9.4 Treatments for Anxiety

Anxiety disorders are generally treated with psychotherapy, medication, or a combination of both treatments.^[1] Support groups, coping strategies, and psychoeducation can also help individuals manage their anxiety.

Psychotherapy

Psychotherapy or “talk therapy” can help people with anxiety disorders. To be effective, psychotherapy must be directed at the person’s specific anxieties and tailored to their needs. Examples of psychotherapy include cognitive behavioral therapy (CBT) and dialectal behavior therapy (DBT). CBT teaches people different ways of thinking, behaving, and reacting to anxiety-producing situations and fearful objects. It can also help people learn and practice social skills, which is vital for treating social anxiety disorder. DBT assists individuals to develop distress tolerance skills and emotional regulation skills in managing their anxiety. CBT and DBT can be conducted individually or with a group of people who have similar difficulties.^[2] Read more about CBT and DBT in the “Depressive Disorders” chapter.

Exposure therapy may be used alone or with CBT to treat social anxiety disorder. Exposure therapy focuses on confronting the fears underlying an anxiety disorder to help people engage in activities they have been avoiding. Exposure therapy can be used in combination with relaxation exercises and/or imagery.^[3] A similar therapy that is particularly helpful with phobias is systematic desensitization. Systematic desensitization is a graduated exposure therapy conducted at a very slow pace used in combination with relaxation techniques and imagery.^[4]

Medications

Medications do not cure anxiety disorders but are used to help relieve symptoms of anxiety, panic attacks, extreme fear, and worry. The most common classes of medications used to combat anxiety disorders are antianxiety drugs (such as benzodiazepines), antidepressants, and beta-blockers.^[5]

Benzodiazepines

Benzodiazepines are prescribed for their immediate effect in relieving anxiety. For long-term use, benzodiazepines are considered a second-line treatment for anxiety (with antidepressants or buspirone considered first-line treatment), as well as an “as-needed” treatment for any distressing flare-ups of symptoms. However, people can build up a tolerance if taken over a long period of time, and they may need higher and higher doses to get the same effect. Benzodiazepines are a Schedule IV controlled substance because they have a potential for misuse and can cause dependence. To avoid these problems, benzodiazepines are typically prescribed for short periods of time, especially for people who have a history of substance use disorders. Short-acting benzodiazepines (such as lorazepam) and beta-blockers are used to treat the short-term symptoms of anxiety. Lorazepam is available for oral, intramuscular, or intravenous routes of administration.^[6],[7]

If people suddenly stop taking benzodiazepines after taking them for a long period of time, they may have withdrawal symptoms, or their anxiety may return. Withdrawal symptoms include sleep disturbances, irritability, increased tension and anxiety, hand tremors, sweating, difficulty concentrating, nausea and vomiting, weight loss, palpitations, headache, muscular pain, and perceptual changes.^[8] Therefore, benzodiazepines should be tapered off slowly.^[9]

Black Box Warning

A Black Box Warning states that concurrent use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. The use of benzodiazepines exposes users to risks of misuse, substance use disorder, and addiction. Misuse of benzodiazepines commonly involves concomitant use of other medications, alcohol, and/or illicit substances, which is associated with an increased frequency of serious adverse outcomes. Additionally, the continued use of benzodiazepines may lead to clinically significant physical dependence. The risks of dependence and withdrawal increase with longer treatment duration and higher daily doses, and abrupt discontinuation or rapid dosage reduction may precipitate life-threatening withdrawal reactions. To reduce the risk of withdrawal reactions, a gradual taper should be used to stop or reduce the dosage.^[10]

Adverse/Side Effects

Children and older adults are more susceptible to the sedative and respiratory depressive effects of lorazepam and may experience paradoxical reactions such as tremors, agitation, or visual hallucinations. Debilitated clients should be monitored frequently and have their dosage adjusted carefully according to their response; the initial dosage should not exceed 2 mg. Dosage for clients with severe hepatic insufficiency should be adjusted carefully according to client response. Benzodiazepines may cause fetal harm when administered to pregnant women.^[11]

Overdosage

Overdosage of benzodiazepines is manifested by varying degrees of central nervous system depression, ranging from drowsiness to coma. If overdose occurs, call 911 or the rapid response team during inpatient care. Treatment of overdosage is mainly supportive until the drug is eliminated from the body. Vital signs and fluid balance should be carefully monitored in conjunction with close observation of the client. An adequate airway should be maintained; intubation and mechanical ventilation may be required. The benzodiazepine antagonist flumazenil may be used to manage benzodiazepine overdose. There is a risk of seizure in association with flumazenil treatment, particularly in chronic users of benzodiazepines.

Patient Education

Clients should be cautioned that driving a motor vehicle, operating machinery, or engaging in hazardous or other activities requiring attention and coordination should be delayed for 24 to 48 hours following administration of benzodiazepines or until the effects of the drug, such as drowsiness, have subsided. Alcoholic beverages should not be consumed for at least 24 to 48 hours after receiving lorazepam due to the additive effects on central nervous system depression. Hospitalized patients should be advised that benzodiazepines increase fall risk, and getting out of bed unassisted may result in falling and potential injury if undertaken within eight hours of taking lorazepam.

Antidepressants

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are commonly used as first-line treatments for anxiety. Less commonly used treatments for anxiety disorders are older classes of antidepressants, such as tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs).^[12] Read more about antidepressants in the “Depressive Disorders” chapter.

Buspirone

Buspirone is a non-benzodiazepine medication indicated for the treatment of chronic anxiety. It is included in the class of medications called anxiolytics, but it is not chemically related to benzodiazepines, barbiturates, or other sedatives. Buspirone should not be taken concurrently with a monoamine oxidase inhibitor (MAOI) due to the risk of fatal side effects. It can also cause serotonin syndrome if used in combination with MAOIs, SSRIs, or SNRIs.^[13]

Buspirone increases serotonin and dopamine levels in the brain. In contrast to benzodiazepines, buspirone must be taken every day for a few weeks to reach its full effect; it is not useful on an “as-needed” basis. A common side effect of buspirone is dizziness.^[14]

Beta-Blockers

Although beta-blockers are typically used to treat high blood pressure and other cardiac conditions, they can also be used to help relieve the physical symptoms of anxiety, such as rapid heartbeat, shaking, trembling, and flushing. These medications, when taken for a short period of time, can help people keep their physical symptoms under control. Beta-blockers can also be used “as needed” to reduce acute anxiety or as a preventive intervention for predictable forms of performance anxieties.^[15] For example, some students who experience severe test anxiety that impairs their exam performance may take prescribed beta-blockers before their exams.

Common side effects of beta-blockers are fatigue, hypotension, dizziness, weakness, and cold hands. Beta-blockers are typically avoided in clients with asthma or diabetes.^[16]

Hydroxyzine

Hydroxyzine may be prescribed to alleviate anxiety for individuals for whom benzodiazepines are not appropriate. It causes sedation, so it must be used cautiously if used in combination with opioids or barbiturates.^[17]

Support Groups

Support groups can be helpful for individuals experiencing anxiety disorders by sharing their problems and achievements with others experiencing similar symptoms. Talking with a trusted family member, friend, chaplain, or clergy member can also provide support.

Stress Management and Coping Strategies

Stress management techniques and coping strategies can help people with anxiety disorders calm themselves and enhance the effects of therapy. Research suggests that aerobic exercise can help some people manage their anxiety. Read more about stress management and coping strategies in the “Stress, Coping, and Crisis Intervention” chapter.

Psychoeducation

Clients should be educated about symptoms of their diagnosed anxiety disorder and techniques to manage it with psychotherapy and medications. For some individuals, even being aware that something is a symptom of anxiety, naming it, and connecting it to anxiety can help reduce the intensity of the anxiety. If antidepressants are prescribed, they can take several weeks to reach their optimal effectiveness, so it is important to teach clients to give the medication appropriate time before reaching a conclusion about its effectiveness. They should be advised to not stop taking them suddenly or without talking to their prescribing provider. Antidepressants should be tapered off slowly to safely decrease the dose because stopping them abruptly can cause withdrawal symptoms.

Certain substances such as caffeine, some over-the-counter cold medicines, illicit drugs, and herbal supplements may aggravate the symptoms of anxiety disorders or interact with prescribed medications. Clients should be advised to avoid these substances.