Restoring Function in Patients With Anxiety
GAD May Be More Debilitating Than MDD
ORLANDO, Fla.—Patients with generalized anxiety disorder (GAD) typically live with symptoms for more than 10 years before seeking treatment, Pratap R. Chokka, MD, FRCPC, told attendees at Psych Congress 2018.
During that decade of untreated anxiety, he explained, GAD works its fingerprint onto the souls of patients in the form of broken relationships, a poor sense of well-being, and reduced productivity at work—if the individual is employed at all (1 in 5 people with GAD are not). Then there are medical consequences of chronic stress exposure, which can include increased risk of hypertension, coronary artery disease, obesity, and type 2 diabetes.
“In terms of what this condition does, I can tell you it’s downright nasty,” said Dr. Chokka, a psychiatrist at Grey Nuns Hospital and CEO of the Chokka Center for Integrative Health, Edmonton, Alberta, Canada. “We often talk about depression as being very debilitating, which it is. But … there are some studies that indicate patients with pure anxiety have much more impact in terms of dysfunction than patients with major depressive disorder.”
THE IMPORTANCE OF FUNCTION
Dr. Chokka implored mental health professionals to consider restored function, not merely symptom reduction, as the treatment goal for patients with GAD.
“What happens to our patients with GAD is it takes a toll on who they are as human beings,” said Dr. Chokka, also a clinical professor at the University of Alberta.
“If you can’t work or you are working poorly, you can’t feel good about yourself. If you are highly anxious and unable to control your thinking, it’s difficult to form relationships and connections—the things that give us meaning in our lives,” he said. “And when you talk about quality of life in patients with GAD, it’s significantly impaired. These are the things that, in addition to symptom reduction, I spend most of my time trying to rehabilitate to bring that quality of life back to patients.”
Treatment often begins with pharmacotherapy, explained Dr. Chokka, because by the time patients with anxiety present in his office for treatment, they have moved beyond a “worried well” classification to having moderate to severe GAD.
“For those types of patients, I believe pharmacotherapy is a really important first step,” he said, “and my experience has been it may actually facilitate better psychotherapy.”
Dr. Chokka’s presentation included a review of Canadian guidelines for GAD treatment, which he explained are similar to guidelines published by the Anxiety and Depression Association of America. Medications with first-line evidence for the treatment of GAD include duloxetine, escitalopram, paroxetine, pregabalin, sertraline, venlafaxine XR, and—although it is not available in the United States or Canada—agomelatine.
“Pregabalin is something to consider when selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors are not effective and especially if you are worried about addictions,” he said.
Second-line recommendations include alprazolam, bromazepam, bupropion XL, buspirone, diazepam, hydroxyzine, imipramine, lorazepam, quetiapine XR, and vortioxetine. Benzodiazepines actually have level one evidence for GAD (alprazolam, especially), Dr. Chokka said, but were shifted to level two because of their potential for misuse, abuse, and tolerance level in a small number of patients.
CBT AND OTHER APPROACHES
“Clinically, I start off with the pharmacotherapies, get some symptom reduction, look at functional outcomes, and then I tailor that with cognitive behavioral therapy (CBT),” Dr. Chokka said.
CBT has been shown to significantly reduce GAD symptoms, although it may require individualization to the patient’s issues. Benefits for CBT seem comparable to pharmacotherapy, according to the presentation, but few studies have compared the two within a single trial.
Other emerging modalities showing promise for reducing anxiety include intravenous ketamine, transcranial magnetic stimulation, and even phytotherapies such as lavender oil and passionflower. Weightlifting, aerobic exercise, meditation, yoga, and balneotherapy—bathing in mineral-rich water—also have evidence supporting their use.
Treatment approaches that may not meet an evidence-based standard but which Dr. Chokka still considers scientifically based and helpful include considering patients’ emotional styles as described in the work of Richard Davidson, PhD, as well as positive psychology’s focus on training patients to see what is going well in their lives. (Dr. Chokka uses the PERMA approach of Marty Seligman, PhD).
Resiliency is something that can be learned, Dr. Chokka explained. Physical exercise, volunteering, and having a moral compass are among the key factors that promote resilience in adults.
LIVING A LIFE OF MEANING
“Our job is to restore functioning and quality of life. Our job is to help our patients really facilitate purpose and meaning. That’s what this is all about,” Dr. Chokka told attendees. “Anxiety is a sidetrack to what is really important, which is to live this life as full and meaningful as you can.”
He ended his talk with a quote by Mark Twain: “There isn't time—so brief is life—for bickerings, apologies, heartburnings, callings to account. There is only time for loving, and but an instant, so to speak, for that.”
“Calming the unquiet mind: an integrative understanding and treatment of generalized anxiety disorder.” Presented at Psych Congress 2018: Orlando, FL; October 27, 2018.