Pharmacologic TreatmentsMatthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C.E. Zupanick, Psy.D. and Mark Dombeck, Ph.D.The use of psychiatric medications for anxiety disorders is somewhat controversial. Some clinicians would argue that medications do not treat the disorder itself, but instead only mask the symptoms. If medication is discontinued, the symptoms will generally return if psychotherapy has not been provided. However, other clinicians believe that anxiety symptoms originate from faulty brain chemistry and thus conclude that medication does indeed treat the disorder. Further study is required before this debate is resolved. In the meanwhile, medication is frequently offered as an adjunct to psychotherapy.
Psychiatric medications fall into six main categories: 1) antidepressants, 2) stimulants, 3) antipsychotics, 4) mood stabilizers, 5) anxiolytics, and 6) depressants. Anxiety disorders are most commonly treated with antidepressants and anxiolytics. Each of these medication classes impact different neurotransmitters. Neurotransmitters serve as chemical messengers in the brain and are thought to play a key role in many psychiatric disorders.
The so-called "anti-depressant" medications target two neurotransmitters, serotonin and norepinephrine, which are believed to be involved in both mood disorders (such as depression) and anxiety disorders. This makes a great deal of sense because depression and anxiety commonly co-occur and are thought to share a similar etiology.
There are two groups of anti-depressant medications that are used to treat anxiety disorders. It generally takes about two weeks for these drugs become effective. The first group is called Selective Serotonin Reuptake Inhibitors (SSRIs). SSRIs are believed to relieve the symptoms of depression and anxiety by blocking (inhibiting) the re-absorption (re-uptake) of serotonin in the brain's receptor cells. This blocking action means there is more serotonin available; therefore, SSRIs increase serotonin. The SSRIs include drugs such as: Luvox®, Zoloft®, Lexapro®, Celexa®, Prozac®, and Paxil®. The second group of anti-depressant medications is called Serotonin Norepinephrine Reuptake Inhibitors (SNRIs). The SNRIs block the re-uptake of both serotonin and norepinephrine, thereby increasing the levels of both serotonin and norepinephrine in the brain. These medications are considered more broad-spectrum medications. Since anxiety disorders have been associated with a dysregulation of both serotonin and norepinephrine, these medications effectively target the symptoms of anxiety. Some commonly prescribed SNRIs include: Effexor®, Pristiq®, and Cymbalta®. Both SSRIs and SNRIs are not considered addicting, nor are they believed to create drug dependence. However, some people have reported difficulty when discontinuing these drugs.
The second class of psychiatric medications, which are used to treat anxiety disorders, is the anxiolytic (or anti-anxiety) drugs. Benzodiazepines are a commonly prescribed type of anxiolytic used to treat the physical symptoms of anxiety. Benzodiazepines offer short-term, immediate relief of anxiety symptoms but can result in drug dependence. Therefore, these drugs are often prescribed cautiously, and for a shorter duration of time; usually until the anti-depressants and/or therapy have a chance to become effective. These drugs work by increasing the action of gamma aminobutyric acid (GABA) in the brain. Bio GABA is a naturally occurring brain chemical that slows down brain activity and results in a feeling of calm and relaxation. Commonly prescribed benzodiazepine drugs are: Xanax®, Librium®, Klonopin®, Valium®, and Ativan®. Another anxiolytic, Buspar®, is a non-addicting and non-sedating anxiolytic that targets the same symptoms as benzodiazepines. Like the antidepressants drugs, Buspar® takes up to 2 weeks to take effect, whereas the benzodiazepines take effect immediately. Buspar is effective for GAD and can be used as an adjunct to the antidepressants.
There are both advantages and disadvantages to using psychiatric medications. For people whose anxiety symptoms make it difficult for them to attend and participate in therapy, or to practice therapy exercises, medications can be very helpful as they can reduce the symptoms which interfere with treatment. Medications can also be beneficial when a person has a co-occurring disorder that interferes with treatment, such as depression. For example, a depressed person with Obsessive-Compulsive Disorder (OCD) who cannot get out of bed to attend treatment, may first need his/her depression alleviated before addressing the OCD. Medications can also help people to better tolerate the more difficult and anxiety-provoking exposure and response prevention (ERP) exercises.
While medications have many advantages, there are also some disadvantages. Although some of the newer medications have fewer side-effects than earlier drugs, some people continue to experience uncomfortable side-effects from medication. Others do not respond as expected to medications, experiencing minimal benefit. The potential for drug dependence, and overuse with the benzodiazepines is also a concern. Sometimes drugs can actually interfere with the therapeutic process. From a theoretical perspective, exposure and response prevention (ERP) works most effectively when people fully confront their anxiety so that habituation and extinction can occur. The excessive use of anti-anxiety medications interferes with that process by over-sedating therapy participants so they are unable to experience anxiety during ERP sessions. Most cognitive-behavioral therapists recommend a conservative use of psychiatric medications and suggest that recovering persons consider taking medication when cognitive-behavioral therapy is leading to less than anticipated improvement; or, when symptoms are severe enough to interfere with many areas of daily life.
People with anxiety disorders are encouraged to discuss medications, and make well-informed decisions with the help of a qualified, healthcare professional. Psychiatrists, psychopharmacologists, neurologists, and psychiatric nurse practitioners are all good choices. When a person is participating in therapy with a non-prescribing practitioner such as a psychologist or social worker, they should discuss their interest in medication with these providers as well. As mentioned, some therapies are less effective when medications are used. However, in general, the combination of medication and cognitive-behavioral therapy complement each other quite well, and have proven to be successful in improving people's symptoms and the quality of their lives.
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