Anxiety

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Chapter 4 Anxiety

With contribution from Dr Katherine Sevar

Introduction

Anxiety disorders are amongst the most common disorders suffered by the Australian population, with approximately 7% of men and 12% of women affected each year.¹

Anxiety disorders are classically under-reported to GPs by the community, with on average only one-fifth of people with anxiety as their primary complaint seeking professional help in 2002.² The reasons cited for this include preferring to individually manage the condition and a desire to pursue self-help strategies.³ Given this finding, it may come as a surprise that anxiety is actually one of the commonest presentations to GPs — when a sub-study of BEACH (Bettering the Evaluation and Care of Health) surveyed a random sample of 379 GPs they discovered that the 3 conditions placing the greatest demand on an individual practitioner’s time were anxiety, depression and back pain.⁴ Recent statistics suggest 1–2% of the adult population suffer panic disorders — common risk factors include female gender, low socioeconomic status and anxious childhood temperament — and this is associated with significant suicide risk, all-cause mortality and cardiovascular disease.⁵

Sub-classifications of anxiety disorders

There are sub-classifications of anxiety disorders according to DSM-IV criteria, which include generalised anxiety disorder (GAD), panic disorder, agoraphobia, obsessive compulsive disorder (OCD), social anxiety disorder (SAD), and post-traumatic stress disorder (PTSD). There is significant co-morbidity with anxiety disorders and depression and substance abuse.¹

Generalised anxiety disorder (GAD)

GAD is commonly encountered in general practice and infrequently referred for specialist management. It may be experienced by 5% of the general population at some point in their lives and affects both sexes equally. It is diagnosable when the preoccupation with worry about the present, past and future, begins to interfere with day-to-day functioning and is characterised by hyper-arousal, insomnia, physical symptoms such as chest tightness, over-breathing, tension headache and diarrhoea. Individuals may abuse drugs or alcohol to manage their symptoms. GAD will benefit from psychological intervention with cognitive behaviour therapy (CBT) being the most commonly employed technique. Psychological, behavioural and lifestyle approaches are helpful for alleviating anxiety. Anti-anxiety or antidepressant medication may also be necessary.

Panic disorder and agoraphobia

Panic attacks can be spontaneous or can occur in relation to a specific stimulus. They include somatic features and cognitive features. The somatic features may include palpitations, chest pain, a feeling of choking, nausea, sweating, dizziness. The cognitive features may include acute fear of dying, losing control, going mad and a need to escape from the current situation and there can also a be a feeling of depersonalisation or non-realisation. In up to 90% of cases, these attacks lead to an avoidance of situations where escape may not be possible — agoraphobia.⁶ Common associations occur with depression, substance abuse and interpersonal difficulties. Panic disorder is currently treated with anti-anxiety medication and a mix of CBT and exposure therapy. Breathing techniques for the short-term management of panic attacks are advocated and benzodiazepines should only be used in the short-term.

Obsessive compulsive disorder (OCD)

Obsessions can be intrusive thoughts, images or impulses which create anxiety in an individual as they feel unable to control how, when or where these obsessive thoughts may occur. Compulsive behaviour develops as an attempt to relieve the anxiety created by the obsession. Compulsions can include extremely ritualistic behaviours and a need to follow a set routine. Although the compulsions initially relieve anxiety they will over time relieve less anxiety, resulting in them becoming more elaborate and taking up more of the individual’s time. OCD becomes a problem when these behaviours interfere with ordinary life. Current treatment strategies include medication with a selective serotonin re-uptake inhibitor (SSRI) or clomipramine (a serotonergic tricyclic antidepressant) in combination with CBT.

Social anxiety disorder (SAD)

Individuals with SAD and/or social phobia describe experiencing extreme anxiety in social scenarios due to a fear they will embarrass themselves and often manifest physical signs of this anxiety by blushing and stuttering if asked to speak in public. They may become avoidant of social situations. They will have typically experienced these problems since childhood and adolescence. Psychological therapies focusing on assertiveness training, CBT, and graded exposure to overcome avoidance behaviour are used in the treatment of SAD and/or social phobia. Pharmacotherapy with SSRIs would be indicated in concurrent depression.

Post-traumatic stress disorder (PTSD)

PTSD may develop months to years after exposure to a situation of extreme traumatic stress. The hallmarks of the condition include re-experiencing the traumatic event, avoidance of the situation in which the event occurred, increased arousal, nightmares related to the event and insomnia. Secondary conditions may develop, such as alcohol dependence or depression, and these may be the first conditions for which people seek help prior to recognising the symptoms of PTSD.

Trends in integrative medicine for anxiety

Research describing long-term trends in complementary medicine (CM) use in the US reported that complementary therapies were used by 57% of people reporting anxiety attacks and 66% of patients consulting a physician for treatment of anxiety. Those surveyed perceived that the efficacy of complementary medicines for anxiety were comparable to conventional drug treatment.⁷

Lifestyle medicine

Lifestyle factors such as chronic stress, poor nutrition, caffeine, smoking, obesity, alcohol and substance abuse may initiate or perpetuate the symptoms of an anxiety disorder ⁸ and there is an increasing interest among medical and health practitioners to address these lifestyle factors in combination with pharmacotherapy and psychological therapies for anxiety disorders.⁹

Mind-body medicine

Psychological therapies

Counselling for anxiety in general practice

Patient-centred care has also become a major focus in mainstream medicine and is being evaluated and promoted within general practice in particular.¹⁰ Active listening, compassion and empathy are vital factors in the counselling of those patients with an anxiety disorder. Patients who feel their doctors listen to them, and respond with empathy, feel they have greater overall improvement across many conditions.¹¹ In a study of 309 women seeking psychological support, GPs with good listening skills and those who provided longer consultation times were highly valued.¹² Women who received referral, counselling and relaxation advice from their GP reported a higher degree of satisfaction.

Cognitive behaviour therapy (CBT) and group therapy

CBT is a talking-based therapy arising from the link between thoughts, feelings and behaviour.¹³ CBT is a valuable tool for the management of anxiety and it is the first-line treatment for adults and children. The central beliefs of CBT and interventions for anxiety disorders include cognitive restructuring, relaxation, breathing techniques, graded exposure to anxiety provoking situations, problem solving, assertiveness training and social skills development. In an 8-week program,¹⁴ CBT including exposure therapy was better than placebo (supportive, non-directive counselling) or moclobemide for the treatment of panic disorder with agoraphobia. Long-term benefits of CBT occurred when used in combination with moclobemide. Self-help CBT programs available on the internet may also be of help in allaying test anxiety. In a study of 90 university students who were randomised to CBT or a control program, both on the internet,¹⁵ anxiety was rated before and after treatment and 53% of the CBT group showed a significant improvement in anxiety related to the test but only 29% of the control group demonstrated benefit. This study supports the use of CBT on the internet for the treatment of test anxiety.

Research supports the role of CBT for social phobia in both group and individual formats.¹⁶ In this study, symptom measures completed at the beginning and end of group therapy found improvement in group cohesion and social anxiety symptoms over time, as well as improvement on measures of general anxiety, depression, and functional impairment.

Clinical guidelines and treatment recommendations by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) are summarised in Table 4.1.¹⁷

Table 4.1 RANZCP clinical practice guidelines for the treatment of panic disorder and agoraphobia

Education for the patient and significant others

(i) the nature and course of panic disorder and agoraphobia

(ii) an explanation of the psychopathology of anxiety, panic and agoraphobia

(iii) rationale for the treatment, likelihood of a positive response, and expected timeframe

Cognitive behaviour therapy (CBT) CBT is more effective and more cost-effective than medication Pharmaceuticals Tricyclic antidepressants (TCAs) and serotonin selective reuptake inhibitors (SSRIs) are equal in efficacy and both are to be preferred to benzodiazepines Treatment choice depends on the skill of the clinician and the patient’s circumstances

(i) Drug treatment should be complemented by behaviour therapy

(ii) If the response to an adequate trial of a first-line treatment is poor, another evidence-based treatment should be used

(iii) A second opinion can be useful

^∗The presence of severe agoraphobia is a negative prognostic indicator, whereas comorbid depression, if properly treated, has no consistent effect on outcome

(Source: RANZCP Guidelines Team for Panic Disorder and Agoraphobia. Australian and New Zealand Journal of Psychiatry, 2003;37:641–56)

Drugs

Social anxiety disorder (SAD) and lack of family cohesion are known risk factors for drug use such as marijuana and alcohol use.¹⁸ Combination of SAD with either alcohol or drug use is associated with higher comorbidity in anxious individuals and may further aggravate anxiety.¹⁹^–²² Patients should be advised to avoid using alcohol and drugs for alleviation of anxiety symptoms.

Hypnotherapy

A growing body of research appears to support the role of hypnosis in the treatment of anxiety. In a large prospective, randomised single-centre study published in the Lancet,³⁶ 241 patients undergoing percutaneous vascular and renal procedures were randomised to receive intraoperative standard care (n = 79), structured attention (n = 80) or self-hypnotic relaxation (n = 82). All patients had access to intravenous analgesia (fentanyl and midazolam). Hypnosis had a more pronounced effect on pain and anxiety reduction. Pain increased linearly in both the standard and attention groups, but remained flat in the hypnosis group. With time, anxiety decreased in all 3 groups, but at a higher rate in the hypnosis group. Drug use was twice as likely in the standard group than the attention and hypnosis groups. Only 1 patient became haemodynamically unstable in the hypnosis group compared with 10 and 12 in the attention and standard groups respectively.

In a small RCT ³⁷ of paediatric cancer patients, 45 children aged 6–16 years were randomised into 1 of 3 groups: local aesthetic, local aesthetic plus hypnosis, and local anaesthetic plus attention for the relief of lumbar puncture-induced pain and anxiety. Patients in the local anaesthetic plus hypnosis group reported less anticipatory anxiety and procedure-related pain and anxiety, and they were rated as demonstrating less behavioural distress during the procedure. The magnitude of treatment benefit depended on their level of hypnotisability and this benefit was maintained when patients used hypnosis independently. Another small hospital study,³⁸ assessing pre-operative anxiety, randomised adult patients into 3 groups: a hypnosis group (n = 26) who received suggestions of wellbeing; an attention-control group (n = 26) who received attentive listening and support without any specific hypnotic suggestions, and a ‘standard of care’ control group (n = 24). Anxiety was assessed before and after their operation. Patients in the hypnosis group were significantly less anxious following surgery, compared with patients in the attention-control group and the control group. Moreover, the hypnosis group reported a significant decrease of 56% in their anxiety level pre-operatively, whereas, the attention-control group reported an increase of 10% and the control group an increase of 47% in their anxiety. In conclusion, the researchers found that ‘hypnosis significantly alleviates preoperative anxiety’. Hypnosis plays a useful role in allaying anxiety for a number of other operative procedures, such as colonoscopy.³⁹

A larger well conducted prospective trial published in Pain 2006, randomised 236 women for large core needle breast biopsy to receive standard care (n = 76), structured empathic attention (n = 82), or self-hypnotic relaxation (n = 78) during their procedures. Patients were rated for pain and anxiety every 10 minutes during their care.⁴⁰

Women’s anxiety increased significantly in the standard group, did not change in the empathy group, and decreased significantly in the hypnosis group. Pain increased significantly in all 3 groups by 50% for standard care, 37% for empathy, and 34% for hypnosis. The researcher concluded that hypnosis ‘provides more powerful anxiety relief without undue cost and thus appears attractive for outpatient pain management’.

A systematic review of studies shows that hypnotherapy is highly effective for patients with refractory irritable bowel syndrome (IBS) and alleviating anxiety, but definite efficacy of hypnosis in the treatment of IBS remains unclear due to limited number of controlled trials.⁴¹

A recent review of the literature identified 60 publications that found hypnotherapy may be useful for a wide range of disorders and problems in children, and is particularly valuable in the treatment of anxiety disorders and trauma-related conditions, especially in conjunction with family therapy and CBT.⁴²

School refusal is considered a form of anxiety. A small study increased school attendance by using a form of self-hypnosis on children suffering school refusal.⁴³

A review of the research acknowledges the important role of hypnosis in health care, especially for difficult to treat patients and for reducing anxiety.⁴⁴ Hypnosis can successfully be used to help alleviate peri-operative anxiety and stress in a hospital setting.⁴⁵

Meditation

A Cochrane review could not conclude from 2 small studies if meditation alone is effective for anxiety.⁴⁶ The researchers identified 2 randomised controlled studies of moderate quality that used active control comparisons, meditation, relaxation, or biofeedback. Anti-anxiety drugs were used as standard treatment. The duration of trials ranged from 12 to 18 weeks. In 1 study, transcendental meditation showed a reduction in anxiety symptoms compared with biofeedback and relaxation therapy.⁴⁶ Another study compared Kundalini Yoga with relaxation/mindfulness meditation, which showed no statistically significant difference between groups.⁴⁶ However, the overall dropout rate in both studies was high (33–44%). Neither study reported on adverse effect of meditation. More studies are warranted.

Relaxation therapies

Patients with an anxiety disorder should be encouraged to learn various relaxation methods as there is strong research demonstrating their benefit. A systematic review of mind–body therapies in 2007 concluded that there was now robust evidence for the use of relaxation therapy in anxiety and insomnia.⁴⁷

A recent meta-analysis of the literature, inclusive of 27 studies, found relaxation training had a significant beneficial effect in the treatment of anxiety.⁴⁸ Efficacy was higher for meditation and for longer treatments. Implications and limitations are discussed.

A separate review found that when the different classifications of anxiety disorder were considered separately then relaxation was most effective for GAD, panic disorder, test anxiety and dental phobia, but that it was less effective for PTSD, OCD and specific phobias.³⁵

Music therapy

Listening to music may also help alleviate pre-operative anxiety. A randomised controlled trial study of 180 patients having day surgery was conducted to assess anxiety before and after listening to patient-preferred music.⁴⁹

Patients were randomised to either an intervention (n = 60), placebo (n = 60) or control group (n = 60). Statistically, music significantly reduced the state of anxiety level in the music (intervention) group compared with the placebo and control groups, with no differences found between socio-demographic or clinical variables such as gender or type of surgery. Another study on patients undergoing cardiac surgery also demonstrated significant reduction in anxiety and pain levels in those receiving music therapy.⁵⁰ Eighty-six patients (69.8% males) were randomised to 1 of 2 groups; 50 patients received 20 minutes of music (intervention), whereas 36 patients had 20 minutes of rest in bed (control). Anxiety, pain, physiologic parameters, and the use of analgesia (opioid) consumption were measured before and after the 20-minute period. The music therapy group demonstrated a significant reduction in anxiety and pain compared with the control group. There was no difference in systolic or diastolic blood pressures, or heart rate. Also, there was no reduction in the use of analgesia (opioid) usage in the 2 groups.

Music therapy may also play a role in palliative care ⁵¹ where research demonstrated statistical improvements in mood and anxiety, and in pain control and reducing anxiety in patients during wound dressings.⁵²

Religion

Religiosity and spirituality have long been seen as a worthwhile buffer against dealing with life’s problems and stresses and a large population study over 9 years showed that all-cause mortality was significantly reduced and life expectancy increased (75 years compared with 82 years) for regular churchgoers. This was not explainable by lifestyle and social variables.⁵³ However, there has been only 1 randomised trial to date which added a religious component to standard pharmacotherapy for GAD and this showed improvement at 3 months but this did not appear to be sustained at 6 months.⁵⁴

Creativity

Anorexia nervosa (AN) is often associated with distressing, intrusive, anxious preoccupations with control of eating, weight and shape. One study of 38 women with AN admitted to a specialised eating disorder unit were offered knitting lessons and free access to supplies.⁵⁵ Of interest, patients reported a significant subjective reduction in anxious preoccupation when knitting, with 74% reporting reduction in the intensity of their fears and thoughts and their minds cleared of eating disorder preoccupations. In addition, 74% reported it had a calming and therapeutic effect and 53% reported it provided satisfaction, pride and a sense of accomplishment. This study demonstrates that creative activities may be of help with anxiety symptoms experienced with AN and more research is required, particularly to see if other creative areas, such as painting and pottery, may also be of help.

Behavioural interventions — summary

The evidence currently suggests using behavioural interventions before considering pharmacotherapy in insomnia. A meta-analysis examining the evidence for behavioural modification CBT, relaxation and behavioural treatment alone, found 23 randomised controlled trials and concluded there were moderate to large effect sizes showing an improvement in sleep for all 3 modalities and the results were the same in both middle-aged adults and older adults (55+).⁵⁶ A review of the increasing evidence for mind-body therapies in 2007 concluded that there was now robust evidence for the use of relaxation therapy in anxiety and insomnia.⁵⁷

Sleep

Anxiety and insomnia are highly co-morbid conditions and physiologically anxiety and low mood increase corticotrophin releasing hormone (CRH) and other stress hormones secreted from the adrenal glands which, in turn, have negative impact upon sleep patterns.⁵⁸ A large health survey conducted in Germany (n = 4186) found that individuals with anxiety disorder and insomnia experienced significantly worse mental-health related quality of life and increased disability.⁵⁹ Most anxiety disorders were moderately associated with reduced sleep quality with GAD (AOR 3.94, 95% CI 1.66-9.34) and SAD (AOR 3.95, 95% CI 1.73-9.04) having the strongest relationship to reduced quality of life scores. For more information see Chapter 22.