Patient's Education For Anxiety

1. What treatments work for anxiety disorder?
2. Key points about treating anxiety disorder
3. Treatments for anxiety disorder:

• Cognitive Therapy
• Antidepressants
• Buspirone
• Hydroxyzine
• Benzodiazepines
• Trifluoperazine
• Applied relaxation

What treatments work for anxiety disorder? Everyone gets anxious from time to time. But if you worry so much that it interferes with your life, your anxiety may have become an illness. Doctors call this illness generalised anxiety disorder. We're calling it anxiety disorder for short. There are several good treatments for anxiety disorder, but there are no quick fixes and no cures.

Key points about treating anxiety disorder

• A talking treatment called cognitive therapy can work well for anxiety disorder.
• Drug treatments (including some antidepressants and a drug called buspirone) can also help.
• We don't know which works best: cognitive therapy or drug treatment. Different treatments suit different people.
• Your doctor may recommend a combination of cognitive therapy and drugs.
• A non-drug treatment called applied relaxation may also help, but we need more research to be certain.
• All drug treatments have side effects. You should discuss them with your doctor.

Treatments for anxiety disorder

Effective treatments are available and new therapies are being discovered to help people who suffer from anxiety disorders.  Which treatments work best? We've carefully weighed up the research on treatments for anxiety disorder and found that they fall into three categories. And we've ranked each treatment to show whether it works. While each anxiety disorder has its own unique characteristics, most anxiety disorders respond well to two types of treatment: medication and psychotherapy. These treatments are prescribed alone or in combination. Although not cures, both treatments are effective in relieving the symptoms of anxiety disorders.

Probably. Cognitive therapy seems to be one of the best forms of psychotherapy (or talking treatment) for anxiety disorder. But we don't know whether cognitive therapy works better than treatment with drugs. If you have this talking treatment, you'll discuss your problems with a specially trained therapist. There are many different types of talking therapy:

• Anxiety management training Anxiety management training teaches you how to cope with worry and tension. With help from a therapist.
• Analytical psychotherapy Analytical psychotherapy is a talking treatment that tries to link what has happened in your past (particularly your childhood) with the problems you are having now. The idea is that if you can understand how your past has affected you, you will feel better about yourself. Some therapists use analytical psychotherapy to help patients with anxiety disorder. But there's no evidence from studies that it works for this condition. Analytical psychotherapy takes longer than cognitive therapy. It could take several years. It's an intense and personal kind of treatment, and you form a close relationship with your therapist. 
• Applied relaxation Applied relaxation is a method for learning to relax. A therapist teaches you how to ease tension in your muscles. The idea is that once your muscles are relaxed, your mind relaxes too. You'll need to practise applied relaxation at home at least once a day. Relaxation techniques can be part of cognitive therapy. They can also be a treatment on their own.
• Non-directive counselling In non-directive counselling, you talk about your problems with a counsellor. The counsellor listens to you talk about your problems and reflects what you say back to you, without actively making suggestions. The idea is that the counsellor helps you work out solutions for yourself.

Cognitive therapy is based on the idea that your anxiety happens because you have negative thoughts about yourself and the world. During a course of cognitive therapy, you learn how to replace negative thoughts with positive thoughts. Your therapist could be a psychologist, a psychiatrist, a psychiatric nurse or a psychotherapist. It can be quite difficult to find a suitable therapist. You will need to find someone you like, trust and feel safe with. Cognitive therapy works faster than other kinds of psychotherapy. You should get between 16 hours and 20 hours of treatment. You will see a therapist once a week for a session lasting one hour to two hours. Or you will be offered a shorter course of about eight hours to 10 hours, with homework in between. Cognitive therapy is not an easy option. You may find it quite upsetting to talk to someone about why you have anxiety disorder.

Your doctor may recommend that you have cognitive therapy and drug treatment at the same time. But we don't know whether this works better than having only cognitive therapy or only drugs. Cognitive therapy isn't always easy to get on the NHS. In some areas there aren't enough trained therapists to go round. But national guidelines say you should get this treatment promptly, without having to wait to be referred to a specialist.

How Can it Help?

Cognitive therapy can help improve symptoms in people with anxiety.Some studies work well for more than half of patients with anxiety disorder.It works better than some other psychological treatments such as anxiety management training or non-directive counselling. Getting better could mean feeling calmer, worrying about fewer things or simply being able to answer the telephone again. It could also mean sleeping better, not having headaches or having more energy. We know that cognitive therapy helps in the short term, but we don't know how well it works in the long term. Most of the studies we found lasted less than a year. However, one small study showed that people who took part in 14 group cognitive therapy sessions were still less anxious two years later.

Why Should it Work?

Researchers think that anxiety disorder is linked to the way we think about ourselves and the world. If we can change the way we think, then we can control our anxiety. Changing the way we think can also help us change the way we behave, so that we can do the things we need and want to do. Cognitive therapy is supposed to be a short, practical treatment. One important goal is to teach you ways to handle anxiety. Then, if your problems come back, you should be able to treat yourself and keep your symptoms under control.

Can it be Harmful?

We found no reports of people being harmed by cognitive therapy.

If you have anxiety disorder, some antidepressants can help. But they have side effects and some of them can be serious. And there are many things we don't know about antidepressants. We don't know:

• Which antidepressants work best
• Whether antidepressants work better than talking treatments such as cognitive therapy
• Whether antidepressants work better than a drug called buspirone
• How likely it is that your symptoms will come back when you stop treatment.

Overall, antidepressants don't work any better than a group of drugs called benzodiazepines. But antidepressants and benzodiazepines help different symptoms. Antidepressants are good for treating tension, irritability or worry. Benzodiazepines are better for treating physical symptoms, such as headaches and palpitations (when you can feel your heart beating faster than normal).

Antidepressants were originally used to treat people with depression. Doctors noticed that these drugs also seemed to lessen feelings of anxiety. We now know that some antidepressants help people with anxiety disorder. There are many antidepressants. The antidepressants (and their brand names) that are generally used to treat anxiety disorder are:

• Imipramine
• Paroxetine (Seroxat)
• Venlafaxine (Efexor)

Another antidepressant that reduces anxiety is called opipramol, but it isn't available in the UK. Antidepressants are divided into groups, depending on their chemical makeup and how they work. Drugs in the same group have similar side effects. 

• Imipramine and opipramol are from a group called tricyclic antidepressants.
• Paroxetine is one of a group of drugs called selective serotonin reuptake inhibitors (SSRIs). These drugs increase the level of a chemical in your brain called serotonin.
• Venlafaxine is from a group called serotonin and noradrenaline reuptake inhibitors (SNRIs). These drugs increase levels of two chemicals in the brain called serotonin and noradrenaline.

Which Antidepressant Should I Take?

Your doctor will help you choose the antidepressant that suits you best. Even if you have side effects, don't stop taking your medicine suddenly unless your doctor tells you to. If you stop taking one of these drugs suddenly, you may get withdrawal symptoms, including nausea, dizziness and a return of your anxiety. Guidelines for doctors say that if you and your doctor decide on antidepressants you should be prescribed an SSRI (such as paroxetine).

If the SSRI doesn't help, your doctor may decide that you should see a specialist in anxiety disorder. This could be a hospital doctor or another GP in your practice who has a special interest in anxiety. The specialist may prescribe venlafaxine.

Before you are prescribed venlafazine, you should have your blood pressure and heart rhythm checked with an electrocardiogram (ECG). When you have an ECG, doctors put electrodes on your chest. This lets them measure the electrical activity in your heart. The electrodes are connected to a machine that shows the electrical activity as a tracing on a moving screen. ECGs don't hurt and don't have any effect on your heart. Your blood pressure, and sometimes your heart rhythm, should be checked regularly while you are taking venlafaxine.

How can They Help?

Antidepressants help to control the symptoms of anxiety. These drugs can:

• Make you feel less anxious, less tense and less fearful
• Help you sleep better
• Help you feel happier
• Relieve physical symptoms of anxiety, such as palpitations
• Help you feel more comfortable around people.

Antidepressants work well for at least half of the people who take them. All the antidepressants seem to work as well as each other. But the research comparing different drugs isn't very good. If you take antidepressants, you'll probably have to wait at least three weeks before you feel any better. We don't know how long the effects of antidepressants last. None of the studies lasted more than 28 weeks. We need more studies to see how these drugs work over a long time.

You should see your doctor regularly after starting treatment, so you can decide if it is helping you. If you are not better in 12 weeks' time, you and your doctor should discuss other options. Even if you feel better, you may need to keep taking your medicine for at least six months. You should see your doctor every eight weeks to 12 weeks to see how well you are doing.

Why Should They Work?

Antidepressants alter the amounts of chemicals called neurotransmitters in your brain. These chemicals carry messages between brain cells. Antidepressants work in various ways to increase the amounts of two of these chemicals, serotonin and noradrenaline (which is also called norepinephrine).

Scientists aren't really sure why this should help reduce symptoms of anxiety or depression, because they don't yet know enough about how the brain works. But they do know that anxiety and depression seem to be linked to the levels of these chemicals in the brain, and antidepressants seem to help improve this.

Can They be Harmful?

All antidepressants have side effects. They affect many different parts of the brain, not just the part that causes anxiety. Antidepressants also change the levels of chemicals in other parts of the body. The side effects vary from one drug to another.

• Tricyclic antidepressants such as imipramine can give you a dry mouth and blurred vision, and make you drowsy, confused or constipated.
• SSRIs such as paroxetine don't affect chemicals in the body as much as tricyclic antidepressants. They seem slightly less likely to cause side effects. But they may make you feel sick, or give you an upset stomach or diarrhoea. And you may gain weight, lose weight or have sexual problems if you take SSRIs.
• Venlafaxine can cause sexual problems (such as erection problems or not being able to have an orgasm) and make you feel sick. Like other antidepressants, venlafaxine can also make you constipated and give you a dry mouth.

Antidepressants and Suicide

Some SSRIs have been linked to serious side effects when they have been used to treat depression in children and teenagers. Some studies have found that children and teenagers taking these drugs were more likely to hurt themselves, think about killing themselves or even kill themselves. Taking these drugs has not been linked to these problems in adults.

Doctors don't know whether these effects happen when these drugs are used to treat conditions other than depression in children and adolescents under 18

Doctors in different countries have been given different advice about prescribing these drugs. Doctors in the UK are advised not to prescribe the following drugs to treat depression in anyone under 18.

• Citalopram (Cipramil)
• Escitalopram (Cipralex)
• Fluvoxamine (Faveril) (Tthere hasn't been any good research on fluvoxamine in children.)
• Mirtazapine (Zispin)
• Paroxetine (Seroxat)
• Sertraline (Lustral)
• Venlafaxine (Efexor)

If you are taking antidepressants and are worried about any thoughts or feelings you have, see your doctor straight away.

If you have anxiety disorder, a drug called buspirone could help you. But we don't know whether buspirone works any better than other helpful drugs, such as antidepressants, benzodiazepines or hydroxyzine. We also don't know whether buspirone works as well as cognitive therapy, a talking treatment. Buspirone can have side effects.

Buspirone is a drug that can reduce feelings of anxiety. It's one of a group of drugs called anxiolytic drugs. Its brand name is Buspar and you take it as a tablet. Your doctor will probably recommend a low dose to start with, working up to a higher dose over a few weeks.

Buspirone takes longer to work than some other drugs used to treat anxiety disorder. You need to take buspirone for at least six weeks for it to work. We don't know how long you should keep taking buspirone after that. You and your doctor should decide how well buspirone works for you and whether you should keep taking it.

Your doctor may recommend that you take buspirone and also have cognitive therapy. But we don't know whether this combination works better than only taking buspirone or only having cognitive therapy.

How can it help?

Buspirone can help in several ways:

• It can help symptoms such as feelings of anxiety, tension and fear.
• It can help you sleep better.
• It can make you feel happier.
• It may improve physical symptoms of anxiety, such as palpitations (when you can feel your heart beating faster than usual).

In the studies we looked at, about half of the people who took buspirone felt better or much better. But about a third of the people who were given a dummy treatment (a placebo) for comparison felt better. If you're thinking about taking buspirone, bear in mind that:

• Buspirone may not work as well if you have recently taken drugs called benzodiazepines, such as alprazolam (Xanax)
• Buspirone seems to be better at reducing worry and irritability than helping with physical symptoms such as muscle tension and headaches
• We don't know how long you should keep taking buspirone
• Buspirone seems to work as well as the benzodiazepine drug diazepam, the antidepressant venlafaxine and another drug used to treat anxiety disorder called hydroxyzine. But there hasn't been enough research to be sure.

Why Should it Work?

We're not certain. Like many other drugs, it affects chemicals in your brain called neurotransmitters. These chemicals carry messages between brain cells. Buspirone mimics a neurotransmitter called serotonin, which has an important effect on your mood. Serotonin works on many different cells in your brain. Buspirone works on the same cells, but less powerfully.

Scientists don't know why this should make you feel less anxious, because they don't know enough about how the brain works. All they know is that influencing the activity of serotonin seems to help.

Can it be Harmful?

Buspirone can have side effects. The most common side effects are feeling sick or dizzy. Here's a list of side effects from a study that compared buspirone with a dummy treatment (placebo). The list shows what proportion of people in each treatment group said they had each side effect.

Also, more than 1 in 10 people taking buspirone said that they had headaches, indigestion or diarrhoea. But about the same proportion of people who took a placebo also said they had these symptoms. When a side effect shows up equally often in people taking a drug and people taking a placebo, that means that the drug probably didn't cause the side effect.

Hydroxyzine seems to work about as well as buspirone and benzodiazepines, two other drug treatments for anxiety disorder. But there isn't enough good research to be certain.

Hydroxyzine belongs to a group of drugs called antihistamines . These drugs make you feel calm and may make you feel sleepy. Doctors sometimes give hydroxyzine to people who are nervous before having surgery. Your doctor may offer you an antihistamine if your anxiety suddenly gets a good deal worse. Antihistamines are normally only prescribed for a few weeks. You can take hydroxyzine as a tablet or a liquid. Brand names for hydroxyzine are Atarax and Ucerax. If you take hydroxyzine, you feel the calming effects within a few hours of the first dose. Higher doses make you sleepier than lower doses.

How Can it Help?

In two out of three studies, hydroxyzine improved people's symptoms.2 3 Researchers measure symptoms using symptom rating scales. They look for improvements in a long list of symptoms including worry, tension, fear, and depression. They also look for overall improvements in how you feel. Hydroxyzine seems to work about as well as two other treatments for anxiety disorder - buspirone and the benzodiazepine bromazepam.2 3 But we need more studies to be certain.

Why Should it Work?

Hydroxyzine is an antihistamine, which means it blocks the effects of a chemical called histamine. Blocking the effect of histamine in your brain makes you feel calm. Hydroxyzine works in a similar way to benzodiazepines. Doctors know that benzodiazepines help people with anxiety disorder, so they think that hydroxyzine might also work as a treatment for anxiety disorder.

Can it be Harmful?

About 4 in 10 people taking hydroxyzine get side effects, including headaches and drowsiness. Of the people who took a placebo, more than 2 in 10 got side effects. If you take a drug that makes you sleepy, you're more likely to have an accident. If you're feeling drowsy, do not drive or operate any machinery.

Treatments That Work, But Whose Harms May Outweigh Their Benefits:

If you are feeling very anxious, benzodiazepines can make you less worried and more relaxed. They can also help some patients sleep better. They work faster than other treatments for anxiety, but they can have serious side effects. You may feel sleepy or doped up. You may have trouble remembering things or concentrating. If you stop taking benzodiazepines suddenly, your symptoms may come back worse than before. And if you take benzodiazepines for more than a few weeks you can get addicted to them. If you're pregnant or breastfeeding, benzodiazepines can harm your baby.

What are They?

Benzodiazepines are a type of tranquilliser. This means they calm down some of the thought processes in your brain. Your doctor may prescribe these drugs if something happens that suddenly makes your anxiety a lot worse. This is because benzodiazepines can make you feel better quickly. Benzodiazepines make you feel calmer, but they can also make you feel sleepy and sluggish. Some benzodiazepines are good for treating anxiety, and others are good for helping you sleep. Most benzodiazepines do a bit of both. In high doses, they can also help your muscles relax.

There are many different benzodiazepines. We have listed the benzodiazepines that can help people with anxiety disorder.

• Diazepam : You can take this as a tablet or a liquid. It may just be called diazepam, or it may have a brand name, such as Tensium, Rimapam or Dialar. You may hear it called Valium. This is its brand name in the US.
• Alprazolam : The brand name for this drug is Xanax.
• Lorazepam : This may be called lorazepam, or it may have the brand name Ativan.
• Bromazepam :  
• Mexazolam : 

Some people with anxiety disorder take another benzodiazepine called clonazepam (Rivotril). But there hasn't been any good research on this drug as a treatment for anxiety disorder.

All these drugs come as tablets. Benzodiazepines generally work faster than other drug treatments for anxiety disorder, usually within a week. Your doctor will probably suggest that you take benzodiazepines for two weeks to four weeks. Some benzodiazepines last longer than others. If you take diazepam or alprazolam, the effect will last only a few hours. So you have to take them several times a day. 

You Shouldn't Stop Taking Benzodiazepines Suddenly, especially if you have been taking them a long time. Talk to your doctor if you want to stop taking benzodiazepines. If you need to stop taking benzodiazepines, you should gradually reduce your dose until it's safe to stop completely. 

Benzodiazepines can be addictive if you take them for more than a few weeks. It can then be hard to stop taking them. This is why you shouldn't take them for more than two to four weeks. 

How Can They Help?

Benzodiazepines can help in several ways. 

• Benzodiazepines can help symptoms such as worrying too much, feeling tense or feeling afraid. 
• More than two-thirds of people with anxiety disorder feel better a week or two after starting to take benzodiazepines. 
• Benzodiazepines can also improve physical symptoms such as chest pain, palpitations (when you can feel your heart beating faster than normal), headaches and sore muscles. 

Why Should They Work?

Benzodiazepines change the way a chemical called gamma-aminobutyric acid (GABA) works in your brain. GABA stops some cells in your brain communicating with each other, slowing down your brain. Benzodiazepines help GABA work harder, slowing down your brain even more. As a result, you feel calmer. Benzodiazepines also help you sleep. 

Can They be Harmful?

Benzodiazepines can have serious drawbacks. Here are some of the most common side effects. 

• Feeling sleepy: This is the most common side effect of benzodiazepines. About two-thirds of the people who take diazepam say it makes them drowsy. This may be a minor inconvenience, or it could mean you can't do anything but lie on the sofa and watch television all day. You certainly shouldn't try to drive or operate machinery.This drowsiness could stop you getting the full benefit from psychological treatments (such as cognitive therapy). 
• Problems with memory: Benzodiazepines can make your memory worse. You may find it harder to remember things such as shopping lists and appointments. Your memory may not return to normal until a few weeks after you stop treatment.  
• Dizziness: About 1 in 3 people say benzodiazepines make them dizzy.
• Getting addicted (dependency): When you become addicted to a drug, you feel a strong need to keep taking it, and you can't stop taking it without getting unpleasant symptoms. (This is known as going through withdrawal.) With benzodiazepines, withdrawal symptoms may include feeling agitated or irritated, being unable to sleep and losing your appetite. Some people get seizures or twitching muscles.
• Rebound anxiety: This means that your anxiety can return quickly when you stop taking the drug. You may feel worse than before. Up to a third of people taking benzodiazepines have this problem.
• Accidents: Taking benzodiazepines increases your risk of having an accident. You may be twice as likely to have a traffic accident.

If you take a benzodiazepine while you're pregnant, the drug will get into your baby's body. So your baby may get addicted. There is also a risk that your baby will be malformed if you take benzodiazepines during the first three months of pregnancy. And if you breastfeed your baby while you are taking a benzodiazepine, your baby can get the drug through your breast milk. We don't know what the exact risks to babies are, but we do know what symptoms you might see. If you took benzodiazepines while you were pregnant or breastfeeding, your baby may:

• Go limp
• Get very cold
• Have trouble breathing
• Spend too much time asleep to eat a healthy amount.

In general, it's important to tell your doctor if you're pregnant or breastfeeding before you take any drug.

If you take a drug called trifluoperazine (brand name Stelazine) for four weeks, it can reduce your anxiety. But it does have side effects and these can be serious. We don't know what happens if you take trifluoperazine for longer than four weeks. It's one of a group of drugs called antipsychotic drugs. These drugs can damage your nervous system if you take them for a long time.

Trifluoperazine is an antipsychotic drug. These drugs are normally used to treat people with a serious mental illness called psychosis. Psychosis includes disorders such as schizophrenia. It is a different type of illness to anxiety disorder. But one of the drugs used to treat psychosis, trifluoperazine, has a calming effect that may help people with anxiety disorder.

You may be offered trifluoperazine it your anxiety gets very bad or if other treatments are not working. Trifluoperazine works faster than some of the other drugs used to treat anxiety disorder. You should start to feel better within a week or two. If you take trifluoperazine for a long time, you may get serious side effects. You should talk to your doctor about the risks if you want to take the drug for longer than a month.

How can it help?

Trifluoperazine can:

• Lessen feelings of anxiety and tension
• Help you feel less afraid
• Help you sleep better
• Make you feel less miserable
• Help physical symptoms of anxiety such as palpitations (when you can feel your heart beating faster than normal).

Why Should it Work?

Antipsychotic drugs work by altering chemicals in your brain called neurotransmitters. These chemicals help carry messages between brain cells. Antipsychotic drugs act on a neurotransmitter called dopamine. Dopamine helps control your muscle movements, thoughts and emotions. Antipsychotic drugs seem to lessen the effects of dopamine. Researchers don't really know why this helps reduce symptoms of anxiety.

Can it be Harmful?

Damping down the effects of dopamine can cause side effects. And antipsychotic drugs affect other chemicals in the brain. This also causes side effects. The side effects from antipsychotic drugs are common and can be serious.

• More than 4 in 10 people who take trifluoperazine for anxiety disorder say it makes them feel drowsy
• About a quarter of patients have side effects such as a dry mouth, blurred vision or constipation.
• Antipsychotic drugs can interfere with the way your muscles work. The muscles in your head, neck or face may twitch (this is called dystonia). This side effect isn't common.
• If you take antipsychotic drugs for months or years, you risk getting a more serious muscle problem called tardive dyskinesia. People with this condition lose control of their arms and legs, and may writhe around. It can also affect the face and tongue. People who get tardive dyskinesia may pull faces, stick their tongue out a lot, smack their lips and blink rapidly. The risk of getting this disorder seems to be higher if you keep stopping and starting the drug. This side effect is rare with trifluoperazine, but you should discuss the risks with your doctor before starting treatment.

There hasn't been enough research to say for certain whether applied relaxation works or how it compares with other treatments. Applied relaxation is a kind of talking treatment (or psychotherapy). It may work as well as another kind of talking treatment called cognitive therapy.

If you have anxiety disorder, you may never be truly relaxed. You may not even realise that you've lost the ability to relax. Applied relaxation is a way of teaching you how to release the tension in your body and relax your muscles. This helps to calm your mind. It doesn't involve taking any drugs.

Most people having this treatment have weekly sessions with a therapist. Week by week the therapist teaches you to relax your body and your mind. You also learn how to relax in difficult situations instead of getting stressed or avoiding them. For example, if you dread letting your children get the bus to school, you could learn how to use relaxation techniques each morning as you get them ready.

Applied relaxation is also called relaxation training. Like all training, it can be hard work. You have to practise between sessions. Treatment usually starts with exercises to relax your muscles. In some exercises, you relax groups of muscles, such as in your shoulders and neck. In other exercises, you relax your whole body. When your body relaxes, your mind also seems to relax or calm down.

You'll need a quiet spot and time to yourself to practise your exercises. By the end of the course you should have learned how to:

• Recognise tension and what causes it
• Relax your whole body
• Relax different parts of your body
• Relax in everyday situations
• Relax in stressful situations
• Relax quickly when you need to.

How Can it Help?

About half the people who learn applied relaxation feel better at the end of treatment. That's about the same proportion of people who benefit from cognitive therapy. But 'feeling better' meant different things in different studies. In one study, it meant that the therapist thought the patient had improved. In other studies, it meant the patients got better scores on symptom rating scales. These are tests used to measure symptoms. In one study, 1 in 5 people who learned applied relaxation were completely better two years after their treatment. So were about 1 in 7 people who had cognitive therapy. 

Why Should it Work?

 Researchers don't know enough about the effects of relaxation to say exactly how applied relaxation helps reduce the symptoms of anxiety disorder. We do know that when you relax: 

• Your body stops releasing chemicals that make your heart race and your body tense up
• You breathe more slowly
• You sweat less
• Your muscles relax.

Can it be Harmful?

 We found no reports of side effects from applied relaxation.  

Source adapted from: http://www.besttreatments.co.uk