Medication or Therapy for Anxiety?

As a psychiatrist, I can tell you that anxiety is the most common psychiatric symptom that makes patients seek professional help. It is also well known that psychiatrists and therapists treat anxiety using interventions such as medication and therapy, and that, when combined, these usually lead to the best outcomes. What appears to be less well understood is what patients can learn to do to help themselves.

 

It’s human to want relief from the sheer discomfort that anxiety causes such as generalized agitation, excessive worrying, palpitations or panic. What proves more challenging is recognizing how to manage anxiety as a lifelong disorder. Yes, you read that correctly: as a lifelong disorder. That does not mean symptoms will never go away. It just means that there will be relapses and remissions. Or to put it more simply, times when one experiences symptoms and times when one does not.

 

The good news is that anxiety does get better with age. This is why I tend to see far fewer anxious patients who present for the first time above 50 years old than those in adolescence and early adulthood. Perhaps because there really is a learning curve with it, and that how we cope does indeed influence how it pans out.

 

The idea behind treatment is to make the bumps less bumpy. I educate patients that anxiety is hard-wired into all human beings’ central nervous system biology to help ward off real life threats. Thus, it’s not that anxiety itself that is the problem, it’s just how excessive it can become in situations that most would not react that way like going out of the house, entering an elevator, or putting up a hand in class.

 

Here’s where the concept of soothing comes in. Ask any anxious patient, and they will tell you how raw and intense their anxiety can feel like. They will also tell you how discomforted and victimized they feel at the time they experience it, as if they are almost throttled by it.  That’s where both medication and self-soothing play a part.

 

Let’s talk about medication’s role first. There are certainly medications that can reduce anxiety and even rapidly so. That would be the equivalent of Tylenol for a headache. They are called symptomatic treatments. However, just like Tylenol may make the headache go away temporarily, it will not treat the underlying cause – a so called top-down approach. Some “as needed” medications, or PRN as physicians refer to it, for anxiety cause physical dependence while others do not. There are the long-term treatments such as Prozac®, Zoloft®, Celexa®, Lexapro®, Effexor® etc. These may take several weeks to take proper effect and need to be dosed up over time. Not exactly the answer many anxious patients so urgently seek. More on this later.

 

So, what about the “as needed” medications? Will they suffice when it matters? The problem paradoxically lies in the fact that if medication does indeed wipe away all the anxiety, then that makes the person more beholden to that medication and even more victimized by their own anxiety, seeking something external to magic wand it away and rescue them entirely. And what happens if they inadvertently run out of the medication? That’s the cruel irony about life. It makes you feel most vulnerable when you are at your most vulnerable: up the creek, and without the paddle you so badly needed. This is what physicians refer to when they use the term psychological dependence.

 

So, am I saying deal with it? No, I am not. There is a more subtle point I am making here: to draw attention to a concept called distress tolerance. It means the learned ability to tolerate lower levels distress without acting upon it. That means having a higher threshold before reaching out for the PRN medication, for example. Note that I am not saying that no PRN medications are needed. I am instead arguing for lower doses that reduce, but do not eliminate, anxiety. But why? Because psychiatric research has repeatedly proven that the ability to tolerate lower levels of distress is the key to a good prognosis in anxiety disorders. And I believe it does so because it is, in and of itself, an intervention of sorts.

 

But how can the ability to tolerate anxiety actually be a tangible intervention? Or is it more of an attitudinal shift? The point is that how we think about anxiety can influence how much it upticks and how powerfully we believe it dominates our consciousness.

 

Going back to the throttling example, most anxious patients will tend to give in to the controlling aspect of their anxiety that makes them so fearful that they avoid the feared action. It is such avoidance behaviors that paradoxically reinforce the very anxiety that they fear. That is why the fear looms even larger when we avoid facing it. This has been proven repeatedly over decades. Hence, facing anxiety, whether abruptly (flooding) or gradually (graded exposure or systematic desensitization) is the key attitudinal shift required of the patient.

 

Of course, this part requires the help of professional therapy to practice exercises. Nonetheless, the buy-in of the patient is behind such a shift in attitude. When it comes to treatment, attitude is everything. This is not easy to develop, but with patience, practice, and the support and care of one’s psychiatrist and therapist, it is possible. Think of it as fashioning a can-do mentality, one that gradually eclipses and eventually supersedes the victimhood that chronic anxiety tends to box us into. Like watering an acorn that grows into the oak tree. Or as Voltaire once put it, “cultivating one’s own garden.” This means learning to love oneself: a deep internal shift in one’s attitude to the self, that cultivates self-care. Psychiatrists and therapists are trained in this respect to model what is termed unconditional positive regard, helping to counter what previous figures in a patient’s life may not have adequately demonstrated, with such inner warmth and nurturance never somehow being instilled into the patient’s consciousness.

 

Have I de-emphasized medication’s role? I  hope not. I just want to emphasize their rightful role. I spoke about as-needed medications, as well as the longer-term treatments. I discuss these in more detail in my other blogs on this site. When I prescribe long-term medications to my anxious patients, I first educate them about how they are all designed to enhance the effectiveness of the calming neurotransmitter in the brain called serotonin.  It is believed to be lower in anxious patients who have almost invariably experienced psychological trauma in their histories.

 

I am also candid about realistic expectations for medications. That they are not supposed to eliminate all anxiety. Medication merely eases it and makes it more tolerable, in that a) they can practice self soothing, b) experience a modicum of relief, and c) be functional enough to be able to get through their day more productively and meaningfully.

 

The interesting part is that as patients become more confident in their self-soothing/coping skills, I notice two things: 1) they no longer feel victimized and experience feeling increasingly empowered to manage their anxiety when it occurs and 2) they want to lower their dose of medication and eventually to taper it. This usually sparks a discussion about whether their amplified anxiety is a lifelong tendency that may always need a biological tweak with medication, or whether therapy has helped re-wire their neuronal circuitry such that they do not need medication in the long term.

 

I go with my patient’s lead and am with them to revisit this decision whenever the need arises. Sometimes a patient’s own life experiences and their success in navigating their associated anxious fears can help with this answer. Ongoing support, structure, refraining from drugs and alcohol and good sleep habits are always helpful in any case.

 

I hope the above helps to deconstruct what anxiety feels like for many and how it can be successfully addressed. No matter all the professional help, advice and interventions available, I have found that a self-loving attitude is a potent tool to help patients truly manage their own anxiety.