One of the most common reasons you’ll have patients coming to you is for anxiety. Anxiety is all around us today, as it has been, and will continue to be. Most providers don’t know how to effectively treat anxiety disorders and patients (and you) suffer as a result.
Now, I want to preface that (at first) you probably won’t be the most beloved provider by effectively treating your patients. But, if your goal is to help your patients experience anxiety-relief long term, stay with me.
How anxiety works
So, first it’s super important to understand the mechanism of how anxiety manifests.
Because your understanding will keep you from inappropriately prescribing, and keep you from inadvertently exacerbating the issue.
Below is a cognitive model of anxiety from Dr Barbara Fleming and Dr James Pretzer.
We all have beliefs about ourselves and the world. Our beliefs about the world influence our perceived (or anticipated) ability to cope with life. We also have situations, physical sensations, thoughts, or images that influence our perceived (or anticipated) risks in the world. Our perceptions of our ability to cope, along with our perception of the risks ahead of us, contribute to a perception of a situation as threatening.
These perceptions then cause anxiety which leads to a host of reactions.
What research says.
Anxiety does three things – it causes us to avoid, experience physical sensations, and become hypervigilant.
3 responses to anxiety
Avoidance. Physical sensations. Hypervigilance.
These 3 responses are problematic, because:
- Avoidance undercuts our sense of self efficacy that we can handle the thing causing us anxiety, which makes us feel more anxious (feedback loop).
- Physical sensations, such as a racing heart or difficulty breathing, lead to more thoughts or physical sensations which perpetuates the cycle.
- And vigilance, likely hypervigilance, puts us on alert for a higher perception of risks ahead.
All of these factors increase anxiety and the cycle continues.
Avoidance is critical in anxiety
Avoidance is an important component of this cycle. Why? Basically, anxiety makes you doubt that you can appropriately handle what’s coming ahead. This leads you to avoid facing the things that cause anxiety which then perpetuates the anxiety.
But there’s light at the end of the tunnel!
The true way to address this feedback loop is through exposure.
Exposing yourself to the thing you have been avoiding. And continuing to face that thing until you’re no longer fearful or are able to get through it. It’s something no one wants to do – you, me, our patients. But research shows that exposure therapy works.
Now you’re not likely going to be doing exposure therapy with your patients if your day-to-day role as a provider is in medication management. But, your understanding of how anxiety works is crucial so that the medications you prescribe do. not. make. the. problem. worse.
What do I mean by that?
Well, when you prescribe (or continue to prescribe, if you’re inheriting a patient) benzodiazepines for your patient’s with anxiety, you are perpetuating their avoidance. Benzos are a form of avoidance and undercut a patient’s sense of self efficacy and belief that they can face the thing. Whatever the thing is for them.
So, your job is to slowly taper off of benzos, prescribe evidenced-based treatment which is likely an SSRI, and ensure your patient is receiving appropriate, quality therapy, specifically exposure- based therapy.
3 tips for treating anxiety disorders
Understand the content of your patient’s anxiety
The cognitions surrounding their anxiety are important as well as understanding the content of their anxiety. Is the thing they fear a specific thing like heights, spiders? Is their anxiety generalized and non-specific (ie worry about a lot of things like about not being in control? Fearing social interactions? Health of family members? How they’re doing at work and school?). The cognitions surrounding the anxiety helps you determine your patient’s diagnosis which can then help direct how you’re treating them. You treat generalized anxiety disorder differently from how you treat obsessive-compulsive disorder, for example.
Just a side note, patients with anxiety disorders generally require higher doses of SSRIs and take longer periods of time to be responsive to SSRIs than other individuals receiving SSRIs.
What you prescribe your patients may not change an incredible amount when you know the content of their anxiety, and their diagnosis, but it does change the type of therapy they receive. The appropriate therapy treatment is very different for OCD (which is ERP, or exposure and response prevention) than it is for PTSD (CBT or EMDR) or GAD (CBT along with high intensity exercise).
Taper your patients off of benzodiazepines (or don’t prescribe them if they’re not on them)
One of the more contentious parts of our job is to remove harmful treatment from our patients. This can be tough at times, particularly if our patients feel the medication (benzos likely) are helping their anxiety and that without them they would be more anxious.
You’ll want to highlight that there’s no good scientific evidence that benzodiazepines are effective for treating anxiety long term. Benzos are like a blunt instrument. They are non- specific for anxiety and they cause issues such as falls and confusion because they work in many areas of the brain.
Your job is to have a solid understanding of why benzos make your patients worse in the long run and then convey this in a very clear, compassionate way with your patients. This will likely not be a single conversation but an ongoing series of conversations you have with your patients, especially if they come to you having been on a long history benzos for years. Likely they are coming to you because they are still anxious. You understand why this is, as discussed above, so your job is to work with your patient to slowly get them off the benzo (and onto evidence-based treatment if they’re not currently on it).
This all can be easier said than done so you should remember the bottom line. The bottom line is that your job is to keep your patients safe and provide evidence-based treatment. There is little in the literature that supports the long term use of benzodiazepines. In fact, there are no studies outside of case reports that support the use of benzodiazepines as adjunctive or symptomatic treatment.
Understand that the goal is not completely removing the emotion of anxiety
Your goal of successfully treating your patients with anxiety is not defined by your patients never experiencing any amounts of anxiety ever again. This is not realistic and likely not possible, unless you’re snowing your patients with multiple sedating medications (and even then, without other proper treatment, anxiety will likely remain).
Anxiety serves a purpose. Anxiety, as an emotion in and of itself, is not inherently bad. We all need to be able to experience a range of emotions – anxiety, anger, sadness, joy, disappointment. The human experience involves experiencing a diversity of emotions.
Anxiety serves a purpose and not all anxiety is a bad thing. Some questions to allow your patients to think about include – What could anxiety be telling you? What purpose is anxiety serving for you?
You are also capable of feeling more than one emotion at a time. Patients can often get consumed with feelings of anxiety. There are other emotions present at times as well. Your patients should explore sitting with multiple feelings at once. Feeling anxious and brave. Fearful and courageous. Strong and vocal. Help empower your patients of this as you are working through medication management with them.
These tips will help you stay the course of effective, long term treatment of your patient’s anxiety. If you want to delve a bit deeper in treating mental disorders, you can check out this free 60 minute training for how to diagnose and treat mental disorders.
If you want my most detailed, step-by-step support, you can sign up for my Mental Disorders Crash Course.