Anxiety Treatment in Seattle
Evidenced-based Treatment for Anxiety Disorders
Anxiety disorders affect many people, causing them to be filled with fearfulness and uncertainty. Unlike the relatively mild, brief anxiety caused by a stressful event, such as speaking in public or a first date, anxiety disorders last at least 6 months and can get worse if they are not treated.
Anxiety disorders commonly occur along with other mental or physical illnesses, including alcohol or substance abuse, which may mask anxiety symptoms or make them worse. In some cases, these other illnesses need to be treated before a person will respond to treatment for the anxiety disorder.
Social Anxiety Disorder is characterized by marked, persistent, and unreasonable fear of being observed or evaluated negatively by others in social performance or interaction situations and is associated with somatic and cognitive symptoms. The feared situations are avoided or else are endured with intense anxiety or distress. These situations include fear of speaking in public, speaking to unfamiliar people or being exposed to possible scrutiny by others.
Generalized Anxiety Disorder
The main features of Generalized Anxiety Disorder (GAD) are excessive anxiety and worry. The patients suffer from somatic anxiety symptoms as well as from restlessness, irritability, difficulty concentrating, muscle tension, sleep disturbances and being easily fatigued. Some patients may express constant worry that they or a relative will shortly become ill or have an accident.
Obsessive-Compulsive Disorder (OCD)
OCD is characterized by recurrent obsessions or compulsions, or both, that cause impairment in terms of distress, time, or interference with functioning. Concerns involving contamination, harm, hoarding, and sexual, somatic and religious preoccupations are the most common obsessions. Compulsions include washing, checking, repeating, ordering, counting, hoarding and touching (rare).
Panic Disorder is characterized by recurrent panic attacks. Panic attacks are discrete periods of intense fear or discomfort, accompanied by at least four somatic and psychic symptoms (palpitations, sweating, trembling, dyspnoea, choking sensations, chest pain, nausea, abdominal distress, dizziness, feeling of unreality, fear of dying, etc.). A panic attack reaches a peak within 10 min and lasts 30 – 45 min on average. Usually, the patient is afraid that he has a serious medical condition such as myocardial infarction.
About two-thirds of all patients with panic disorder suffer from agoraphobia, which is defined as fear in places or situations from which escape might be difficult or in which help may not be available in the event of having an unexpected panic attack. These situations include being in a crowd or standing in a line, being outside the home alone, or traveling in a bus, train or automobile. These situations are avoided or endured with marked distress.
Post-traumatic Stress Disorder (PTSD)
PTSD develops after a terrifying ordeal that involved physical harm or the threat of physical harm. The person who develops PTSD may have been the one who was harmed, the harm may have happened to a loved one, or the person may have witnessed a harmful event that happened to loved ones or strangers. The condition is characterized by recurrent and intrusive distressing recollections of the event, nightmares, a sense of reliving the experience with illusions, hallucinations, or dissociative flashback episodes, intense psychological or physiological distress at exposure to cues that resemble the traumatic event, avoidance of stimuli associated with the trauma, inability to recall important aspects of the trauma, loss of interest, estrangement from others, sleep disturbances, irritability, difficulty concentrating, hypervigilance, and exaggerated startle response. The full symptom picture must be present for more than 1 month.
Benzodiazepines: Xanax (alprazolam), Valium (diazepam), Klonopin (clonazepam), Ativan (lorazepam)
TREATING ANXIETY IN SUBSTANCE ABUSERS
Given how common substance abuse is in psychiatric patients, we are often confronted with the tricky decision about prescribing potentially abusable
drugs to substance users. In making these decisions, it is important to estimate how likely it is that a given patient will misuse a drug, either by
abusing it or by giving or selling it to someone else. You must balance that estimate with the drug’s potential benefit for the patient.
A particularly common scenario is the patient with a history of substance abuse who suffers anxiety and is requesting benzodiazepines. While benzodiazepines are effective antianxiety workhorses for many patients, most guidelinestell us to avoid prescribing them to substance abusers. The concerns are that the benzo high will remind patients of their substances of choice, and that benzo withdrawal symptoms will lead to old substance-abusing habits.
However, one review of the literature concluded that benzos can safely be prescribed for some alcoholics in recovery (Lingford-Hughes et al, 2002),
and most psychiatrists can manage such patients by making sure that they do not escalate their doses and do not get early refills. Psychotherapy is always an option, and it can work well. For example, a two-week pilot trial of cognitive behavioral therapy–based integrated treatment for panic disorder and alcohol abuse in 48 patients showed benefit over alcoholism treatment alone (Kushner et al, 2006).
But assuming therapy has already been tried, what are some reasonable non-benzo approaches?
SSRIs/SNRIs and other antidepressants
Most substance abusers with anxiety will end up rotating through several SSRIs and SNRIs. These are robustly effective medications with few side
effects, and we all have our own “go to” meds. Paroxetine carries the most FDA-approved indications for disorders on the anxiety spectrum, but it
also is the most likely to cause sexual dysfunction, weight gain, and sedation. Sertraline and escitalopram are good choices in terms of minimal side
effects and few drug/drug interactions. The SNRIs, especially duloxetine, may be especially appropriate if your patient has a comorbid chronic pain condition, because both of these meds carry FDA indications for pain syndromes.
The newer antidepressant vilazodone was effective for GAD in one placebo-controlled trial (Gommoll et al, 2015).You might also consider mirtazapine (Remeron), effective in a small open-label study of GAD and also helpful for insomnia. Bupropion, while not effective for anxiety disorders per se, is effective for anxiety when it is a symptom of depression—but watch out for its common early side effects of insomnia and jitteriness, and note that it is contraindicated in patients withdrawing from alcohol or other sedatives.
Buspirone has been around a long time, and many of your patients will say they’ve already tried it. Maybe they have, maybe they haven’t. Here are two
tips to optimize patient response. First, don’t oversell it as a benzodiazepine substitute—it doesn’t work as quickly or as well, and patients expecting
the benzo feeling will be disappointed and stop taking it. Second, get the dose high enough to be effective before throwing in the towel. A robust
dose is 60 mg a day, split up either twice or three times daily. Dizziness and sedation may limit the dose.
Hydroxyzine (Atarax, Vistaril)
Some are surprised to hear that hydroxyzine has an FDA indication for anxiety (albeit an old one). It is effective—for example, in one large randomized
placebo-controlled trial, patients with GAD randomly assigned to hydroxyzine 50 mg/day did just as well as those assigned to bromazepam
6 mg/day (bromazepam is a benzodiazepine approved in Europe; 6 mg is equivalent to about 10 mg of diazepam). Patients on the benzodiazepine
experienced more sedation (Llorca et al, 2002).
Pregabalin is a Schedule V controlled substance (the same category as cough suppressants with codeine), so it might seem an odd choice for
treating anxiety in patients with substance abuse histories. Wouldn’t it pour fuel on the fire? Apparently not. In fact, pregabalin has been compared with
naltrexone as a treatment for alcohol dependence; in one small randomized controlled trial, pregabalin was as effective as naltrexone and led to greater
improvement in anxiety (Martinotti et al, 2010). Pregabalin’s efficacy for GAD (in the absence of substance abuse) is pretty well-established. Clinical
trials have shown that the drug is as effective as lorazepam and alprazolam, and more effective than venlafaxine for GAD. Placebo-controlled trials
have also shown that it is more effective than placebo for patients who have had only a partial response to SSRIs or SNRIs (for a recent review of these
studies, see Reinhold & Rickels, 2015). Start at 100 mg QHS, and gradually titrate to 300 mg BID. Pregabalin’s potential drawbacks in addition to its
addictive properties include high rates of dizziness and sedation (20%–30% of patients), and an average weight gain of about 5 pounds after 4 weeks.
There aren’t any drug-drug interactions currently noted for pregabalin.
Gabapentin was originally used to prevent seizures as an anti-epilepsy drug. Its off-label uses include treatment for anxiety disorders as well as withdrawal from alcohol or benzodiazepines. (The drug was once also touted
as a treatment for bipolar disorder, but well-designed trials discredited this use.) One small placebo-controlled trial found gabapentin (average dose
2,868 mg/day) superior to placebo for social phobia, but the response rates were low (32% for gabapentin, 14% for placebo) (Pande et al, 1999). For
alcohol dependence, in one large double-blind trial, a rapid 4-day taper of gabapentin (from 1,200 mg/day to 800 mg/day) was more effective than
a taper of lorazepam in terms of preventing relapse (Myrick et al, 2009). Common gabapentin side effects include dizziness and sedation, and there
is increasing evidence that many patients abuse it for its sedative properties.
Quetiapine is hardly the first antipsychotic to be used or approved for anxiety. Stelazine (trifluoperazine) is approved for the short-term treatment
of GAD, while Triavil (the combination of the antipsychotic perphenazine and the antidepressant amitriptyline) is approved for “depression and anxiety.”
In addition, many clinicians use low-dose chlorpromazine (Thorazine) off-label for anxiety. The advantage of quetiapine is that its efficacy evidence is more robust, with placebo-controlled trials of over 2,600 patients showing that the medication eases symptoms of GAD better than placebo, just
as well as paroxetine, and better than escitalopram (for a review of these studies, see Gao et al, 2009). Lower doses of quetiapine XR, 50–150 mg
QD, appear to be more effective than higher doses. Quetiapine has not won FDA approval for GAD, probably because its disadvantages literally
outweigh its advantages (it’s one of the worst antipsychotics in terms of weight gain and metabolic disturbances). Quetiapine, like gabapentin, has
become a drug of abuse in some circles (Sansone & Sansone, 2010).