Thursday, September 19, 2019

Introduction

Anxiety is one of the most universal human experiences. It consists of worry about the future, or about specific situations, as well as the physiological reaction to being in those situations (heart racing, sweating, and trembling, for instance). Stomach problems and difficulty sleeping are also commonly seen with anxiety.

As with most psychological diagnoses, it is considered a “disorder” only if it impacts the ability to engage in normal life activities. Psychiatrists may argue that those who have an anxiety “disorder” have some form of neurological difference that makes their experience of anxiety more extreme than others. However, no such neurological difference has been found.

Some contextual situations in which anxiety can impact a person’s ability to engage in life include open places with many people (agoraphobia), parties or other social events (social anxiety), and particular triggers like spiders or needles (specific phobia). There is also a term for overall constant worry in many situations: generalized anxiety.

Panic attacks are sudden physiological reactions that are generally related to over-awareness of bodily sensations and a related worry about health (for instance, noticing your heart racing leads to worry about heart attacks, which leads to faster heartbeat, sweating, and other anxious symptoms, which increases the worry even more).

Obsessive-Compulsive Disorder (OCD) involves frightening thoughts or images which intrude without warning and which the person obsesses about, and the use of compulsive “ritualistic” behaviors in order to prevent feared outcomes or to make the frightening thoughts go away.

All of these types of anxiety can interfere with the ability to engage in aspects of life. For instance, having difficulty leaving the house due to agoraphobia or difficulty connecting with others due to social anxiety can leave one without a job, without groceries, and feeling isolated and alone.

That’s why there are a number of interventions, based on broadly different theories, designed to improve the “symptoms” of anxiety and to enable one to re-engage with life activities.

 

Treatment of Anxiety

I.  Psychotherapies

There are four major psychotherapies that have been well-studied and are used to either reduce anxiety or to increase a person’s ability to engage in life despite anxiety. CBT and exposure therapy are typically delivered together, and are the most studied therapies for anxiety. There is a great deal of evidence that they are effective in reducing anxiety as well as in enabling fuller engagement in life.

A study that compared the effectiveness of CBT/exposure therapy to the use of an antidepressant found that CBT/exposure therapy was just as effective as an the pharmacotherapy for the reduction of anxiety in general.

For OCD in particular, psychotherapy was significantly more effective than antidepressant medication, both in that study and in others. This may be because exposure therapy is so specifically linked to the concerns in OCD.

Studies have found large effects for Mindfulness-Based Stress Reduction (MBSR) on reducing anxiety, both for people with anxiety diagnoses and for people with other diagnoses or physical health issues.

Studies have also found that Acceptance and Commitment Therapy (ACT) is comparable to CBT in its effectiveness for anxiety reduction and quality of life improvement.

Psychotherapy may also have more lasting effects and fewer adverse effects than pharmacotherapy, making it an attractive alternative for the reduction of anxiety.

A. Cognitive-Behavioral Therapy (CBT)

CBT focuses on identifying and challenging/changing “distorted” or “maladaptive” thoughts (cognitions) about the self and the world.

For instance, in social anxiety, a person may be worrying about a large number of potentially embarrassing social situations that could arise. A CBT therapist might help that person do two things: first, determine how likely the embarrassing situation actually is (many of them are probably very unlikely to occur); and two, determine how dangerous that embarrassing situation actually is (even if the situation is likely to occur, it is likely to be less dangerous than expected). The therapist might then help the person brainstorm ways of dealing with potentially embarrassing situations if they do arise.

CBT includes homework, in which the client identifies when these thoughts arise, and challenges them in real-time using logic and alternative explanations.

B.  Exposure Therapy

Exposure therapy involves controlled, safe experiencing of the thing that triggers fear/anxiety. According to the theory of conditioned responses, it is the avoidance of the triggering situation that reinforces the idea that it’s dangerous. As one is exposed to the feared situation, one learns that it is not as dangerous as expected.

For instance, a person with social anxiety might fear that some social gaffe will lead to them being the target of mockery at a party. They might begin by attending a small gathering with a trusted friend or partner, and slowly work their way up to being able to attend larger gatherings with strangers by themselves. They will likely learn, through experience, that small faux pas are common from everyone, that these mistakes are generally ignored at parties, and that even if addressed, moments of embarrassment are fleeting and tolerable.

Exposure therapy is often delivered as part of a CBT program, but is distinctive enough in theory to warrant its own entry here.

C. Mindfulness-Based Stress Reduction (MBSR)

MBSR involves relaxation and mindfulness, which involves keeping the attention in the present moment. Because much of anxiety is fed by worrying about the future or regretting the past, mindfulness may be an excellent resource. For instance, keeping the attention on the body in the here-and-now prevents one from worrying about future events and beating oneself up about past mistakes.

D. Acceptance and Commitment Therapy (ACT)

ACT is based on similar ideas to CBT, and often includes exposure therapy elements. However, it features a functional, rather than mechanistic, approach. That is, ACT focuses on whether thought processes or behaviors are effective for a person navigating their environment, not whether they are “irrational” or “false.” ACT puts primacy on being able to work toward one’s life goals while being true to one’s values, whether there are “irrational” beliefs present or not.

ACT also includes mindfulness approaches of being present-centered and engaging in valued action, rather than ruminating about past events or worrying about the future.

Thus, an ACT therapist would teach someone with social anxiety how to acknowledge the risk of embarrassing situations, yet still engage in social events in order to connect with others, despite the presence of anxiety. In this type of intervention, the problem is seen as the avoidance of situations, not the presence of anxiety. One is capable of engaging in meaningful pursuit of life goals, even though one is experiencing anxiety.

ACT encourages “psychological flexibility” and “cognitive defusion” which involve being aware of thoughts and feelings without the need to act on them. The person can then choose to engage in actions driven by their values and goals. For instance, the thought “I can’t go to this party because it’s too dangerous” might become “I feel like this party is very dangerous, but I have a choice about whether to go or not, and it’s important that I try to meet new people.”

 

II. Additional types of psychotherapy

Additional types of psychotherapy are less well-studied, but may have significant effects on reducing anxiety and increasing ability to engage in life activities.

A study comparing self-help and psychodynamic approaches for social anxiety specifically found that they were somewhat less effective than CBT, but that they still had some effect on reducing anxiety. Psychodynamic therapy was the least effective of the two.

A study that compared interpersonal therapy (IPT) with cognitive therapy (CBT) for social anxiety found that IPT was less effective than CBT, but still far better than no treatment. Reduced anxiety was maintained after a year.

A. Self-Help

Self-help can be delivered in many ways, such as through books and videos. It can also be supported by a therapist, or delivered without support. It usually follows CBT methods, and is basically teaching someone how to do their own thought-challenging and exposure work. It appears to be more effective when supported by a therapist.

B. Psychodynamic Therapy

Current psychodynamic therapy focuses on interpersonal relationships and current life stresses. It borrows from psychoanalytic theory in its focus on early-life attachment styles, but has little else in common with psychoanalysis or the psychodynamic therapies depicted in the mass media. It is probably more similar to interpersonal therapy than to Freudian psychoanalysis.

C. Interpersonal Therapy (IPT)

IPT focuses on improving interpersonal functioning by developing strategies for dealing with relational conflicts. It involves discussions of interpersonal situations and boundaries, as well as a communication-skills building component. The therapist may role-play social situations with the client.

 

III. Wellness Therapies

A.  Exercise

Being physically active is helpful for both physical health and psychological well-being. Engaging in exercise of some kind has been shown to reduce anxiety as well as to improve overall mood. Exercise is likely not as effective as other therapeutic approaches, and is usually studied as an add-on intervention to psychotherapy or medication treatment.

B. Yoga

Yoga may have an effect on reducing anxiety and improving OCD; however, the studies included in the review were of generally poor quality and sometimes used obscure diagnoses and terminology. According to the reviewers, data contained errors and calculations were unreliable in some of the studies. All the studies were vague about how they conducted the study, making it difficult to have confidence in their results.

C. Hypnotherapy

Hypnotherapy involves a person willingly entering a suggestible state in order to become relaxed and suggestible. The therapist then provides vivid language for achieving the person’s goals. If hypnotherapy involves delving into the past, it carries the risk of eliciting very strong emotional reactions, and may lead to developing false memories.

Studies have found that hypnosis reduces anxiety in the moment, and that hypnosis as an add-on to CBT appears to have a greater effect. However, effects on longer-term anxiety are unclear. Studies also appear to be poor quality, with unclear methodologies, few cited references, and grammatical errors which reduce confidence in their trustworthiness (e.g. this study).

D. Acupuncture

Acupuncture, based on traditional Chinese medicine, involves tiny needles being inserted into the body at specific spots which are traditionally considered focal points of life force energy (qi). It is an individualized practice that involves non-standardized approaches.

This intervention has barely been studied for anxiety. However, in several studies on whether acupuncture can relieve immediate anxiety (such as test anxiety or anxiety before a medical procedure), sham (fake) acupuncture was either as good, or almost as good, as the actual intervention, and neither were much better than no treatment.

E. Relaxation

Relaxation encompasses a wide variety of interventions, including meditative practices and physical relaxation practices such as progressive relaxation. The effects of relaxation vary just as widely, with some studies finding a slight effect for reducing anxiety, and other studies finding a much larger effect. Meditative practices appear to have the largest effect. Younger people, students, and volunteers appear to have the greatest effect from relaxation.

F. Therapeutic Touch (TT)

TT is based on a theory that posits that all humans are part of an energy field that can be affected by touch and near-touch by other humans, provided they are in a meditative state. This energy field has never been observed scientifically. The therapeutic act is in the “detecting and balancing of energy,” since “imbalances and blockages in the energy field lead to illness.” Although this technique has been taught since the 1970s, a recent review of the evidence found very little to go on, concluding that no study met their criteria. Another review of TT for other indications (healing wounds) was withdrawn due to “serious concerns over the validity of included studies.”

The studies that do exist have shown small effects, and it has been argued to be the “practice of placebo.”

G. Cannabidiol (CBD Oil)

CBD has been suggested as the anxiety-reducing chemical in the cannabis plant. A review of the research on the drug suggest that it can reduce anxiety associated with THC, which is the anxiety-provoking chemical in that same plant.

However, a search turns up no evidence that CBD oil can be used to reduce anxiety in populations that have diagnosed anxiety disorders. A review suggests one study that appears to demonstrate reduced anxiety in “simulated public speaking” but it is unclear how this might generalize to people in real-life situations. That review was also funded by a pro-cannabis group and its researchers are consultants within the cannabis industry.

The long-term safety and efficacy of CBD are also completely unstudied, and CBD is known to interact negatively with other drugs and medications.

H. Naturopathy

 A study in 2007 compared naturopathy to psychotherapy. Participants in the naturopathy group received an herbal supplement, Withania somnifera, as well as a multivitamin. Both groups received dietary advice. The study found that the herb/vitamin combination was better for reducing anxiety than psychotherapy.

However, the study’s editor did not disclose that he was from the same naturopathy program as the researchers, bringing up conflict-of-interest concerns. Additionally, the “psychotherapy” appears to include several contradictory approaches (both CBT and “patient-directed counseling”) for shorter sessions than are customary, and appears to have been conducted by one of the naturopathic researchers who was unlicensed for psychotherapy, raising concerns about whether the comparison was fair or even whether the study was ethical.

These concerns, and the fact that there is only one study, make it difficult to evaluate the evidence for naturopathy.

I. Herbal Remedies

Valerian is one herbal remedy that purports to increase calm and reduce anxiety. However, there is very limited research on its effectiveness. One study found that it was no more effective than placebo for reducing anxiety. As with many supplements, valerian is associated with adverse effects such as headaches, stomach problems, and insomnia. It may also interact negatively with other substances, particularly alcohol and benzodiazepines.

Passiflora (Passionflower extract) is another herbal remedy used for increasing calm and reducing anxiety. There is very limited research on its effectiveness, but at least one study found it to be about as effective as medications for anxiety. Without further research it’s impossible to tell if this is a fluke.

Research compiled by Peter Simons

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