Psychological versus pharmacological interventions for anxiety disorder - Essay Example

Critically consider the relative merits of psychological versus pharmacological interventions for anxiety disorder Anxiety disorder is a blanket term used to describe and define a variety of regular abnormal psychological states, followed by fear, anxiety and nervous conditions that may have considerable impact on individual's daily routines and to great extent impair them especially in sense of psychological functioning (emotional life as well as behavior) (Corbman, 1997). Anxiety disorders have similar symptoms, but different nature and causes (Corbman, 1997), but anxiety is the key aspect that unites all these disorders into the large group. Anxiety is associated with irrational and unexplainable fear of certain object or event, which is commonly known as 'safe' (Bushnell, 1998; Corbman, 1997). Anxiety is a dangerous psychological state, since it is followed by corresponding changes in neural system: persistent irradiation and irritation lead to long-lasting exhaustion and fatigue, especially if anxiety fits are frequent and happen 5-10 times a day (Goisman, 1994). According to G.Bushnell, "Anxiety is an umbrella term for physical, mental and behavioral changes which automatically occur in the face of threat. People feel apprehensive and 'on edge', and may worry. They may also find it difficult to concentrate on anything other than the threat" (Bushnell, 1998, p.5). The present essay focuses on three forms of anxiety disorders: panic disorder, obsessive compulsive disorder and separation anxiety disorder and is designed to compare psychological and pharmacological treatment of the diseases and possible research-based combinations. Panic disorder with and without agoraphobia is a debilitating and often relapsing condition that affects about 1 out of 75 persons worldwide (Bushnell, 1998) and sometimes changes the whole personality structure. In the late 1960s, psychiatrists and scholars (Bushnell, 1998; Ciarocchi, 1995; Goisman et al, 1994) began to distinguish panic disorder as a separate form of anxiety disorder, and the final version of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (Bushnell, 1998) gives detailed description of this condition. The main symptoms of panic disorder are faintness, instability of feelings, trembling or shaking, shortness of breath, nausea or distress, headaches or chest pains, paresthesias or inadequate emotional reactions, associated with fear of death or 'crazy' or inappropriate acts (Bushnell, 1998). Panic attacks might occur even during sleep and affect overall health state, decreasing productivity and 'emotional performance' of individual (Marks, 1987). Panic disorder, similarly to the rest of anxiety disorders, has no relation either to genetic predisposition or to other heredity factors, but occur in sensitive suspicious people after they have experienced stress (long lasting rather than episodic - public punishment and tense job environment, close sibling's death, serious disease which might have had fatal outcomes and so on) (ibid). Cognitive-behavior and exposure therapies are the most effective psychological approaches to treating panic disorder (Clark, 1994), but these methods are usually debated by mental health professionals who insist primarily on pharmacological intervention (CNCPS, 1992), i.e. view psychological therapies as supplementary treatment, whereas medications, according to CNCPS (ibid), is a basis of successful anxiety-coping. The investigation conducted by Goisman et al in 1994, suggests that the separation of these two approaches decreases satisfaction with the treatment. Let's examine the details of their research. Four per cent of the patients received neither medication nor psychological therapy, fifty per cent had received such drugs as benzodiazepines (diazepam, lorazepam), tricyclic antidepressants (doxeprine, imipramine) and herbal medicine. Twenty per cent of patients had received cognitive-behavior, person-centered and exposure therapies, and the percentage of those who had experienced both therapeutic models is 26. "Non-psychiatrists (general practitioners, internists and others) showed a different prescription profile, as reported by the patients. Benzodiazepines, neuroleptics, and herbal preparations were more often prescribed by non-psychiatrists as compared to psychiatrists, whereas psychiatrists tended to use more tricyclic antidepressants" (Goisman et al, 1994, p.73). The research shows that patient satisfaction with benzodiazepines and tricyclic antidepressants is highest, whereas herbal medicine and neuroleptics are less favored drugs. Furthermore, cognitive behaviorism is recognized to be the most workable psychological therapy, and the research findings suggest that overall satisfaction with psychological interventions (69%) is higher than contentment with appropriate medications (57 %), particularly because of unpleasant side effects of anti-depressants: sleepiness (70%), physical weakness (60%), inability of putting thought in order (10 %), emotional paresthesias (12%) and benzodiazepines: dizziness (8%) and nausea (9%), whereas only 11 per cent reported absolute ineffectiveness of psychological therapies (Goisman et al, 1994). The most evident effectiveness was shown by combined approach: 92 per cent of patients reported positive dynamics of treatment, and 56 per cent recovered in shorter terms than those who had been given only medications. Nevertheless, the scholars assume: "A substantial number of patients could not indicate the psychological therapy school applied to them. In these cases patients were asked if specific techniques like exposure to fearful situations had been performed during sessions (Goisman et al, 1994, p.79). In all cases, patients denied the use of such techniques so it can be excluded that these patients had been treated with behavior therapy" (Goisman et al, 1994, p.79). Other experts (Hatch and Saito, 1990; Hoffart and Martinson, 1990) claim that exposure therapies should be used at final stage of treatment, and the therapy should begin with cognitive restructuring, i.e. outlining the interrelation between possible causes of anxiety and unpleasant states experienced by patients. Clark (1994) writes that the key objective of cognitive-behavior therapy is the creation of alternative non-threatening interpretations of possible irritants and irritable factors through cognitive discussions, behavioral experiments and systematic desensitization, but somatic symptoms also need treatment, especially at initial stages of cognitive-behavior course, because the patient's perception of therapy will be biased by panic attacks, i.e. they won't be able to think clearly and analyze the nature of their fear unless they are given some medications. Due to the fact that panic disorder occurs in individuals who regard themselves as 'weak' or 'powerless' and the contribution of psychological factor is much more considerable, it is important to eliminate primary cause of the disorder, i.e. look into the intrinsic and internal roots of this problem (Hatch and Saito, 1990). Obsessive compulsive disorder is a condition characterized by obsessions and/or compulsions, which are likely to interweave and create stable patterns of perception and behavior (Schwartz, 1996). Obsessions might contain thoughts, impulses and images emerging out of the person's control and 'capturing' their mind (ibid). "The person does not want to have these ideas, finds them disturbing and intrusive, and usually recognizes that they don't really make sense (Ciarocchi, 1995, p.46). People with OCD may worry excessively about dirt and germs and be obsessed with the idea that they are contaminated or may contaminate others" (Ciarocchi, 1995, p.46). Obsession is followed by negative emotions such as disgust, scorn and fear. Compulsions are in fact the main behavioral demonstration of obsession, as they include routinized and ritualized acts, which gradually turn into unbreakable rules (ibid). The most popular form of cognitive behaviorism applied in anti-obsession treatment course is ritual prevention and exposure (Greist, 1994). The therapy involves empowering patients and stimulating them to expose themselves to the events, which normally point to a need for ritualization (Greist, 1994), and the continuous increase in exposure frequency and duration is known as more successful than flooding techniques (without systematic desensitization this method sometimes amplifies the patient's fear of loosing rites as the necessary attribute of their life) (Zohar and Insel, 1997). "As a rule, patients are reluctant to undergo guided exposure to cues that normally trigger rituals, and the research shows that 15-25% of patients recommended for cognitive-behavior therapy either refuse to comply or do not complete treatment" (de Araujo, 1996, p.748). The majority of clients who drop out or fail to complete the course, indicate that exposure was proposed too early and lacked gradualness, so they were not ready to eradicate all their 'bad habits' (ibid). On the other hand, the same research suggests that cognitive behavior therapy, run by experienced specialists, bring 70-85% success (ibid; also mentioned in Marks, 1987; Schwartz, 1996). In case of obsessive compulsive disorder, pharmacological approach shows 50-60% efficacy (Zohar and Insel, 1997). Patients react to anaframil, tricyclic antidepressant, in different ways and the scholar indicates that such elementalistic treatment model leads to personality problems (such as low attention concentration and decrease of sociability) in future. Serotogenic antidepressants are a little more helpful, but another trouble emerges - the disorder recurs after 5-6-year remission (ibid). Other medications such as fluvoxamine, sertaline and fluoxetine have advantage comparing to the two previous groups, as they do not oppress neither cognitive activity nor wish for higher human needs satisfaction (according to Maslow's hierarchy) (in Ciarocchi, 1995). All types of serotogenic antidepressants as well as clomipramine are compatible with appropriate cognitive-behavior therapy, as Zohar and Insel (1997) suggest. "Relapse is common upon withdrawal of the medication, suggesting the need for long-term prescriptions, while cognitive-behavior therapy is still effective even if administered in a time-limited fashion" (Zohar and Insel, 1997). Baer challenges psychological approach with a question whether cognitive behaviorism can be defined as a kind of 'endogenous medication'. The scholar refers to Marks's (Marks, 1987) earlier findings which suggest that psychotherapy seeks to restore normal glucose balance, especially visualization that seems to be designed as logical continuation of serotonin therapy. As one might assume, there emerges a huge 'white spot' to explore and research, but it is possible to say that the approximation of psychotherapeutic approach to pharmacological models and their convergence in case of OCD should be stronger than therapeutic combination of anti-panic treatment. In my opinion, it is important to prevent competition between the two approaches and build therapy on the basis of mutual compensation - for instance, if antidepressants have negative impact on patient's sociability than cognitive-behavior treatment should include a kind of communication sessions, which revitalize social skills and help avoid the patient's isolation and moral separation. Furthermore, I would recommend concentrating on relaxation techniques (more attention to breath control and so on) that will follow general 'anti-tension' treatment, yet keep the client's mind and body fit rather than idle. Separation anxiety disorder is a psychopathology that appears in children and teenagers, who have experienced their parents' separation or divorce, hospitalization or death of relative or sibling (Lepine and Pelissolo, 2000). The major symptoms are: apparent suffering when child is separated from home or main attachment persons or such separation is anticipated; stable and excessive fear connected with losing possible harm happening to those who the child is attached to; unrelenting and extreme worry that an unfavorable event will cause separation from a those who are child's caretakers, as rule, from parents (e.g., getting lost or being kidnapped); reluctance to attend school (Corbman, 1997). The main trouble faced by therapists treating SAD is inappropriateness of pharmaceutical intervention for infants, as medications can't be used for children under 6 years old (ibid). Thus, there is an array of alternative techniques: play therapy, cognitive behavior therapy, systematic desensitization, relaxation techniques and family therapy (Lepine and Pelissolo, 2000). Tofranil (imipramine) and Luvox (fluvoxamine) are major antianxiety medications, but their use is limited (ibid). The study conducted by the Research Unit on Pediatric Psychopharmacology Anxiety Study Group (2001) that compares the efficacy of medication and family therapy, suggests that pharmaceutical treatment shows only 45-per-cent success, whereas family therapy is effective in 61 per cent cases. Another research by Lepine and Pelissolo: the group estimated the extent of possible fluvoxamine use for 6-14-year-old children with severe SAD. "The children had serious symptoms that were resistant to nonpharmacologic therapy and had substantially impaired function. Only 5 of the original cohort of 153 children (3 percent) had a response to a three-week course of a psychotherapeutic educational intervention" (Lepine and Pelissolo, 2001, p.88). The 128 participants, who were enrolled in the investigation at the end of the research had received 300 mg of fluvoxamine per day or placebo during the whole eight-week treatment course (control group). 64 per cent of those who were assigned to take fluvoxamine had considerable reduction of anxiety symptoms, whereas only two per cent of placebo group participants experienced the same effect. Nevertheless, the scholars indicate that "well-designed studies of adults and children with separation anxiety disorder, demonstrate that psychological interventions, including relaxation training, anxiety management, and especially cognitive behavioral therapy, are effective and may reduce symptoms for at least one year" (ibid, p. 92). Still, there are almost no investigations which explore the separate usefulness (self-efficacy) of cognitive behaviorism, as psychoeducational therapy, according to the theoretical framework, included merely relaxation sessions and play therapy, whereas the use of systematic desensitization, recommended by the majority of scholars (Corbman, 1997; de Araujo, 1996; Grist, 1994). In my opinion, due to the fact that fluvoxamine causes side effects in 8% cases, it is necessary to reduce gradually its dose in treatment course up to the complete replacement of medications with a complex of cognitive- behavior therapies. Furthermore, due to the fact that the nature of the disorder is rooted in close connection between siblings (Bushnell, 1998), it is vital to involve all family members into the treatment course and combine systematic desensitization with minimal fluvoxamine doses, at first stages of treatment in particular. To sum up, anxiety disorders differ in sense of symptoms and appropriate treatment, and the comparison of pharmaceutical vs. psychological intervention shows different results (Corbman, 1997) in cases of separation anxiety disorder, obsessive compulsive disorder and panic disorder. My conclusion will be following: medications are likely to normalize neural system functioning and remove negative symptoms (Schwartz, 1996; Corbman, 1997), but they don't actually change the patient's behavior, as the disorder often leads to the kind of behavioral addiction, e.g. in case of OCD the person is addicted to self-imposed rites (Lepine and Pelissolo, 2000), and anxious children are to great extent psychologically dependant upon their siblings, psychotherapy should be aimed at establishing positive and independent behavior patterns (Clark, 1994) and decreasing anxiety in response to certain irritants (parental separation, germs threat etc). I believe the competition between the two approaches is unreasonable (Zohar and Insel, 1997), since medications are essential part of treatment during the first weeks of the course, as they actually allow the beginning of systematic desensitization, removing the most acute symptoms. Reference list 1) de Araujo, L. , Ito, L., Marks, I. (1996) Early compliance and other factor predicting outcome of exposure for obsessive compulsive disorder. British Journal of Psychology, 169: 747-752 2) Baer, L. (1996) Behavior therapy: Endogenous serotonin therapy Ournal of Clinical Psychiatry, 57: 33-35. 3) Bushnell, G. (1998) Guidelines for Assessing and Treating Anxiety Disorders. National Health Committee Press. 4) Ciarrocchi, J.(1995)The Doubting Disease. Paulist Press 5) Clark, D. (1994) Cognitive therapy for panic disorder. In: Wolfe B, Maser J, eds. Treatment of panic disorder. A consensus development conference. American Psychiatric Press, Washington, DC, pp. 759-69 6) CNCPS (1992) Cross-national collaborative panic study. Drug treatment of panic disorder. Comparative efficacy of alprazolam, imipramine, and placebo. Br J Psychiat, 160, 191-202 7) Corbman, G. (1997). Anxiety Disorders. In Current Diagnosis. Vol. 9. Ed. Rex B. Conn. Philadelphia: W. B. Saunders Co 8) Goisman, R., Warshaw M. and Peterson L. (1994) Panic, agoraphobia, and panic disorder with agoraphobia. Data from a multicenter anxiety disorders study. J Nerv Ment Dis, 182, 72-9. 9) Greist, J. (1994) Obsessive Compulsive Disorder: A Guide, 2nd Edition.. Obsessive Compulsive Information Center 10) Hatch, J. and Saito, I. (1990) Growth and development of biofeedback: a bibliographic update. Biofeedback and Selfregulation, 15, 37-46. 11) Hoffart, A. and Martinsen, E. (1990) Exposure-based integrated vs. pure psychodynamic treatment of agoraphobic inpatients. Psychotherapy, 27, 210-218. 12) Lepine, J. and Pelissolo, A.(2000) Why take social anxiety disorder seriously Depress Anxiety ,11:87-92 13) Marks, I. (1987) Fears, phobias and rituals. Oxford: Oxford University Press 14) The Research Unit on Pediatric Psychopharmacology Anxiety Study Group. (2001) Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med, 344:1279-1285. 15) Schwartz, J. (1996) Brain Lock. Harper Collins. 16) Zohar, J. and Insel, T. (1997) Obsessive compulsive disorder. Psychobiological approaches to diagnosis, treatment and pathopsychology. In Essential Papers on Obsessive Compulsive Disorder, edited by Dan J.Stein and Michael Stone, pp.277-303. NY: New York University Press. Read More