The Diagnosis and Treatment of Anxiety Disorders

The Diagnosis and Treatment of Anxiety Disorders – free full-text /PMC6206399/ Sep 2018 

Background

Anxiety disorders are the most common type of mental illness in Europe, with a 12-month prevalence of 14% among persons aged 14 to 65.

Their onset is usually in adolescence or early adulthood. The affected patients often develop further mental or somatic illnesses (sequential comorbidity).

Methods

This review is based on pertinent publications retrieved by a selective search in PubMed.  

Results

The group of anxiety disorders includes

  • generalized anxiety disorder (GAD),
  • phobic disorders,
  • panic disorders, and
  • two disorders that are often restricted to childhood—separation anxiety and selective mutism.

A comprehensive differential diagnostic evaluation is essential, because anxiety can be a principal manifestation of other types of mental or somatic illness as well. Psychotherapy and treatment with psychoactive drugs are the therapeutic strategies of first choice.

Of all types of psychotherapy, cognitive behavioral therapy has the best documented efficacy.

Modern antidepressants are the drugs of first choice for the treatment of panic disorders, agoraphobia, social phobia, and GAS; pregabalin is a further drug of first choice for GAS.

Conclusion

In general, anxiety disorders can now be effectively treated.

There’s a huge difference between being “treated” and being “cured”…

Patients should be informed of the therapeutic options and should be involved in treatment planning. Current research efforts are centered on individualized and therefore, it is hoped, even more effective treatment approaches than are available at present.

This is the end of the article abstract, with the full text below, including some meaningful tables.

Introduction

Anxiety is a a normal and necessary basic emotion without which individual survival would be impossible.

Pathologically increased anxiety can arise not only in anxiety disorders per se, but also in most other types of mental illness. Anxiety can also be a warning signal of potential harm in somatic illnesses, such as myo-cardial infarction or hypoglycemia in a diabetic patient; it naturally requires an entirely different therapeutic approach in such situations.

For any patient presenting with pathologically increased anxiety, a thorough psychiatric and somatic evaluation is needed so that an underlying

  • pulmonary,
  • cardiovascular,
  • neurological, or
  • endocrine

disease (e.g., of the thyroid gland) can be ruled out.

Anxiety reactions as such are important indicators of a possible threat to homeostasis; anxiety is considered a disease requiring treatment when it arises in the absence of any threat, or in disproportionate relation to a threat, and keeps the affected individual from leading a normal life.

Like wearing dark sunglasses, I feel doomed to interact with much of life through a “doomsday filer”, always dreading the next moment.

The World Health Organization (WHO) reported that, in 2015, anxiety disorders ranked in sixth place among all mental and somatic illnesses worldwide as a cause of so-called years lived with disability (YLD), and in fourth place in highly developed countries; they are thus among the chronic illnesses with the greatest impact on patients’ lives. Specific phobias are the most common type of anxiety disorder.

Table 1

Clinical manifestations of anxiety disorders according to ICD-10
Anxiety disorder Clinical manifestations
Generalized anxiety disorder
(F41.1)
Anxious worry. tension. and fears about everyday events and problems
Panic disorder
(F41.0)
Repeated and unexpected panic attacks (anxiety attacks) with both physical manifestations (palpitations. dyspnea. diaphoresis. paresthesiae. nausea) and mental ones (fear ranging to mortal fear. fear of losing control. feeling of alienation)
Panic disorder with
agoraphobia (F40.01)
Repeated and unexpected panic attacks plus agoraphobia
Agoraphobia
(F40.0)
Phobias involving fears of leaving home. entering shops. crowds and public places. or traveling alone in trains. buses or planes
Social phobia
(F40.1)
Fear of scrutiny by other people leading to avoidance of social situations. More pervasive social phobias are usually associated with low self-esteem and fear of criticism. They may present as a complaint of blushing. hand tremor. nausea. or urgency of micturition
Specific phobia
(F40.2)
Fear and/or avoidance of certain objects or situations._Types: animals. natural events (thunder. etc.). blood. injections. injury. or other triggering situations or objects
Selective mutism
(F94.0)
Language competence in some situations. but failure to speak in other (definable) situations
Separation anxiety
(F93.0)
Unrealistic and persistent worry about adverse events that might befall the patient‘s most significant others. or about the potential loss of same

Genetic factors
The heritability of anxiety disorders, i.e., the degree of participation of genetic factors in their development, lies in the range of 30–67%, with the remainder of the variation accounted for by individual negative environmental factors, such as life events

Treatment
Anxiety disorders can be treated with psychotherapy, drugs, or both.

Psychotherapy
Cognitive behavioral therapy is the tpe of psychotherapy of first choice in the treatment of the anxiety disorders.

The drugs with the highest level of supporting evidence are the selective serotonin reuptake inhibitors (SSRI) and SNRI, as well as the calcium-channel modulator pregabalin for generalized anxiety disorder (table 2).

Table 2
The pharmacotherapy of anxiety disorders. according to the German guidelines

Evidence level/
recommendation grade *1
Active substance class Drug Daily dose
Social phobia
Ia; A SSRI Escitalopram 10–20 mg
Paroxetine 20–50 mg
Sertraline 50–150 mg
Ia; A SNRI Venlafaxine 75–225 mg
CCP MAO inhibitors Moclobemide 300–600 mg
Panic disorder
Ia; A SSRI Citalopram 20–40 mg
Escitalopram 10–20 mg
Paroxetine 20–50 mg
Sertraline 50–150 mg
Ia; A SNRI Venlafaxine 75–225 mg
Ia; B TCA Clomipramine 75–250 mg
Generalized anxiety disorder
Ia; A SSRI Escitalopram 10–20 mg
Paroxetine 20–50 mg
Ia; A SNRI Venlafaxine 75–225 mg
Duloxetine 60–120 mg
Ia; B*2 Anticonvulsants Pregabalin 150–600 mg
Ib; 0 Anxiolytic drugs (tricyclic) Opipramol 50–300 mg
Ib; 0 Azapirones Buspirone 15–60 mg

Treatment with psychoactive drugs
The drugs most commonly used are the selective serotonin reuptake inhibitors (SSRI) and the selective noradrenaline ruptake inhibitors (SNRI).

The off-label use of drugs that have not been approved for the treatment of anxiety disorders

  • The atypical antipsychotic drug quetiapine has not been approved for the treatment of anxiety disorders. Still, a meta-analysis of three randomized, double-blind, placebo-controlled trials of this drug for the treatment of generalized anxiety disorder (GAD), given for a period of 10 weeks in each trial, showed that it is significantly more effective than placebo in the 50 to 300 mg/day dose range, albeit with an unfavorable profile of metabolic side effects.
  • Agomelatine acts as an agonist at melatonin MT1- and MT2-receptors and as an antagonist at the serotonin 2C receptor. Multiple studies published from 2008 onward have shown it to be well tolerated and highly effective against GAD in the 25–50 mg/day dose range, yet this drug has not been approved for the treatment of anxiety disorders either.
  • Silexan, a patented active substance derived from lavender oil, has been approved since 2009 in Germany for the treatment of subsyndromal anxiety and tension states at a daily dose of 80 mg, but not for the treatment of anxiety disorders. Nonetheless, randomized controlled trials (RCTs) have shown its effectiveness against GAD and so-called mixed anxiety and depression.

Is it even possible to be anxious without also being depressed?

Fear is literally the most uncomfortable emotion, so feeling fear in every moment is pure horror. I believe this is what drives people to suicide, not depression. Depression provides the direction (down) while anxiety stomps on the gas and keeps it floored, until… (that’s the fear).

Benzodiazepines
Benzodiazepines are approved in Germany for the acute treatment of “states of tension, excitation, and anxiety.” Nonetheless, the German guidelines on the treatment of anxiety disorders discuss the use of benzodiazepines for this purpose in decidedly critical terms because of their marked side effects.

The essential components of the treatment of panic disorder with agoraphobia are:

  • Counseling
  • Psycho-education about anxiety and anxiety disorders
  • Anxiety-confronting exercises in real-life situations
  • Self-help manuals

While cognitive behavioral therapy and psychopharmacotherapy are considered first-line treatments for anxiety disorders, further treatment strategies have been studied and applied in routine clinical practice in recent years, such as the following:

  • Metacognitive therapy
  • Acceptance and commitment therapy (ACT) 
  • Mindfulness-based techniques 
  • Noninvasive stimulation techniques, such as repetitive transcranial magnetic stimulation (rTMS) or transcranial direct-current stimulation (tDCS)
  • Physical activity and exercise

Prevention

The development and assessment of preventive measures against anxiety disorders should have a high priority in view of

  • these disorders’ high prevalence and chronicity,
  • the severity of the suffering that they cause, 
  • their high socioeconomic costs, and
  • their role as precursors of depression and substance-abuse disorders and as complicating factors in somatic disease

Universal preventive measures, applied regardless of the risk status of the individual, might prevent many cases of clinically manifest anxiety disorders, even if their individual effects were not very strong; yet their application to large, unselected target groups would be both very expensive and very labor-intensive.

Targeted prevention in persons who already display subclinical symptoms has been shown to significantly lessen the rate of development of clinically relevant anxiety disorders and is thus probably the most cost-effective primary measure.

2 thoughts on “The Diagnosis and Treatment of Anxiety Disorders

  1. Kathy C

    This is kind of terrifying. There is nothing new here or even remotely effective. Pharma marketers are really clever when it comes to marketing these drugs, often off label or one version of marketing for low income clinics and another for higher end practices. Pushing Lyrica for anxiety, is just another one of these misleading marketing and deceptive practices. Usually the only metric is that practitioners are willing to prescribe it, after all it is not that toxic, and the side effects from the anti psychotics are a lot worse.

    They are Gaslighting us all. Perhaps the reason they have not come up with any real answers, is that the current practices are profitable enough. For Lyrica they did not have to go through all of those pesky trials and expensive RCTs all they had to to is market it off label. It is really clear that researchers chose to ignore why people are anxious, studying that would not be as profitable or bring in pharma research dollars. It is really clear that pain can trigger anxiety, but they chose not to study that either.

    Like everything else, that fact that they treat anything with some drug, does not mean that it is effective. We can’t expect any of the providers treating any of these conditions to be able to parse through the deceptive marketing. The abject refusal to acknowledge that pain, stressors, trauma, economic, and environmental factors can cause anxiety, has widespread repercussions. In the meantime people will turn to alcohol, drugs, and suicide to relive the symptoms. “Treating” anxiety with no metric for improvement is really lucrative.

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  2. Kathy C

    I should also mention that comparing European studies and applying them to the American system is not really equal. Here in the US, unlike other developed nations, many health conditions are allowed to fester and become much worse. In America a lot of these data points are not collected, and most diagnosis have more to do with billing and reimbursement than actual conditions. In Europe people would have less anxiety over healthcare, less stigma, and lowered economic stressors. Europeans would have a closer trust based relationship with their health providers. There are also lower rates of child abuse, and otehr factors that lead to anxiety. In Europe people don’t postpone healthcare for years, because they can’t pay for it, and physicians are less likely to prescribe a medication before looking at environmental factors.

    I suspect the Europeans are catching on, they used to trust the FDA, and American research, but the tide is turning. They realize that the profit driven model, and regulatory capture makes all research from the US suspect.

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