5.4 The treatment and management of anxiety disorders – an overview
What may be perceived as stressful to one person is not necessarily always perceived as such by another. People can react to situations in different ways. Let’s take a moment to reflect on what we have learned about stress and anxiety. Physical or mental ‘stress’ can be caused by a variety of external factors including work (pressures from deadlines, work overload, or the loss or change of a job), financial strains (mortgages, bills, debts, unforeseen expenses, unemployment), relationship problems (break-up or divorce), status of one’s general health (serious illness, accidents, trauma), and major life events (having children, moving home, getting married, exams, being the victim of a crime or of violence, etc.). Anxiety can develop as a result of trauma or significant life events, childhood or past experiences, a complex interplay between biological, genetic, environmental and psychosocial factors, underlying medical causes, or side effects of certain medications. Physical and mental wellbeing and personality (temperament) or thinking style can also impact on how anxiety can develop and is maintained.
Some of the main forms of treatment and management of stress and anxiety disorders are summarised in Box 11.
Box 11 Brief overview of the treatment and management of anxiety disorders
Cognitive behavioural therapy (CBT) − 'talk therapies' – strategies to reduce anxiety (e.g. shifting attitude, managing underlying feelings or emotions such as grief or anger, identifying and modifying ‘catastrophic’ thinking), exposure therapy (‘facing your fears’).
Pharmacological therapies – anxiolytic and antidepressant drugs.
Combined therapies − CBT with pharmacological therapy or augmented pharmacological therapies.
Making adjustments to lifestyle, eating regularly, keeping to regular sleep schedules, engaging in leisure activities, managing own expectations (avoiding perfectionism), seeking assistance for difficulties (e.g. relationship problems), understanding factors that contribute to (or can trigger) vulnerability, finding healthy ways to deal with feelings (e.g. talking to family and friends, or going for a walk), seeking and accepting professional support, relaxation techniques (e.g. meditation, visualisation, yoga), eschewing ‘avoidance’ (avoidance of situations or interactions maintains anxiety).
Activity 9 Treatments for Anxiety
Listen to the podcast below and consider the questions that follow. You might wish to listen to the entire recording first and review this again thinking specifically about the questions the second time around. Alternatively, you can consider the questions as you listen to the recording the first time around. Choose whichever approach suits you best.
BBC World Service Health Check 'Anxiety' Extract 2
Claudia Hammond from the BBC talks about anxiety, speaking to Claire and Scott about their experiences of anxiety and the effect it has on them, and to Nick Grey, a clinical psychologist from the Centre for Anxiety Disorders and Trauma at the Maudsley Hospital in London, in this second part of a recording broadcast in 2014 (you listened to the first part in Activity 4).
In the interview, Claire talks about different treatments that she has been receiving for her social anxiety disorder. What are these?
How has Claire come to terms with her anxiety?
Scott has also come to terms with his anxiety. How does he manage his anxiety?
Both Claire and Scott refer to the amygdala as being affected by treatment. Why is this part of the brain important to understanding anxiety?
How does Scott define ‘resilience’ in the context of anxiety and depression?
Nick Grey describes some common ‘precautions’ that people get into a habit of taking when experiencing severe acute anxiety or a panic attack ‘to try to prevent the worst from happening’. What example does he give?
Why does he not consider this to be an effective way of managing anxiety?
What is exposure therapy and how can it be used for treating social anxiety?
Is it possible to rid people of their anxiety?
Claire mentions taking Sertraline, a selective serotonin reuptake inhibitor, or ‘SSRI’, which also works as an antidepressant. She says that she has also received a course of cognitive behavioural therapy which helped to ‘retrain’ her brain by ‘neutralising the negative thoughts’ that she had and replace these with ‘more rational ones’. She exercises a lot, going to the gym three times a week. And she says the ‘biggest’ treatment for her has been exposure therapy, where she ‘puts herself in situations that make her uncomfortable’.
She has accepted that ‘being nervous is a completely natural emotion’ and ‘not a symptom of a bigger problem’ and has a positive outlook (‘accepting that feeling, but doing it anyway because it might be fun, and it’s never as bad as you think it’s going to be’).
Scott mentions that he recognises that his anxiety may never be ‘cured’ but that it is ‘an acceptable part of who he is – and his personality’. He talks about SSRI antidepressants and benzodiazepines, a class of tranquillisers that he says help with severe anxiety. He also refers to mindfulness meditation which he says can be highly effective, and relaxation techniques such as breathing exercises, and the importance of sleep and regular exercise. He also stresses the importance of maintaining an optimistic outlook to mitigate anxiety.
Scott refers to the amygdala as the ‘seat of fear’ and Claire says that exposure therapy can ‘retrain her amygdala not to go off every time she is in the situation in the future when there is no danger’. Recall the function of the amygdala, a key brain structure within the temporal lobes involved in the neural circuitry of anxiety, which was discussed in Section 4. Parts of the amygdala are involved in triggering the responses we associate with fear (e.g. submission, fleeing, or ‘freezing’ on the spot). Other regions within the amygdala elicit feelings of bliss or peacefulness, or evoke aggression and attack.
He describes resilience as a ‘trait that... makes you resistant to developing anxiety and depression’, that is 'somewhat encoded into your genes’, but ‘also something that can be learned’.
He gives the example where ‘your heart’s racing very, very fast and you think you’re going to have... a heart attack or you’re going to pass out it makes sense to sit down, try and take weight off your feet. Do some breathing exercises to... calm your breathing down. Because you have this belief that otherwise you’re going to die’.
Nick Grey explains ‘you never learn that if you didn’t do these kinds of precautions that actually you’d still be OK’, and that ‘whilst a panic attack is very frightening and feels awful it’s not in fact dangerous’. He identifies cognitive behaviour therapy which helps people learn that some of the things they do to help themselves are probably unnecessary, as one of the most effective treatments for anxiety and panic attacks.
Claudia notes that exposure therapy allows the individual to 'gradually get used to things that [she] fear[s]’ referring to Claire’s social anxiety. Nick explains that ‘trying to hide your anxiety or trying to... manage your image... actually makes you more self-focused, more self-conscious’, and one of the things that they would do as part of treatment for people with social anxiety is to video record them, so they can compare how they feel while ‘in the moment’ with how they actually come across in the recording. He notes that ‘almost always people are surprised by how they look and how they sound on video compared to how it felt to them’. And that people tend to have a visual image of themselves, of how they’re coming across – looking red in the face, looking anxious or having a panic attack.
Nick explains that the aim is not to rid people of anxiety, which may not be a realistic goal, but rather to have a discussion around ‘the normality of fear and worry and anxiety’.