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July 27, 2006

By Leigh Woosley

Editor's note: This is the last of five articles looking at the complex problem of anxiety disorders, the most prevalent mental health disease in America.

A cure for anxiety disorders does not exist.

It's not like a headache, easily treated with an aspirin.

What might temper one person's anxiety won't always do so for someone else.

Treatment is oftentimes guesswork, a juggling act of medication, psychotherapy or both.

What works best is contested by professionals, especially since recent studies of the brain show that both medicine and therapy change brain patterns that cause anxiety and fear.

Right now, the remedy, short of a miracle, requires mental footwork from anybody dealing with the disease.

But you won't fight anxiety disorders on a psychiatrist's couch dredging up the past.

Treatment most often addresses the present – relieving the extreme fear and worry that 40 million Americans with anxiety disorders fight each day.

"In the beginning, it doesn't matter if your mother was a good mother or not. I don't care," said Charles Cobb, a local psychiatrist who specializes in the treatment of anxiety disorders.

"It's not really about your past. It's about learning to deal with this (anxiety) right now. If we get you back in control of your anxiety, and you're coming back into life and there are other issues that need to be dealt with, then we'll deal with them. But for right now, it doesn't matter."

Out of the Trenches

A key factor to relieve anxiety is thought control. People with anxiety disorders have disturbing thoughts, as everyone does, but unlike others, they can't shake it. It replays in their brain and creates anxiety, fear, even terror.

"It's like driving down a muddy road," said Cynthia Naff, a local licensed professional counselor who treats anxiety disorders. "You get in this rut in the road, and the more you drive in the ruts, the deeper it gets. It's self-enforcing. You have to learn to not drive in the ruts."

Various types of medicine and therapy help people avoid and emerge from the trenches.

"Both approaches can be effective for most (anxiety) disorders," reports the National Institute of Mental Health. "The choice of one or the other or both depends on the patient's and the doctor's preferences, and also on the particular anxiety disorder."

The most common type of therapy for anxiety disorders is cognitive-behavioral therapy, which teaches people to change their thinking patterns and their response to anxiety-provoking situations.

Medicine is a less complicated but more controversial approach. Better drugs with fewer side effects are proving effective for anxiety disorders, but pharmaceutical treatment has been attacked, most recently and publicly by Tom Cruise and his public diatribe on psychotropic drugs.

But regardless of opinion, medicine helps many deal with anxiety.

When Kevin Gaylor was diagnosed with obsessive compulsive disorder last fall, he began taking Prozac, an anti-depressant in the family of selective serotonin reuptake inhibitors or SSRIs.

This type of drug, one commonly prescribed for anxiety disorders, raises the brain's level of the neurotransmitter called serotonin, which is needed to metabolize stress hormones. Low levels of serotonin could cause anxiety disorders.

Many are skeptical of prescription drugs for mental disorders. Medicine you take for a backache is one thing. Prozac and the like address the brain and thoughts -- people are generally not as comfortable with that.

Including Gaylor, who feared the drug would change his personality, dull his quirky wit and sarcastic humor.

"But what I've discovered is that I'm more me than I've ever been in my life," he said. "In the first three days (of taking the medicine) I felt better. I knew I was better."

His anxiety slightly eased, and the compulsive counting he does to deflect intrusive thoughts lessened. This is how SSRIs effectively break down and interrupt the intrusive thought patterns that fuel anxiety, Naff said.

No Magic Pill

SSRIs and other antidepressants aren't addictive, but that's not the case with benzodiazepines, a completely different type of drug used for anxiety disorders. These are drugs like Valium and Xanax, and they relieve symptoms of anxiety quickly with few side effects except for drowsiness.

Benzodiazepines are prescribed to use when anxiety is very high, like in the beginning stages of a panic attack, because they immediately reduce the feeling. They are not to be taken regularly for long periods of time, but SSRIs are.

"I caution people that if they take this medication (benzodiazepines) every time they feel a little tinge of anxiety, they are going to get addicted," Cobb said. "So I watch for that very carefully, about how much they are using it and how much they are learning to get through it on their own."

Mental dependency on medication is another concern for some professionals who treat anxiety disorders, especially because advertisements for anti-anxiety drugs – addictive or not – are plastered in mainstream media by pharmaceutical companies that make them.

Such advertising is a good thing because it increases awareness of anxiety disorders, but "in some ways, it may create a market for medications when medication is not necessarily the best treatment," said Dr. Jack Gorman, former president of McLean Hospital, a psychiatric facility at Harvard Medical School.

"The concern that many of us have is that it's creating the impression in the public's mind that the only way to treat this (anxiety disorders) is medication," he said. "Sometimes medication is very useful and helpful, and there are people who should be on it, but there is a concern that people think about medication too quickly."

Then there's a group of people who want to avoid medication completely and opt for therapy.

"Most patients prefer a non-drug treatment for whatever reason – survey after survey shows that," said David Barlow, psychologist and director of the Center for Anxiety Disorders and Related Disorders at Boston University. "Then there are some patients who say, 'Look, I don't want to talk about anything, just give me a pill.' "

A Question of Choice

Studies find medication and therapy are almost equally effective.

"Every time a serious attempt is made at comparing them for almost all disorders, it ends in a dead heat," Gorman said. "Patients in psychotherapy don't get the side effects from pharmaceutical therapy, for the most part, and there's evidence that psychotherapy is longer-lasting and more durable."

People who stop taking medication lose the benefits of it, but when people stop therapy, they carry with them lessons learned from it.

"Medicine has been very helpful to give people a foundation and let them know they can get better," Cobb said. "But they still have to learn how to handle those anxious situations so they're not just taking medication to get through it."

Treatment for anxiety disorders is often a combination of medicine and therapy, but the mixture isn't any more effective than one of them alone, Barlow said.

"There's no reason to do it because it's much more costly," he said.

Many patients choose therapy, which for anxiety disorders addresses how one deals with fear and anxiety. They must work with his or her brain and body because anxiety starts in the mind and manifests in the body.

Confronting the mind means addressing the irrational thoughts that spark and then escalate the anxiety.

"You replace the thoughts instead of trying to discuss why this is irrational or illogical," said Naff, the local counselor. "We just replace the thoughts with some better ones and try turning off the anxious thoughts. It's hard at first because the thoughts are like watching a clothes dryer go round and round."

The thoughts don't stop, and that's what stirs the anxiety.

For example, a patient may worry he'll have a panic attack in public. He imagines in an unending loop of thought all the terrible things that could happen: He'll lose it. People will think he's crazy. The attack won't stop.

So he stays home, day in and day out.

Therapy teaches the patient to take control of those thoughts, to realize that even if he did have a panic attack in a crowded store, there are plenty of ways to maintain control. He can sit until it passes. He can go out to his car. He can ask for help.

The patient finally goes to the grocery store. Maybe he just sits in the parking lot at first, dealing with the anxiety that will certainly come.

It's exposure to the anxiety-producing event and the resulting fear that breaks the cycle. Eventually, going out in public is less daunting, although the process could take weeks or months.

This is the foundation of exposure therapy, which has been proven to reduce anxiety by making the patient face what he or she is afraid of. That's the cognitive part of therapy.

"The thinking part of it, decatastrophizing the catastrophic thoughts," said Jane Vantine, a therapist and director of the YWCA of Tulsa's Women's Resource Center, where she specializes in the treatment of anxiety disorders.

"It's really lots and lots of repetition. Many clients I work with have just done the same things over and over for so long. It's habit, and even though they feel awful doing it, the habit is familiar."

Cognitive-behavioral therapy also teaches how to control anxiety when it comes up. Relaxation exercises, like deep breathing, effectively calm an anxious body because anxiety has a major physical component. Images of the brain prove this.

Meditation and physical exercise also can help manage anxiety and are among the tactics Vantine teaches her clients.

"It's not the kind of therapy where we talk for an hour and then you go home and come back next week," she said.

"I tell my clients you have to be willing to work, or it's not going to make a difference. There are tools to deal with the physical effect of anxiety, tools to deal with the thinking and tools to deal with the behavior."

These tools are no different from real ones. A hammer is useless in the garage but highly helpful when picked up and used.

Regardless of what's in the toolbox – medicine, therapy or both – relief from an anxiety disorder requires work from those coping with it.

Scientists are improving medication. Therapists are developing better methods. These treatments alone are effective, but with the strength and tenacity found inside every person suffering, they can overpower almost any anxiety disorder.

It's the closest thing to a cure, which many believe will one day come.