According to DSM V, anxiety disorders include
disorders that share features of excessive fear and anxiety and related
behavioral substances. According to (Munir et al. 2019) anxiety disorders are
the ones that crop up the most frequently, making them the most prevalent kind
of mental illness in this world. Fear is the emotional response to a real or perceived imminent threat,
whereas anxiety is the anticipation of future threats. Obviously, these two states overlap, but
they also differ, with fear more often associated with surges of autonomic
arousal necessary for fight or flight, thoughts, immediate danger, and escape
behaviors, and anxiety more often associated with muscle tension and vigilance
in preparation for future danger and cautions or avoidant behaviors. Panic
attacks feature prominently within anxiety disorders as a particular type
of fear response. Panic attacks are not limited to anxiety disorders but rather
can be seen in other mental disorders as well. The picture below explains in a simple way differences between fear and anxiety.
The majority of anxiety problems begin in childhood
and, if untreated, are likely to continue throughout adulthood. The vast
majority manifest themselves more commonly in females than in males
(approximately 2:1 ratio). A diagnosis of an anxiety disorder can only be made
if the symptoms cannot be attributed to the physiological effects of a
substance or medicine. Anxiety, which can be seen as the pathological
counterpart of normal fear, is characterized by mood disruptions, as well as
changes in thinking, behavior, and physiological activity.
The anxiety disorders include separation anxiety disorder, selective mutism, specific
phobias, social anxiety disorder (social phobia), panic disorder, agoraphobia, and generalized anxiety disorder (GAD). In addition, there are
adjustment disorders with anxiety features and disorders due to general
medical conditions and substance-induced anxiety disorders (Greenberg et al. 1999). Anxiety disorders differ from one another in the types of objects or situations
that induce fear, anxiety, or avoidance behavior, and the associated cognitive
ideation. Thus, while anxiety disorders tend to be highly comorbid with
each other, they can be differentiated by close examination of the types of
situations that are feared or avoided and the content of the associated
thoughts or beliefs. The various kinds of anxiety disorders, along with an
explanation of each, are outlined in the picture below.
TREATMENT TECHNIQUE
As recommended in the S3
guideline on the treatment of anxiety disorders issued in May 2014 (Bandelow et
al. 2014), psychotherapy and pharmacotherapy should both be offered, and the
two are considered comparably effective. Decisions about treatment should be
made in light of the severity of the disorder, the preference of the
informed patient, the expected latency and durability of the treatment effect,
the expected side effects, and the availability of the treatment in question.
If one form of the treatment proves to be ineffective, the other (or a combination of
both) should be tried. Only for the specific phobias is there very good
evidence, and therefore a very strong recommendation, for psychotherapy alone;
drugs are not indicated in the treatment of the specific phobias. For all types
of anxiety disorder, cognitive behavioral therapy is the type of psychotherapy
for which there is the strongest evidence and which receives the highest-level
recommendation. For Pharmacotherapy, the drugs most commonly used are selective serotonin reuptake inhibitors (SSRI) and selective noradrenaline
reuptake inhibitors (SNRI) (Ströhle, Gensichen & Domschke 2018). The table below shows the method of treatment and the side effects of each type of anxiety.
No.
Anxiety
Type
Method of
Treatment
(Pharmacotherapy)
Side Note
Method of
Treatment
(Psychotherapy)
Side Note
1
Agoraphobia
Tricyclic antidepressants (imipramine) – stop panic attacks, but are
not effective in reducing anxiety in general
Alprazolam (Xanax), a type of benzodiazepine – Fast reaction, effective.
Side effects – addiction & psychological &
physical dependence
– 60% panic attack free with effective drugs, – 20% –
50% experience relapse when tricyclic antidepressants are discontinued – 90%
experience recurrence when benzodiazepines are discontinued
Focus – reduce the avoidance behavior of agoraphobia through
exposure to the feared situation
Relaxation Exercises & Breathing Techniques – 70% effective in reducing anxiety, panic, and
avoidance behavior of agoraphobia.
Panic Control Training – Exposure to feared physical sensations
Cognitive Therapy – Identify & modify cognitive processes,
attitudes & perceptions towards feared situations or places
-80-100% panic free after 12 weeks in treatment.
-Follow-up study shows no relapse, improved after 2
years
2
General Anxiety
Disorder (GAD)
Benzodiazepine – Reduces anxiety & muscle tension
-Lack of long-term effectiveness
-Side effect: lack of cognitive & motor
functionality
-Physical & psychological dependence
Cognitive Behavioral Treatment
Focus on the process of anxiety & anxious feelings
-Confront images that raise anxiety and
anxious thoughts
-Learning techniques to prevent or control
the anxiety process
3
Social
Anxiety Disorder (Social Phobia)
Tricyclic Antidepressant & Monoamine Oxidase Inhibitors
(MOIs)
– Effective for treating severe social phobia
When drug intake is stopped, relapse occurs
Group
psychotherapy
Role Play – Facing problematic social situations in groups
–Therapists
and group members give feedback.
Cognitive Therapy
-Identify and modify negative perceptions about
perceptions or expectations of danger in social situations
-Follow-up studies, after 5 years still show the effectiveness
4.
Specific Phobias
Drugs are not indicated in the specific phobias
Cognitive Therapy
-Gradual, consistent, and structured exposure to
feared objects or situations
-If one’s are afraid of panic attacks, one’s can
focus on panic attack treatment.
– If a person has a phobia of blood, injections, or
injury, he/she can be given gradual, consistent, and structured exposure, as
well as muscle tension exercises to increase blood pressure
5.
Selective
mutism
Antidepressant
(Carlson et al 1999) showed that antidepressants
were used most commonly to treat selective mutism. After antidepressants,
anti-anxiety medications and other psychotropic interventions are also
employed depending on the child’s comorbidities
SSRIs
-SSRIs (fluvoxamine and fluoxetine in particular),
have yielded decreased selective mutism symptoms in selective case reports.
Combine Therapy
Other case report studies suggest the enhanced
effectiveness of combination treatments. For example, Wright et al. (1995) reported
a positive response to treatment with fluoxetine in a combined treatment plan
that also included family and behavioral therapy. The four-year-old female
patient in the case report at the beginning of this article began talking in
familiar surroundings after just five days of medication and continued to
improve so that talking in all settings was observed by 20 days.
– In a trial by (Black and Uhde 1999) among six
children with selective mutism, children actively administered fluoxetine
over a period of 12 weeks showed improved ratings on mutism and anxiety
although other symptoms remained unchanged.
-In a separate case report written by (Black and Uhde
1995), a 12-year-old girl who had never spoken at school was treated
successfully with fluoxetine. Although other approaches to treatment including
psychotherapy, behavioral therapy, and desipramine failed to demonstrate
efficacy for this individual, taking fluoxetine for one month resulted in
this girl speaking freely with teachers and peers. Moreover, at seven months,
other social communication and interactions were normal after the evaluation
Psychodynamic therapy
Psychodynamic therapy in children is called
individual play therapy (Krysanski V. L. 2003) This form of treatment is
time-intensive and involves a comprehensive exploration of the individual
case history. The focus is on exposing an underlying intrapsychic conflict
-Behavioral therapy
Behavioral therapy is typically a multimethod
approach that must account for symptoms in the broader context of the child’s
environment. Specific techniques including reinforcement, stimulus fading,
token procedures, shaping or prompting, contingency management,
self-modeling, and response initiation provide more empirical
data-substantiating efficacy.
– Treatment ideally begins with addressing the verbal
and nonverbal negative reinforcement that sustains selective mutism behavior.
For example, teachers who withdraw requests for children to speak exhibit one
form of negative reinforcement that sustains behavior.
– Self-modeling is one approach that involves viewing
edited videotapes modeling appropriate behaviors. The child watches himself
receive the desired reward (the mystery motivator) for speaking in an audible
and clear tone in front of the class.
Family therapy
-Family therapy is another treatment option that is
especially relevant when family factors play a role in the potential
development and perpetuation of selective mutism
– Since only a few case studies have been examined,
the efficacy of this psychodynamic therapy is unknown.
– While the effectiveness of family therapy is
unproven, incorporating the family in the therapeutic process can play a
vital role in the child’s recovery. Cooperation and understanding from
parents and siblings help the child overcome anxiety and avoidance.
Collaborating with school staff is another vital component of healing given
that the diagnosis is usually made as children become school age. Education
about selective mutism should be clearly communicated to teachers and
guidance counselors, as teachers can play an invaluable role in breaking
cycles of negative reinforcement
6.
Separation
Anxiety Disorder
Benzodiazepines are an available treatment option in
adults but are generally not appropriate for treating children.
-SSRIs are normally prescribed for at least six
months past the initial response before being gradually discontinued.
Pharmacological treatment is limited due to a paucity of FDA-approved
medications for children younger than six years resulting in clinicians
providing CBT alone
– Limited evidence exists regarding
serotonin-norepinephrine reuptake inhibitors (SNRIs) or antidepressants such
as tricyclic antidepressants, and they are therefore not prescribed.
Cognitive behavior therapy (CBT)
-Cognitive behavior therapy utilizes both cognitive
restructuring and exposure techniques to reduce anxiety and enable anxious
individuals to cope more effectively with their anxiety.
– If CBT is not sufficient to reduce symptoms,
combination therapy with second-line psychopharmacological intervention may
be initiated (Level 1). Several RCTs showed that combined CBT and
administration of an SSRI are the most effective in improving anxiety
symptoms
– CBT
is considered the first-line treatment of SAD, given its efficacy and very
few adverse effects associated with treatment.
-Additionally, CBT often includes psychoeducation
about the nature and treatment of anxiety and anxiety reduction techniques,
including breathing retraining and progressive muscle relaxation. While
several controlled studies have shown the efficacy of CBT for anxiety
disorders in children and adolescents,
the majority of these
investigations have excluded youth under the age of seven (Ehrenreich,
Santucci & Weiner. 2008).
7
Panic Disorder
-Counseling,
-Psycho-education about anxiety and anxiety disorders,
-Instructions for anxiety-confronting exercises in real-life situations
-The use of self-help manuals
SSRI
-Citalopram, Escitalopram, Paroxetine, Setraline
SNRI
Venlafaxine
Among patients with panic disorder, for example, relapse is seen in 15–50% within 6–12 months of the discontinuation of tricyclic antidepressants, SSRIs, or venlafaxine. It is therefore recommended that maintenance therapy with SSRI or SNRI be continued for at least 6–12 months after the end of the acute phase, at the effective final dose that was attained. Any attempt to discontinue medication should be gradual, e.g., over the course of 12 weeks if the duration of treatment until now has been 40 weeks (Perna et al. 2016)
Bandelow, B.,
Wiltink, J., Alpers, G. W., Benecke, C., Deckert, J., Eckhardt-Henn, A., &
Beutel, M. E. 2014. Deutsche S3-Leitlinie Behandlung von Angststörungen.
Black, B.,
& Uhde, T. W. 1995. Psychiatric characteristics of children with selective
mutism: a pilot study. Journal of the American Academy of Child and
Adolescent Psychiatry, 34(7):847–856.
Ehrenreich,
J. T., Santucci, L. C., & Weiner, C. L. 2008. SEPARATION ANXIETY DISORDER
IN YOUTH: PHENOMENOLOGY, ASSESSMENT, AND TREATMENT. Psicologia conductual
16(3): 389–412.
Greenberg, P.
E., Sisitsky, T., Kessler, R. C., Finkelstein, S. N., Berndt, E. R., Davidson,
J. R., Ballenger, J. C., & Fyer, A. J. 1999. The economic burden of anxiety
disorders in the 1990s. The Journal of clinical psychiatry 60(7): 427–435.
Krysanski V.
L. 2003. A brief review of selective mutism literature. The Journal of
psychology 137(1): 29–40.
Munir, S.,
Gondal, A.Z., & Takov, V., 2019. Generalized anxiety disorder. https://www.ncbi.nlm.nih.gov/books/NBK441870/
[ 14 September 2022].
Perna, G.,
Alciati, A., Riva, A., Micieli, W., & Caldirola, D. (2016). Long-Term
Pharmacological Treatments of Anxiety Disorders: An Updated Systematic Review. Current
psychiatry reports 18(3): 23.
Ströhle, A.,
Gensichen, J., & Domschke, K. 2018. The Diagnosis and Treatment of Anxiety
Disorders. Deutsches Arzteblatt international 155(37): 611–620.
Wright, H.
H., Cuccaro, M. L., Leonhardt, T. V., Kendall, D. F., & Anderson, J. H. 1995.
Case study: fluoxetine in the multimodal treatment of a preschool child with
selective mutism. Journal of the American Academy of Child and Adolescent
Psychiatry 34(7): 857–862.
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