. Interestingly, even if they do, they still present highly disabled and unable to cope adequately with life.
If you make a commitment to coping skills and bona fide therapy for anxiety, you will build more of a lasting foundation for healing from anxiety. There is a positive momentum component, in that through small strides in therapy, you will start to feel empowered over your fear and anxiety. This empowerment will encourage further efforts in the right direction. Setting the stage from the get-go is of utmost importance.