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.
Claire, who we heard from earlier, has tried a range of different treatments.
I now take a mild anti-depressant called Sertraline, which is an SSRI inhibitor.
Lin Lin Ginzberg:
So a selective serotonin reuptake inhibitor. Is that right?
That’s the one. And so I take that and I also did a course of cognitive behavioural therapy which helped me to retrain my brain by neutralising the negative thoughts that I have with more rational ones. I exercise a lot. I go to the gym three times a week to keep my adrenalin levels down in a healthy way. And the biggest one for me actually is what I call exposure therapy, whereby I put myself in situations that make me uncomfortable in order to retrain my amygdala in my brain not to go off every time I’m in the situation in the future because there is no danger. I’m always going to be a little bit nervous but for me it was exacting that being nervous is a completely natural emotion. It’s not a symptom of a bigger problem. People get nervous before interviews and people get nervous before they meet new people. That’s 100% fine and it’s just about 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 too has come to terms with the fact that he’s never going to be entirely free from anxiety but that he can manage it.
I may never be cured, but I can come to terms with the anxiety and recognise that it is an acceptable part of who I am and it comes with certain elements of my personality that may be favourable. There are many things that I have therapies and techniques that I’ve used, that do help. Certain medications help a lot in certain circumstances and obviously, you know, medication works in different ways for different people. But SSRI anti-depressants and benzodiazepines which are the class of, sort of, minor tranquiliser help a lot with severe anxiety.
Mindfulness mediation, I’ve not probably explored that enough myself, but there is lots of evidence that that can be highly, highly effective in literally reshaping your brain, of strengthening the rational part of your brain and literally shrinking the amygdala which is the seat of fear. So there’s a lot of evidence that that works.
And then many psychiatrists will say there are, you know, if you’re in the throes of a panic attack or if you’re feeling overwhelmed do breathing exercises to help yourself calm down. And then any doctor or dietician or psychiatrist will tell you sleep is incredibly important, regular exercise is incredibly important and cultivating what the psychiatrists today talk about resilience which is a trait that, you know, makes you resistant to developing anxiety and depression. Resilience too is thought to be somewhat encoded into your genes but it’s also something that can be learned. The military is studying how can they make soldiers at the US military, make their soldiers more resilient so that they’re resistant to breaking down with PTSD after combat. So cultivating a resilient, optimistic outlook is probably one of the more effective things you can do to mitigate anxiety.
Now Nick, trying to accept your anxiety as part of you, you know, sounds like very good advice but is it easier said than done when it feels so unpleasant?
Yeah, I think it is easier said than done. I think there are also things that people do with the best of intentions that actually serve to keep the anxiety going. And I think that one of the things that, kind of, the effective treatments do is to try and identify what those, kind of, maintaining sort of factors are. And then to try and help change those.
What sort of things might someone do that maintain it?
Well the, kind of, things really similar to, kind of, like Scott and Claire have mentioned is that people do things to try and prevent the worst from happening. So if your heart’s racing very, very fast and you think you’re going to have kind of a heart attack or you’re going to pass out it makes sense to sit down or to try and take your weight of your feet. Do some breathing exercises to, kind of, to calm your breathing down. Because you have this belief that otherwise you’re going to die.
The problem is of course, is that whilst a panic attack is very frightening and feels awful it’s not in fact dangerous, yeah. And one of the things doing these precautions, these things to save yourself, do, is you never learn that if you didn’t do these kind of precautions that actually you’d still be OK. So one of the things that, kind of, the most effective treatments in anxiety is typically cognitive behaviour therapy, is to help people learn that some of these things they do to save themselves are probably unnecessary.
So is that where Claire was talking about exposure therapy and gradually getting used to the things that she fears?
Yeah, partly, and actually certainly for people with social anxiety disorder it’s kind of moved really, kind of beyond pure exposure therapy now. And it’s really looking at not just, you know, exposing yourself and kind of grinning and holding on to, kind of, you know, the nearest chair until the anxiety passes but it’s really looking at what your predictions are. What do you think is going to happen? And how can you, kind of, really kind of test that out? And also in, kind of, social anxiety one of the things that happens is that people often try to kind of hide their anxiety, something I think Scott mentioned. And one of the things that trying to hide your anxiety or trying to kind of manage your image does is it actually makes you more self-focused, more self-conscious. And if you’re kind of more self-conscious and self-focused you’re not really paying attention to what’s going on out there. You’re not paying attention to how people are really reacting to you, so it may feel as though some of your fears are coming true, but the reality may be that may not be the case. One of the things that we would do as part of treatment actually for people with social anxiety disorder is actually to video record them as part of treatment.
That sounds horrible.
It’s certainly anxiety provoking, but of course one of the things about it being anxiety provoking is that then their fears are activated. Their fears of whether they’re looking shaky or whether they feel that they’re going red, or fear that they’re saying something stupid and how it feels to them at that moment. They can then compare with how it actually looks on the video. And one of the things that certainly we kind of find in treatment is that, you know, almost always people are surprised by how they look and how they sound on video compared to how it felt to them.
So even though they might be cringing at the beginning it’s still not actually as bad as what they were imagining?
Absolutely. And one of the things we guide people to do is to look at it as if they were watching TV, as if they were watching somebody else rather than busy criticising themselves when they’re watching it. But just to, kind of, see it as if somebody else would. And then, usually it’s the case of what they’re seeing, what they’re hearing is very different to how it felt at the time.
And sometimes you were using imagery in your work as well. What’s that and how would that work?
Yeah. And this is certainly something that’s, kind of, been a development over the last kind of ten or 15 years in anxiety disorders that some of the worst fears that people have aren’t just kind of like a verbal thought like 'I’m going to die' or 'people can see I’m looking red'. But they have an image of either how they’re coming across. They have an image of themselves looking red in the face. They have an image of themselves kind of looking anxious or they may have an image of themselves actually kind of collapsed in the street from a panic attack. Certainly a person that I treated with panic disorder some time ago, he actually had an image of a blood clot moving around his body. And the fear of this then, kind of, reaching his heart, when his heart was racing, he feared that this blood clot that he had in this image was going to stop his heart.
So after people have had some sort of treatments like possibly medication as Claire and Scott were talking about, or cognitive behavioural therapy like this, what sort of outcomes do you see? How easy is it to actually rid people of their anxiety?
I don’t think we rid people of anxiety. I don’t think we ever aim to rid people of anxiety, and if people come in with a goal of saying I never want to be anxious again, yeah, we need to have kind of a discussion around actually the normality of fear and worry and anxiety. And what’s kind of realistic in those terms.
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’.