“Doctor, I am not as concerned about depression as I am about anxiety, can you recommend a non-benzodiazepine medication for my anxiety?”
Anxiety is a common problem for the people we see at Gateway Psychiatric, and some variation of request above is one of the most frequent questions people ask and yet it is also one of the most complicated to answer.
To begin with, anxiety comes in many forms and means different things to different people. For example, it is common to hear someone say that they’re not anxious but they do worry a lot. Dread and hopelessness, which is one of the most common manifestations of depression, can also be confused with excessive anxiety.
So let’s begin by describing some of the types of anxiety that people experience.
Types of Anxiety
These are the most common types of anxiety that we see:
- PTSD: Intrusive fear or anxiety related to a traumatic event.
- Panic: Sudden overwhelming anxiety that feels as though you are going to die or go crazy.
- Generalized Anxiety: Worrying about many different things over a fairly long period of time.
- Obsessional Anxiety: Worrying about one thing over and over.
- Fearfulness or Paranoia: Fear that perhaps all is not as it seems, that perhaps people cannot be trusted.
- Phobias: Anxiety that is linked to specific situations.
- Agitated Anxiety and Racing Thoughts: Anxiety can also be a manifestation of what is called a “mixed state” and distinguishing this from other kinds of anxiety is both extremely important and very difficult.
PTSD or Traumatic Anxiety
Many people with mood disorders have experienced a traumatic event, which, as defined by the diagnostic manual for psychiatry, means “direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.”
Common examples in our experience are: experiencing something as a child that felt like a threat to life, a sexual assault, experiencing other forms of violence.
These traumatic events seem to create the conditions for mood instability, and addressing them and their consequences in treatment is important for good recovery.
Panic or Sudden Extreme Anxiety
The most common form of this type of anxiety is a “panic attack”. Again, the diagnostic manual defines a panic attack as:
“intense fear or discomfort in the absence of real danger that is accompanied by many of the following physical or thought symptoms. Symptoms can include: palpitations, sweating, trembling or shaking, sensations of shortness of breath or smothering, feeling of choking, chest pain or discomfort, nausea or abdominal distress, dizziness or lightheadedness, feeling that suddenly things aren’t real or feeling disconnected from your self, fear of losing control or “going crazy,” fear of dying, funny tingling sensations in the body, and chills or hot flushes. The attack has a sudden onset and builds to a peak rapidly (usually in 10 minutes or less) and is often accompanied by a sense of imminent danger or impending doom and an urge to escape.”
Generalized Anxiety or Ongoing Worry about Many Things
This kind of worry, called “Generalized Anxiety” in the diagnosis manual, is very common among those with mood disorders, and is often the first “symptom” to develop, very commonly present in childhood. However, because it is chronic, many people don’t recognize it as something worth noting.
Here again is a description:
“The person finds it difficult to keep worrisome thoughts from interfering with attention to tasks at hand and has difficulty stopping the worry. Adults with Generalized Anxiety Disorder often worry about everyday, routine life circumstances such as possible job responsibilities, finances, the health of family members, misfortune to their children, or minor matters (such as household chores, car repairs, or being late for appointments). Children with Generalized Anxiety Disorder tend to worry excessively about their competence or the quality of their performance.”
Obsessional Anxiety or Recurring Worries
Some people tend to worry over and over again about specific worries. There are many types of worries, but the key to this type of worry is that the worry is intrusive and disturbing and is difficult to control. It may be about:
- Cleanliness, germs
- Neatness, order
- Forgetting to lock a door or turn off an electrical appliance
- Being overweight
- Or many other types of things.
This type of worry seems to be particularly responsive to a specific type of psychotherapy: behavioral therapy, and a particular type of medication: agents that enhance serotonin in the brain.
Fearfulness or Paranoia
These fears, that somehow everything is not as it should be, or that people around one can’t be trusted, are often very difficult to discuss with anyone. However, recognizing them and discussing them with a therapist or psychiatrist is extremely important since they may not respond much, or at all, to typical treatment.
Agitation and Racing Thoughts in Energized States
Often when someone is in an energized state there is a sense of “agitation” or needing to move as well as the experience that thoughts are “racing” or difficult to keep up with. Both of these experiences can happen with anxiety. Also, energized states that are associated with agitation are often not at all pleasant (not the happy state that people associate with being “manic”). In fact, despite the increased energy, they are often experienced as depressed states. The key to identifying this type of agitation is:
- Getting a lot done, or needing less sleep
- The racing thoughts are not about one thing, and they are not about familiar “worries”, they still have the quality of novelty that accompanies more typical hypomania.
Agitation in Depression
There is considerable controversy about agitated depression. Some people feel it doesn’t exist. Certainly it is very difficult to distinguish from anxiety and depression. In fact, the “agitation” and “racing thought” in this kind of depression is similar to the “recurrent anxiety” described above. It tends to be about one or more worries that recur over and over again. And if there is physical activity, it also tends to be repetitive: pacing up and down, wringing hands, etcetera.
Relationship between Anxiety and Other Mood Symptoms
in addition to various means of anxiety another important issue that has to be explored before making any recommendations for treating anxiety is the relationship between this symptom and other mood symptoms.
Anxiety and Mood Symptoms Are Independent
For some people there is no relationship between depressive symptoms or other mood symptoms and anxiety. In our experience this is most common for people who have generalized anxiety and discrete episodes of depression. Often the generalized anxiety shows up first, with many symptoms of worry present even in early childhood, and then discrete episodes of depression beginning in late adolescence or early adulthood.
Anxiety and Mood Symptoms Co-occur
For other people anxiety and mood symptoms tend to occur at the same time, or in a recurring pattern or sequence. Perhaps the first symptom of an episode of depression might be an increase in anxiety, or anxiety may show up in conjunction with moderate depression but disappear as the depression becomes more severe and lethargic. The importance of this kind of pattern is that it suggests that adequate treatment of mood symptoms should resolve the anxiety.
Anxiety and Mood Symptoms Alternate
Some people experience little anxiety when depressed, but as their depression lifts anxiety may emerge. The anxiety that follows depression can sometimes be a realistic response to the need to “pick up the pieces” after a period of impaired functioning.
Treatment of Anxiety
Given the complexity of the various types of anxiety and the relationships between anxiety and mood symptoms, it may not be too surprising that the question of how best to treat anxiety is one of the most challenging questions we face in the practice.
Avoidance and Chronic Anxiety
A key issue to consider is that avoidance of anxiety or the things that provoke anxiety is often a very bad long-term strategy. Whereas in the short run it may make sense to try not to experience anxiety, for many people, doing this over time leads to more and more restricted lives. For this reason we pay particular attention to certain kinds of statements…
“I have to get rid of my anxiety…”
“I just can’t…”
These suggest that someone has unrealistic goals for coping with anxiety. All of us experience anxiety every day and any attempt to get rid of that anxiety is likely to be self-defeating.
Because avoidance is such an important problem we usually argue that the treatment of anxiety needs to begin with psychotherapy and medications should be considered as an adjunct to psychotherapy rather than as the primary modality of treatment. And psychotherapy needs to focus on teaching effective strategies for dealing with avoidance.
For most of the patients we see treatment of depressive symptoms and other mood symptoms with medications plus psychotherapy is the most effective combination. For some people there may be a role for medications for treating anxiety.
Probably no topic in the field of psychiatry is more complicated and controversial than the role of benzodiazepines in the treatment of anxiety, and particularly in the treatment of chronic anxiety.
Some psychiatrists argue that there is no role for chronic treatment with benzodiazepines, others feel that, for all of their flaws, these medications may be helpful in selected patients with chronic anxiety.
One of the key issues in using benzodiazepines is that they are easily used as part of a pattern of avoidance that is harmful. If when I feel anxious I take a medication to get rid of that anxiety and I don’t act to deal with the sources of that anxiety the result can be a very restricted life. We have seen people who are essentially unable to function because they have become so enmeshed in this pattern of using medications to numb anxiety.
And this can be especially problematic if benzodiazepines are combined with alcohol or other medications that have a similar numbing effect.
Antidepressants, particularly serotonin antidepressants (SSRI’s and SNRI’s – see below), are the most common medications used to treat generalized anxiety, PTSD, obsessional anxiety and panic anxiety.
They can be quite effective although, in our work with people with anxiety and mood symptoms we find there is a very large range of effective doses, with some people responding to tiny doses and others requiring doses well above the normal therapeutic range.
Also, anxiety symptoms tend to gradually improve over an extended period of time. For that reason, a trial of one of these medications can take months.
Buspirone has been repeatedly shown to be as effective in managing chronic generalized anxiety is benzodiazepines and almost as effective as serotonin antidepressants and yet it is medication that is rarely prescribed and when we do use it hard to convince people that it is really working.
For one thing, people who have been treated for a long time with benzodiazepines appear to be less likely to respond to buspirone. And buspirone does not cause sedation, which many people associate with effective anti-anxiety medication.
Finally, buspirone has a very gradual onset, since anxiety levels naturally vary from day to day, and even hour to hour, noticing a gradual reduction can be very difficult.
Off Label Medications
This is essentially the list of medications that have been approved in the treatment of anxiety. The remainder of this list consists of medications that are used “off label” to treat anxiety.
Gabapentin and Pregabalin
These medications which were initially developed as anticonvulsants and are often prescribed for chronic pain and fibromyalgia, can be helpful for some people with generalized anxiety. Unfortunately, they may have mood destabilizing effects and so should be used with caution in anyone with a bipolar spectrum depression.
In some areas of the country these medications have replaced benzodiazepines as sedating agents used for the treatment of anxiety states, especially when prescribed by primary care doctors. This is worrisome given the significant long-term side effects, which are in some ways worse than the long-term side effects of benzodiazepines.
In our practice we tend to prescribe them either as adjuncts to medications being used to treat depression or bipolar, or as primary medications for treating fearfulness and paranoia.
Medications like hydroxyzine and diphenhydramine are sedating antidepressants that may help some people with generalized anxiety. Since these medications have significant anticholinergic effects they should be used with caution in older patients and their effectiveness for most people is modest.
Propranolol is probably the medication most often prescribed for performance anxiety. It is most helpful for treating the physical manifestations of high anxiety such as tremor, racing heart, and to a lesser extent flushing and sweating.