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	James L. Holly, M.D.

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Your Life Your Health - Stress Disorders - Part IV Treatment of Stress Disorders

James L. Holly,M.D.

October 23, 2008

Your Life Your Health - The Examiner

Anxiety disorders require treatment. Simply trying to talk oneself out of anxiety is as futile as trying to talk oneself out of a heart or stomach problem. Most anxiety disorders, especially phobias, respond well to treatment. They may, however, require long-term treatment. Many patients have a recurrence and may require additional medications. Nevertheless, most patients do not receive appropriate care for anxiety disorders. Many patients do not receive any treatment at all.

Because anxieties result from our response to events based on how we think about those events, faith can be an important aspect of our dealing with anxieties. Our faith - our beliefs - gives us a context in which to deal with things which "bother" us and which create anxiety and stress. However, it is most often the case that in order to deal with stress and anxiety, we need help, guidance, support or counsel. And, all of these are aspects of the activity of faith. Prayer, meditation, contemplation are all effect means of approaching anxiety, but these should not prevent us from seeking help or cause us to think that we are "weak" if we need help. Helping others is one of the core values of any faith, thus receiving help is no a contradiction but an affirmation of faith. Sometimes, however, because of the temptation of "perfectionism" it is possible for a distortion of faith itself to create anxiety, worry or stress.

The treatment for any anxiety or stress disorder must include a health lifestyle. A healthy lifestyle that includes exercise, adequate rest, and good nutrition can also help to reduce the impact of anxiety. Fatigue, diets high in simple carbohydrates such as sugar, sleeplessness and/or inactivity all magnify or potentiate the affects of anxiety. Getting proper sleep, improving the content of your diet and beginning and sustaining an appropriate exercise program all can diminish the impact of stress disorders.

Treatment Options

The standard current approach to most anxiety disorders is a combination of cognitive-behavioral therapy (CBT) and an antidepressant medication.

Cognitive-behavioral therapy

If we are serious about overcoming an anxiety disorder, we need to approach anxiety from every positive angle and perspective that we have available to us. Therefore, we focus on three main areas, all three of which must be addressed in therapy.

COGNITIVE (thinking/belief processes)

Here we learn new methods and ways to change our old thinking patterns and habits. If we're always thinking and expecting the worst, then we will continue to suffer. We train or condition our minds to think and respond differently than we have in the past. Or think of it this way - if we can be conditioned to think and feel negatively, then we can be reconditioned to think healthfully.

There are dozens of specific methods and techniques that are used -- and it is only necessary to find several methods that work well for you. This is usually where CBT (cognitive-behavioral therapy) starts. Some effective techniques are:

Slow-talk/slow walk/slowing down
Stopping automatic negative thinking (ANTs)
The acceptance paradox: how we keep the fires burning and how to put them out
Rational and helpful self-statements that can become permanent and "automatic"
Continuing to move our self-statements up
Whose voice are you listening to, anyhow? Do we have to listen and believe all those old lies?
The determination factor: becoming more focused and gently determined
Focusing: What are you paying attention to?

Later, it's important to address: perfectionism, anger, frustration, setbacks, and our view of the world BEHAVIORAL (what we do)

The behavioral aspect of therapy is the part where we actually put everything into place in everyday, real-life situations where we are bothered by anxiety and depression. This area is always handled at the same time or after cognitive therapy, because we need a strong foundation of cognitive and emotional skills/strategies so that we can begin living and acting differently before we confront real-life challenges. This stage is essential for people with some of the anxiety problems (such as social anxiety disorder) and serves as a powerful adjunct to individual treatment for others.

EMOTIONAL (relaxation/peaceful/strength and power strategies)

It is important to have some type of relaxation or "de-stress" strategy that is accessible whenever we need it. In this area, calmness and peace are the goals. The more your brain is quiet and relaxed, the easier therapeutic information can get into it and be processed. This is simply another way to let the therapy reach your brain and gently sink in. Our focus is on peace and calmness here. We do not focus on decreasing anxiety by using these methods. Why? As peace and calmness become a little stronger, they tend to "crowd" out the anxieties and fears we have. Therefore, we never need to focus on the anxiety, the nervousness, or the fear. Our focus is on healing, healthiness, and inner peace.

Medication Treatment

A selective serotonin reuptake inhibitor (SSRI) is typically the first choice for stress disorders. The following are drugs in this class:

citalopram (Celexa)
escitalopram (Lexapro)
fluoxetine (Prozac)
paroxetine (Paxil)
sertraline (Zoloft)

The serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor) is an alternative to the SSRIs. If patients do not respond to these drugs, tricyclic antidepressants can be used. This class includes:

amitriptyline -- Elavil, Endep
amoxapine -- Asendin,
desipramine -- Norpramin, Pertofrane
doxepin -- Adapin, Sinequan
imipramine -- Tofranil, Janimine

Benzodiazepines (valium, libirum, ativan, etc.) may be recommended for patients who are not helped by antidepressants. The following table addresses treatment options for specific anxiety disorders

Treatment Options for Specific Anxiety Disorders
Anxiety Disorder	Medications	Cognitive-Behavioral Therapy (CBT) and other Non-Drug Therapies
Generalized Anxiety Disorder	Antidepressants, benzodiazepines, and buspirone are helpful but have varying side effects. Investigational drugs include pregabalin and other anticonvulsants.	Cognitive-behavioral therapy or anxiety management therapy. Anxiety management therapy involves education, relaxation training, and exposure to anxiety-provoking stimuli but does not include cognitive restructuring.
Panic Attacks	SSRIs are treatment of choice. If patients do not respond to SSRIs, short-term treatment with a benzodiazepine may be used, or patients may switch to another type of antidepressant such as venlafaxine or tricyclics.	Cognitive-behavioral therapy, provided in 12 - 16 sessions over 3 - 4 months, focuses on recreating fear symptoms and helping patients change their response to them.
Social Anxiety Disorder	SSRIs or venlafaxine are first-line drug treatments. Benzodiazepines may help patients who do not respond to these antidepressants. In severe cases, an MAOI antidepressant may be prescribed. Anticonvulsants such as gabapentin (Neurontin) and pregabalin (Lyrica) are being investigated.	Cognitive-behavioral therapy can help improve symptoms after 6 - 12 weeks.
Obsessive-Compulsive Disorder	SSRIs are the first choice for adults. Clomipramine (a tricyclic antidepressant) is an alternative for adult patients who do not respond to SSRIs. For children, SSRIs do not seem to work as well for OCD as for other types of anxiety disorders.	Cognitive-behavioral therapy is the first treatment choice for children. For adults, either CBT or drug therapy may be offered as initial treatment. CBT techniques focus on exposure and response prevention (ERP).
Post-Traumatic Stress Disorder	Antidepressants, particularly SSRIs (sertraline and paroxetine approved for PTSD). The atypical antipsychotic olanzapine may be added to an antidepressant for patients who do not respond to a SSRI alone.	Trauma-focused psychological treatments include exposure therapy, trauma-focused cognitive therapy, and eye movement desensitization and reprocessing.
Note: For anxiety disorders in adults, the most effective treatments are usually combinations of drugs and CBT techniques. For children, CBT is usually the first treatment.

It is not necessary to live with chronic, incapacitating anxiety, worry or stress. There are good treatments available.

Other Articles in the Stress Disorders Series

	Stress Disorders - Part I Stress, Anxiety, Illness Stress Disorders - Part II Causes of Stress and Anxiety Stress Disorders - Part III Diagnosing Stress Disorders

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