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Anxiety treatment: keeping up with the British.

There's an old story of a worry-ridden 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.

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 4 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 5 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 self-help educational and coaching interventions as a first step in managing GAD. In addition, NICE supports 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," Clinical Psychiatry News, April 2011, p. 3).

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 and phobias, 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. Also, persistent anxiety has profound effects on many organ systems.

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 have found therapeutic for my patients. Group therapy has been successful when combined with education.

Also, relaxation and hypnotic techniques often are mentioned when treating anxiety disorders, including GAD. Often, 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 used in 1920-1950. During the '40s and '50s, Dr. Joseph Wolpe demonstrated that relaxation can be induced in 20 minutes ("Relaxation Techniques: Adjuncts to Therapy," Clinical Psychiatry News, December 2006). With 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 in less time and can be taught.

Relaxation/hypnosis alone works in many instances, but 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. 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.

The idea of preventing anxiety disorders is an area of research that seems to be gaining attention. Researchers in Australia, for example, have looked at this issue by examining which populations might benefit most from prevention programs (Curr. Psychiatry Rep. 2011;April 12 [Epub ahead of print]).

I'm glad to see that the DSM-5 Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic and Dissociative Disorders Work Group thinks that GAD needs an overhaul. It has been suggested the name be changed to "generalized worry disorder," a change that would recognize worry as the main feature of the disorder.

Woody Allen's preoccupation with worry in his films suggests that he gets it, and I'm heartened to see that the DSM- 5 might catch up. Maybe the DSM-6 will reinvent the concept of neurosis.

Dr. London, a psychiatrist with New York University Langone Medical Center, has no disclosures. He can be reached at
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Title Annotation:COMMENTARY
Author:London, Robert T.
Publication:Clinical Psychiatry News
Article Type:Report
Geographic Code:4EUUK
Date:Jun 1, 2011
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