Article summary of Treatment of anxiety disorders by Bandelow et al. - Chapter

What are the prevalences and causes of anxiety disorders? 

As a group, anxiety disorders are the most common mental health disorders, and they often greatly diminish quality of life. In the DSM-5, the following disorders are listed under anxiety disorders: panic disorder (PDA), agoraphobia, generalized anxiety disorder (GAD), social anxiety disorder (SAD), specific phobias, separation anxiety disorder, and selective mutism. Specific phobias are the most common anxiety disorder, displaying a 12-month prevalence of 10.3% in the general population. PDA is the second most common, with a 12-month prevalence of 6%. SAD and GAD are the third and fourth most common anxiety disorders, with 2.7% and 2.2% 12-month prevalence rates, respectively. Generally, anxiety disorders are chronic, and symptoms fluctuate back and forth over time. However, the only anxiety disorder that still shows up frequently in adults over the age of 50 is GAD. Women are diagnosed 1.5 to 2 times more often with an anxiety disorder than men are. Anxiety disorders are frequently comorbid with depression, personality disorders, and other anxiety disorders. 

Anxiety disorders are thought to be caused by an interaction between a genetic predisposition to the disorder and environmental factors, such as stress, trauma, or adversity during childhood. Although much research has been done, no genetic biomarkers specific to anxiety disorders have been found. 

How are anxiety disorders treated?

Anxiety disorders are commonly treated with psychotherapy, pharmacologically, or a mixture of both. The patients with anxiety disorders who seek help most often suffer from GAD, PDA, and/or SAD. Treatment is not always needed in mild cases, but daily impairment due to the disorder indicates a need for intervention. In rarer cases, patients may need to be hospitalized due to suicidal tendencies, comorbidities, or extreme unresponsiveness to treatment. Patients suffering from certain anxiety disorders (specifically, PDA) are much more likely to seek treatment than those suffering from specific phobias. This may have to do with the perceived severity and imminency of the consequences of a panic attack. Conversely, those with specific phobias might not realize they have a treatable disorder. It had been found that as a group, anxiety disorders go untreated very frequently, with only about 20% of those with an anxiety disorder ever seeking treatment. 

What drugs are used to treat anxiety disorders? 

There are many drugs available to treat anxiety disorders. Selective serotonin reuptake inhibitors (SSRIs) and selective serotonin norepinephrine reuptake inhibitors (SNRIs) are both antidepressants usually prescribed as the first line of defense against anxiety disorders. These drugs are very effective, yet their tendency to increase anxiety symptoms within the first few weeks of treatment may hinder treatment compliance. Because of this, patients are often started at a lower dose of the drug, and work their way up to a higher dose. Many studies show that SSRIs are better tolerated than SNRIs. Withdrawal reactions to SSRIs are possible but unlikely. 

Pregabalin, a calcium modulator, has a sedative effect which is helpful for those with anxiety disorders and a comorbid sleep disorder. This drug works more quickly than antidepressant anxiety drugs but withdrawal is more of an issue. Tricyclic antidepressants are as effective as SSRIs and SNRIs but are associated with more frequent adverse effects. Tricyclic antidepressants should not be used as a first-line defense against anxiety disorders. 

Benzodiazepines are also not recommended for first-line treatment, although they are effective drugs in combatting anxiety disorders. The effects of benzodiazepines are more immediate than the anxiety-soothing effects that come from antidepressants, but they are associated with central nervous system depression, which can cause many adverse effects. Benzodiazepines can be used in coordination with other anxiety-reducing drugs in severe cases, or during the weeks after starting an SSRI or SNRI before it kicks in. 

Drug treatment for anxiety disorders should be continued for at least 12 months after the apparent remission of symptoms in a patient. When the patient does terminate the drug plan, their dose should be tapered off over 2 weeks so as to not cause withdrawal symptoms or other unwanted effects. 

How effective is therapy in psychotherapy in treating anxiety disorders? 

In contrast to drug treatment of anxiety disorders, everyone who suffers from anxiety could benefit from psychotherapy. Cognitive-behavioral therapy (CBT) is especially effective. For those with phobias, exposure therapy techniques are often effective and should be included in treatment. Only 1 to 5 therapy sessions using exposure techniques have been shown to effectively treat phobias. While psychotherapy can be extremely effective in treating anxiety disorders, medication has a stronger pre-post treatment effect size. The effect of therapy on reducing the symptoms of anxiety disorders is similar to that of taking a placebo drug said to treat anxiety. This points not to the relative weakness of psychotherapy but rather the relative strength of a medication-based placebo effect. Both drug treatment and psychotherapy can have a major impact on those suffering from anxiety disorders.