psychiatric disorders
Overview of Anxiety Disorders
Treatment of Anxiety Disorders
Psychoeducation Relaxation techniques Psychotherapies, such as cognitive-behavioral psychotherapy (CBT) Pharmacotherapy (benzodiazepines, selective serotonin reuptake inhibitors [SSRIs]) The following general principles are important to take into consideration when treating anxiety disorders: A variety of interventions are effective for managing anxiety disorders. Most patients can be managed successfully in primary care settings. Accurate identification of the anxiety disorder and pertinent comorbidities is crucial. Treatment of comorbid medical conditions that can contribute to anxiety (eg, asthma). Co-occurring substance use disorders should generally be treated concomitantly with the anxiety disorder. It should be recognized that the substance is often partly being used to reduce anxiety, and withdrawal can induce additional anxiety. Lifestyle modifications such as obtaining adequate exercise and sleep ( Treatment references ) and limiting Treatment recommendations are influenced by patient preferences and access to mental health care professionals. Psychotherapy and medications are effective for most anxiety disorders, particularly when used together ( Treatment references ). Psychoeducation is typically fundamental to the treatment of anxiety disorders. It can feel liberating for the patient to understand how a sometimes bewildering array of symptoms and behaviors can be conceptualized into a diagnosis. Education also provides a cognitive structure to help patients pursue a treatment that may feel uncomfortable. Relaxation techniques should be taught early in the treatment. These techniques are useful both because fear and anxiety are fundamental to anxiety disorders and because the treatment can transiently intensify the disabling thoughts and feelings. Without a tool for controlling anxiety, many patients will not adhere to treatment. Relaxation techniques may include muscle relaxation, breathing management, yoga, hypnosis, and/or meditation, but patient preference is important in determining the specific approach. Relaxation techniques can be briefly described and then "prescribed" as homework. Adherence and effectiveness are more likely to be optimized if the clinician periodically demonstrates the techniques (eg, slow, steady breathing) with enthusiasm. Various psychotherapies are equally efficacious for most psychiatric disorders. This equivalency appears to be related to so-callednonspecific factors, which include the personal characteristics of the therapist and a positive therapeutic climate that allows the patient to effectively engage in the talk therapy and remain adherent with agreed-upon practices and medications. has the most robust evidence as a psychosocial treatment for anxiety disorders ( Treatment references ). CBT involves bothcognitive restructuringandexposure therapy. Cognitive restructuring begins with the idea that patients with anxiety disorders overestimate the danger (catastrophize) and underestimate their ability to deal with the danger. These inaccurate thoughts and antecedent triggers are clarified during treatment. Often, the pattern of anxiety can be neatly laid into a characteristic cycle of triggers, behaviors, and anxiety. As this cycle is clarified, patients are taught to recognize and confront their inaccurate thoughts (ie, cognitive restructuring). CBT also focuses on the behavioral elements of the anxiety disorder. Typically, patients with anxiety disorders respond to perceived danger with a "fight-or-flight" response. Some patients with prominent anxiety are able to "fight" their anxiety, often with a counter-phobic response (eg, an actor with prominent social anxiety), but most respond with avoidance. Exposure therapy aims to identify the avoidance behavior and then present the patient with gradually intensifying opportunities to be safely exposed to the fearful trigger, gradually desensitizing the patient. Other psychotherapiesused for treatment of anxiety disorders combine aspects of CBT, relaxation, and mindfulness along with other strategies that appear to be helpful. These treatments include mindfulness-based stress reduction, hypnosis, panic-focused psychodynamic psychotherapy, interpersonal therapy, and supportive psychotherapy: is a standardized program in which groups meet for 8 consecutive weeks; sessions feature sitting and walking meditation, yoga, and mindful relaxation techniques. There is also a daily home practice to reinforce the principles practiced during the 2.5-hour sessions ( Treatment references ). is used to teach management of the interaction between mental anxiety and physical stress such as muscle tension, increase in respiratory and heart rate, and sweating. Mental anxiety and physical stress tend to reinforce each other, while hypnotic suggestions to imagine being in a safe and comfortable place coupled with visualization of means of successful stress management can reduce anxiety symptoms rapidly while teaching a coping skill ( Treatment references ). is a structured, time-limited psychotherapy that shares features with other interventions, though the sessions tend to focus on the stressors, feelings, and emotional meanings of Panic Attacks and Panic Disorder ( is a structured, time-limited psychotherapy that addresses current problems and relationships. IPT focuses on 1 or more of 4 areas: relationship conflicts, life changes, grief or loss, and problems with relationships. Most often used to treat depression, IPT appears to be well-tolerated and effective for several anxiety disorders ( Treatment references ). While CBT focuses on cognitions and behaviors, IPT focuses on feelings that develop in the context of interpersonal situations. Supportive psychotherapyaims to support the patient's healthy defenses and healthy behaviors through empathy, validation, and nonjudgmental listening. Supportive techniques tend to improve the therapeutic alliance and reduce treatment nonadherence. Supportive psychotherapy can be therapeutic by itself and can also be a fundamental part of other psychotherapies. ) and atypical antipsychotics ( Treatment references ). Selective Serotonin Reuptake Inhibitors (SSRIs) None SSRI antidepressants are generally started at the lowest available dose to minimize adverse effects. Patients with anxiety may be sensitive to bodily changes and may discontinue treatment if they experience adverse effects early on. Once the patient has tolerated the initial dose, the antidepressant can be gradually increased until a therapeutic dose or therapeutic effect is reached. A positive clinical effect may occur at any time but often takes 6 or more weeks to achieve. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) None may be used for acute relief of anxiety but can create Sedatives and a desire for increasing levels that limit their benefit/risk ratio for chronic use ( When present, comorbid substance use disorders and other psychiatric conditions must also be appropriately managed. Comorbid Substance Use Disorders are often not spontaneously reported ( Comorbid Bipolar Disorders can cause specific management difficulties. Many people with bipolar disorder are initially misdiagnosed, particularly because they often have far more periods of depression than mania. Treatment with an antidepressant medication may be an appropriate first-line treatment for an anxiety disorder with comorbid major Comorbid medical disorders can also be challenging to manage. For example, asthma can physiologically cause anxiety, but so can some of the medications used to treat asthma. Anxiety can contribute to an asthma exacerbation, and fears of an asthma exacerbation can lead to avoidance behaviors (eg, diminished activity, medication nonadherence) that in turn can exacerbate asthma and lead to a diminished quality of life. 1.Chellappa SL, Aeschbach D: Sleep and anxiety: From mechanisms to interventions.Sleep Med Rev61:101583, 2022. doi: 10.1016/j.smrv.2021.101583 2.Bandelow B, Michaelis S, Wedekind D: Treatment of anxiety disorders.Dialogues Clin Neurosci19(2):93-107, 2017. doi: 10.31887/DCNS.2017.19.2/bbandelow 3.Cuijpers P, Sijbrandij M, Koole SL, et al: Adding psychotherapy to antidepressant medication in depression and anxiety disorders: a meta-analysis. 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