Reflections From A Chair Thoughts about psychotherapy and mental health issues

This post will return to anxiety treatment topics. More specifically, I would like to address the issue of treatment approaches or techniques.

As my earlier posts on this topic surely indicate, I am a strong adherent of cognitive behavioral therapy (CBT). However, in my experience, this is not always the beginning and end point of psychotherapy for anxiety.

Let’s start with the goals of treatment for anxiety disorders.

Often, treatment for anxiety and other psychiatric illnesses is called successful if the patient has fewer symptoms and is able to resume something close to a normal lifestyle. Even if some symptoms remain, there is general improvement in the person’s overall condition.

However, as Stephen M. Stahl, M.D., Ph.D. points out, “it is necessary to complete the job by aiming for complete recovery, removal of all symptoms, and return to wellness as the goal. ”

He finds this is important because a partial recovery can “increase the likelihood of relapse, poor outcome, future treatment nonresponsiveness, residual disability, and even suicide.”

Relapse into another bout of illness is a significant problem. In 2004, the Anxiety Disorders Association of America issued a report entitled “Improving the Diagnosis & Treatment of Generalized Anxiety Disorder.” The authors write that “GAD has a relatively low rate of recovery when recovery is defined as a reduction to only 1 or 2 symptoms with a subjective sense of returning to normal.” They cite another article, by Martin B. Keller, that reported that 80 percent of patients do not achieve that level of recovery.

Furthermore, a study reported in the journal Psychotherapy and Psychosomatics found that persons with panic disorder with agoraphobia treated with medications only had a relapse rate of 78.1 percent in the first year.

Another study, “Fluoxetine, Comprehensive Cognitive Behavioral Therapy, and Placebo in Generalized Social Phobia,” looked at the response rates of a variety of treatments. 50.9 percent of patients treated with Fluoxetine (Prozac) showed a positive response. 51.7 percent had a positive response to 14 weeks of group cognitive behavioral therapy. And those treated with a combination of Fluoxetine and cognitive behavioral therapy had a positive response rate of 54.2 percent. Another way to state these findings is that no matter what mix of Fluoxetine and/or CBT was utilized, more than 45 percent of the patients did not significantly improve. Also, please note that we are talking about “positive response” here and not the more difficult to achieve full remission from the illness.

Pretty discouraging numbers, especially if the goal of treatment is Stahl’s “gold standard” of complete recovery.

With these results, it seems fair to say that neither medications nor CBT nor a combination of them can claim to have solved the riddle of treating anxiety disorders.

Before going any further, let me rush to say that I am not in any way, shape or form suggesting that neither medications nor CBT are valid treatments.

I was first trained in the days before the arrival of Prozac (circa 1987), Xanax (circa 1981) was not a popular medication yet (at least in the settings where I worked and studied at that time), and Lexapro (circa 2002) was not even a gleam in the eyes of Forest Laboratories. So I have seen the before and after treatment pictures. Never would I want to return to an era when such medications were not available to the people who benefit from them.

My training started after the development of cognitive behavioral therapy (circa 1967). And I cannot imagine removing that from the treatment arsenal either.

What I am advocating is that, so far, our knowledge and understanding of the causes of and treatments of anxiety and many other emotional disorders is limited. Given that, there is no one “cure” for these illnesses. Some anxious people, for instance, seem to not respond adequately to Prozac but do just fine on Zoloft and vice versa. Similarly, in my experience, some patients do quite well with CBT alone whereas others also benefit from adding a psychodynamic approach or a family systems technique after initiating CBT. (Please note that I say adding another approach after CBT is started. From a purely practical point of view, I usually find the quickest route to symptom reduction through CBT. Whatever symptoms remain after that are targets for other treatment methods.)

In my practice, my aim is for complete symptom elimination by whatever clinically sound and effective means are at my disposal. To achieve that, I am eclectic in the use of treatment styles and pragmatic in the sense that I am interested in empirically finding the optimal results for the specific person in my office at that time.

Let me end this post on an upbeat note.

This is the story of my quickest treatment of an anxiety disorder. A woman in her mid-thirties came to my office. She complained of panic attacks that were increasing in frequency and intensity.

She was confused about why she should have panic attacks. She had a recent physical check up and was in good health. She described her life as a very happy and fulfilling one. Her marriage was solid and rewarding. Financially, she was rather well off. This woman had a number of friends and was physically active. She watched her weight and ate a healthy diet. No one in her family had a history of anxiety or other emotional problems. She did not use alcohol or smoke cigarettes. She denied any history of traumatic events. There were no recent stresses in her life to account for the panic attacks.

What had changed at about the time of the onset of the panic was that she began having a single cup of coffee several times per week.

I suggested that she stop drinking coffee and to call me in a few weeks if the panic attacks persisted. She never called.

By sheer coincidence, I ran into her about a year later. This woman had not had any coffee since our meeting and the panic attacks had gone away. She continued to have a full and happy life.

Other than telling a nice story, my point is that in this case treatment was quite pragmatic. It was limited to recommending that she avoid caffeine. She did not want a referral for medication, she did not need CBT or psychodynamic treatment. Unfortunately, this is a very rare situation. But, again the point is that the treatment selected was based upon her specific circumstances and needs with the goal of eliminating her symptoms.

In future posts, I will discuss more complicated treatments of anxiety disorders.