Editorial: U.S. Is Playing Catch-up on Anxiety Treatment

There’s an old story of a worry-ridden, irritable, tension-filled, and apprehensive gentleman who turned over the reins of his thriving company to his two sons. The sons did a fine job of running the company, but their father still hovered – and while doing so, made his anxiety and stress everyone’s business.

Joining forces, the sons gave their father an ultimatum: To remain in the business, he had to get help for his anxiety. He was furious. "Never," he said. As time passed, things became so tense that he gave in and agreed.

In those days, psychiatric patients were scheduled for five visits a week. On Monday or day 1, the father lay on the couch and spoke not a word to the psychiatrist for a full 50 minutes. At the end of the visit, he wrote a hefty check for the doctor’s time. This continued for four more days – right through Thursday. The father remained mute and wrote a check at the end of the visit.

At the very end of the Friday or day-5 visit, the father asked the psychiatrist whether he could ask a question. "Yes, yes," the overjoyed psychiatrist quickly responded.

"If you ever need a partner, would you think of me first," the anxious gentleman asked.

That story illustrates the main approach once used to treat anxiety. Four to five days a week, the therapist aimed to get at the root cause of the person’s "anxiety neurosis," as it was called before the DSM-III left neurosis for historians and Woody Allen movies. With the DSM-III, the "anxiety disorders" nomenclature came to be and was further modified in the DSM-IV.

Today, we might diagnose the father with generalized anxiety disorder or GAD. Benzodiazepines appear to be the most commonly prescribed medications for GAD in the United States and in the United Kingdom, despite the abuse potential of those drugs. However, the U.K. National Institute for Health and Clinical Excellence (NICE) might be on to something. The agency recommends simple self-help and guided self-help educational and coaching interventions as a first step in managing GAD. In addition, NICE recommended low-intensity group therapy as a second step – before moving on to medication management with selective serotonin reuptake inhibitors, ranked as the top medication treatment option ("U.K. Guidelines Promote Self-Help for GAD").

When it comes to the talking therapies and behavioral techniques, the British have been ahead of us for quite some time. For example, Dr. Isaac Meyer Marks, who was born in South Africa but trained in psychiatry at the University of London, has been at the forefront of research in treating anxiety, phobias, and other disorders, and in empowering patients to work on behalf of their own self-interest.

To understand anxiety, specifically GAD, we must appreciate the profound impairments that the illness takes on, particularly its ability to diminish social and vocational functioning, and ultimately, the patient’s quality of life. Also, persistent anxiety has profound effects on many organ systems, which influence physical health and often lead to excessive use of the health care system.

In reviewing the many approaches of psychotherapy for GAD, the best thinking is that various dimensions of cognitive-behavioral therapy, or CBT, can eliminate perceived distortions leading to worry and anxieties. Juxtaposing possibilities with probabilities is a technique I like and have found therapeutic for my patients. Group therapy has been successful when combined with education. The group is a treatment modality that fosters the realization among patients that they are not alone.

In addition, relaxation and hypnotic techniques often are mentioned when treating anxiety disorders, including GAD. Often times, variations of the late Dr. Edmund J. Jacobson’s progressive muscle relaxation techniques (Int. J. Psychosomatics 1989;36:1-4) continue to be effective. At the time, those techniques used up to 50 sessions teaching patients how to relax specific muscle groups. This approach is not inconsistent with the lengthy psychoanalytic approaches of time during 1920-1950. During the ’40s and ’50s, Dr. Joseph Wolpe demonstrated that relaxation can be induced in 20 minutes ("Relaxation Techniques: Adjuncts to Therapy"). Using the Hypnotic Induction Profile as discussed in "Trance and Treatment: Clinical Uses of Hypnosis" (Washington: American Psychiatric Publishing, 2004), the relaxation state can be reached in even less time and can be taught.

Even though relaxation/hypnosis alone works in many instances, I have found that combining a relaxation/hypnotic technique with behavior-modification strategies is an effective treatment and can prove long lasting if patients are taught techniques that they incorporate into their lifestyles with ongoing practice and reinforcement. Using guided imagery, combined with reciprocal inhibition and systematic desensitization, offers the anxiety or GAD sufferers a way to reduce and eliminate their anxiety and worry. In addition, mindfulness-based approaches also are showing promise in treating various anxiety disorders (Clin. Psychol. Rev. 2011;31:617-25).