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What are the anxiety disorders?
An anxiety disorder may make people feel anxious most of the time or for brief intense episodes, which may occur for no apparent reason. People with anxiety disorders may have anxious feelings that are so uncomfortable that they avoid daily routines and activities that might cause these feelings.
Some people have occasional anxiety attacks so intense that they are terrified or immobilized. People with anxiety disorders are usually aware of the irrational and excessive nature of their fears. When they come for treatment, many say, “I know my fears are unreasonable, but I just can’t seem to stop them.”
The major categories of anxiety disorders are classified according to the focus of the anxiety. A brief description of each is given below, based on the diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (dsm-iv).
Although each anxiety disorder can have many different symptoms, one representative example has been chosen to illustrate the typical cognitive, physical and behavioural symptoms of each disorder.
Panic Disorder (WITH OR WITHOUT AGORAPHOBIA)
• Panic disorder involves “repeated, unexpected panic attacks (e.g., heart palpitations, sweating, trembling) followed by at least one month of persistent concern about having another panic attack”.
• Panic attacks may be accompanied by agoraphobia, when someone avoids or endures with marked distress specific situations, such as being outside the home alone, being in a crowd or standing in a line.
Treatments for anxiety disorders
Many psychological treatments such as relaxation training, meditation, biofeedback and stress management—can help with anxiety disorders. Many people with anxiety disorders also benefit from supportive counselling or couples or family therapy.
However, experts agree that the most effective form of treatment for the anxiety disorders is cognitive-behavioural therapy (cbt). Medications have also been proven effective, and many people receive cbt and medication in combination.
1. Cognitive-behavioural therapy(cbt)
cbt is a brief, problem-focused approach to treatment based on the cognitive and behavioural aspects of anxiety disorders.
Typically, cbt consists of 12 to 15 weekly one-hour sessions. In the initial sessions, the person with the anxiety disorder works with the therapist to understand the person’s problems. The person’s symptoms of anxiety are assessed within a cognitive-behavioural framework, and the goals and tasks of therapy are established.
As the therapy progresses, behavioural and cognitive tasks are assigned to help the person with the anxiety disorder learn skills to reduce anxiety symptoms. As the symptoms improve, the therapist also focuses on underlying issues that may pose a risk for “relapse,” a term used to describe the return of symptoms.
Homework assignments between sessions can include facing a feared situation alone, recording thoughts and feelings in different anxiety-provoking situations, or reading relevant material. Following treatment, therapists often schedule less frequent “booster” sessions.
What does cbt involve?
A standard component of cbt treatment is exposure therapy, which involves gradually exposing the person, either directly or through the person’s imagination, to his or her feared situation that triggers anxiety.
For instance, the person who fears dogs will be asked to spend time with dogs, the person who has panic attacks in the mall will be requested to go to malls, and the person who fears embarrassing himself or herself in social situations will be asked to attend gatherings and speak with others.The rationale behind exposure therapy is that by practising exposure to their fears, people have the opportunity to learn that their fears are excessive and irrational, and that the anxiety decreases with more and more practice. This process is called habituation.
An important part of cbt is helping people with anxiety disorders to identify, question and correct their tendencies to overestimate danger and their perceived inability to cope with danger. Cognitive strategies are developed in combination with exposure therapy to help people recognize that their thoughts, attitudes, beliefs and appraisals can generate and maintain anxious states.
2. Medication options
Research has shown that people with anxiety disorders often benefit from medications that affect various neurotransmitters, particularly serotonin, norepinephrine and gaba. Medications can help reduce symptoms of anxiety, especially when combined with cbt.
The main medications used to treat anxiety are selective serotonin reuptake inhibitors (ssris), norepinephrine and serotonin reuptake inhibitors (nsris) and benzodiazepines (bzds). ssris and nsris belong to a class of drugs called “antidepressants,” which are commonly prescribed to treat both anxiety disorders and depression.
Benzodiazepines are classed as “sedatives” and are generally used to treat anxiety or insomnia. Doctors treating anxiety disorders will usually prescribe an ssri or an nsri. Research indicates that these medications help reduce the symptoms of anxiety for about 70 per cent of the people who take them.
For those who do not benefit from taking an ssri or nsri, other drug treatments can provide relief. In some cases,
specific symptoms of anxiety may be addressed with other medications, such as “beta blockers” to reduce hand tremors or slow down the heart rate, or “anticholinergics” to reduce sweating. Such medications can be taken in addition to an ssri or nsri.
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Antidepressants are usually the first medication prescribed to treat anxiety disorders. These medications are safe, effective and non-addictive, and have not been shown to have any long-term effects. The drawback of antidepressants is that they often have side-effects.
For most people, the side-effects are mild and shortlived, an easy trade-off for the benefits of the medication. For others, the side-effects might be more troubling. People often experience the side-effects of an antidepressant within the first few weeks of treatment, before experiencing its benefits.
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What’s involved in trying antidepressants?
For best results, antidepressants should be taken regularly, generally once or twice each day. These and all medications should be taken only as prescribed. Taking more or less than the prescribed amount can prevent medications from working, and may even worsen some symptoms.
Most doctors recommend starting at a low dose and then, if the person tolerates the medication well, slowly increasing the dose until the ideal dose is found. The ideal dose is one that provides the greatest benefit with minimum side-effects.
How long should I take an antidepressant?
When the right antidepressant has been found, doctors usually advise taking the medication for at least six to 12 months. In some cases, the doctor may recommend taking the medication for several years, as there might be a greater risk of relapse if the medication is stopped. Even when taken for the long term, these medications are safe and non-addictive.
No long-term side effects have been associated with the use of antidepressants. The following guidelines can help lower the risk of relapse when a person wants to discontinue using medication:
• Lower the dosage gradually by “tapering,” or reducing, the medication over a period of time, possibly several weeks to months.
• Follow up regularly with a health care professional to help monitor the severity of any recurring symptoms of anxiety.
• Combine cbt with medication and use the skills learned to control any symptoms of anxiety that may arise when medication is discontinued.
Side-effects of antidepressants
People who take antidepressants are likely to experience side-effects. Side-effects often begin soon after the person starts treatment, and generally diminish over time. In the early stages of treatment, side-effects may resemble anxiety symptoms, causing some people with anxiety disorders to abandon the treatment before it has had a chance to take full effect.
Such side-effects, however, usually only last a couple of weeks. Some side-effects may be reduced by adjusting the dose, or by taking the medication at a different time of the day. If this approach does not improve the side-effects, the doctor may prescribe another medication.
Drug interactions with antidepressants
When taking an antidepressant, or any medication, it is important to check with your doctor or pharmacist for possible drug interactions before taking any other prescription or over-the-counter drugs, or any herbal products.
Check also with your doctor before using alcohol or illicit drugs, as these may also interact with certain medications or reduce the effectiveness of treatment. Even on their own, alcohol and illicit drugs can create symptoms of anxiety.
Selective serotonin reuptake inhibitors
ssris are often the first medication prescribed to treat anxiety disorders. These medications are known to reduce symptoms of anxiety, to be safe, and to have milder side-effects than some other antidepressants. ssris have their primary effect on serotonin neurotransmitters.
4. Other medications
Buspirone (Buspar) can be used to treat generalized anxiety disorder. It works mainly through the serotonin neurotransmitter system and usually takes two to three weeks to become effective.
Antipsychotic medications are rarely used to treat anxiety disorders. When prescribed, they are generally given at a low dose in combination with antidepressants to people with severe anxiety who do not respond to antidepressants alone.
5. Herbal therapies
Over the years, many herbs have been thought to have some effect on mood and mental health. Although many plants may have active ingredients that can be somewhat effective in relieving various symptoms, their effectiveness has not been formally tested.
In North America, the herbal industry is unregulated, meaning that the quality and effectiveness of herbal products is not consistent. Adverse effects are possible, as are toxic interactions with other drugs. If you are considering herbal medicines, you should discuss this with your doctor and review the medications you are already taking.
Some herbal products have sedative effects and are believed to reduce symptoms of anxiety. These include German chamomile, hops, kava kava, lemon balm, passion flower, skullcap and valerian.
Other herbs without sedating effects, such as Drs. have also been suggested for treating anxiety disorders. The effectiveness of all of these medicines in the treatment of anxiety disorders, and their effectiveness in comparison to antidepressants, have not yet been studied.
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