Anxiety: The Latest Research and Newest Findings for Better, More Effective Treatment
This past week I took my kids to the Smokey Mountains for a getaway. Any time away from my doctor duties is a welcome escape. Add the mountains, endless hiking trails and zero cell coverage and I'm in heaven.
One thing my wife and I often find ourselves doing on vacation is people watching. Maybe this is a compulsion or maybe it's our inescapable callings in the medical field where we constantly read cues and symptoms in sleuth-like fashion to crack the code and help people. As we hiked on a particularly busy trail to a well-visited waterfall in the park we were followed by two young women who spent the hike sharing and swapping notes about their problems with anxiety. To my wife and I this was ear candy as we studied them in our rear view and listened intently, eaves dropping on their issues of anxiety. We later reflected that these two women seemed to further each other's understanding of their individual issues toward helping on at least some level.
Indeed, recent research is supporting that personal and professional understanding of an individual's anxiety is paramount in the overcoming this problem. Several factors are important in this process.
Got anxiety? You're not alone
Recent estimates put anxiety at the top of the prevalence charts for mental illness in America. It is estimated that 18% of adults and an astonishing 30% of young people suffer from anxiety disorder. The disorder occurs more commonly in women than in men. While everyone worries to some degree, anxiety disorder is separated out as having chronic worry for at least six months out of proportion to the worry-provoking stimuli. Often times worry occurs with no provoking factor whatsoever. Anxiety often runs with other mental health problems such as depression, panic disorder and attention deficiency disorder.
The Traditional Approach
Standard therapy in treating anxiety involves a "one or both" scenario. Those with anxiety are generally offered pharmacological (medication) therapy or talk (counseling) therapy.
SSRIs: The most common medications, Selective Serotonin Reuptake Inhibitors (SSRI's), aim at boosting stores of the serotonin neurohormone in the brain. Serotonin is a chemical messenger in the brain that, when deficient, can lead to anxiety, depression and/or panic disorder.
Counseling: Talk therapy generally centers around a technique called Cognitive Behavioral Therapy (CBT). CBT works to identify the cause of the anxiety and replace the responsive anxiety with positive behaviors and emotions.
While evidence exists that both of these routes work and that they even work better when both incorporated, it seems to be a bit of a cookie cutter approach.
The New Approach
Evidence is emerging that a more meticulous deciphering of an individual's anxiety will yield better results with appropriate therapy. This comes through improving understanding of brain function.
CBT: Within the realm of CBT, a subtype called exposure-based therapy is considered one of the best therapies for anxiety. This type of therapy involves repeatedly exposing a patient with gradually increasing intensity to an anxiety-inducing stimulus to both understand and desensitize the response. Curiously, though, it works wonderfully for about half and not for the other half. Experience has shown that children without emotional trauma are the best candidates and research is beginning to confirm why this is so.
Exposure Therapy: Studying exposure-based therapy and applying our understanding of brain function, animal models and functional brain mapping technology has revealed some important new understandings in this realm. In general, it was shown that fear causes increased activity in a deep area of the brain called the amygdala. It has long been known that the amygdala is key in the regulation of our emotions. It is in this area that anxiety becomes a deep brain loop of anxiety-provoking memory. Functionally, success in dealing with fear has been observed as increased activity in an area of the brain called the prefrontal cortex (PFC) leading to decreased amygdala activity in the presence of exposure-based therapy. The prefrontal cortex is important in higher level reasoning and brain function. Exposure CBT relies on a PFC-amygdala link where desensitization can occur. In other words, therapy aims to reason things out in the PFC to put a damper on the amygdala anxiety memory loop.
An Anxiety Study
So, the correlation has been made between an intact and able prefrontal cortex desensitizing anxiety activity in the amygdala. Further study has worked to tease out the haves and the have-nots in regards to this link. Who does it work for and who does it not work for? This research has been creative in giving objective data to something subjective like anxiety.
One study looked at children and adolescents with anxiety who were raised in orphanages where controlled stressors took place. Even though there were a number of variables that could not be accounted for in each subject's past, a general trend was seen that children with the early exposure to stress in the orphanage were helped less by exposure CBT than their anxious controls. The older children in the study were helped the least by exposure CBT. From this, a preliminary conclusion can be drawn that early stress reduces the PFT-amygdala link and its ability to deregulate.
Runs in The Family
Family traits have also been noted to prevail with anxiety. In other words, it runs in families. As science maps the genome, findings are being revealed for the genetic expression of a number of traits linking genetic issues with physically expressed issues. In regards to anxiety, it was found that defective coding in the production of a brain chemical called brain derived neurotrophic factor (BDNF) is linked to anxiety and passed on as a trait. BDNF is important in maintaining growth and longevity of the nerves in the brain. In animal models where BDNF is deficient, it was found that exposure therapy was not as effective as compared with controls. Conclusions can be loosely made from this that genetic factors in anxiety reduce the PFT-amygdala desensitization.
Finally, therapists have long noted that some of the most challenging anxiety patients to treat have those with a history of trauma or post-traumatic stress disorder (PTSD). History of emotional trauma in patients compared to anxious counterparts without a trauma history shows decreased responsiveness to exposure CBT. Based on these findings, conclusions can be made that emotional trauma reduces the PFT-amygdala desensitization.
What Does It All Mean?
While this is a lot of theory and science, important considerations can be made directing therapy. I have enough of a challenge coaxing my patients into seeing a therapist. Engaging in futile therapy may amount to nothing more than a waste of time or claims that therapy in general doesn't work.
In the subcategories of patients with a high probability of reduced PFT-amygdala desensitization, different technique is needed. Brain exercises to rev up the prefrontal cortex to suppress the anxiety generated from the amygdala (exposure cognitive behavioral therapy) might not work in these groups. Exciting evidence is emerging, however, that it is possible to bypass the prefrontal cortex link with therapy based on altering the anxiety driving memories within in the amygdala. In theory, memories from the amygdala (anxiety) can be tweaked within a short time after retrieval, altering them for when they come out again. Splicing in positive memories can help to dampen triggered anxiety outside of the therapy session. Research in this arena has been encouraging, provoking anxiety and then reflexively attaching it to a positive memory.
Treating Your Anxiety
My point in dragging the reader on this heavy stroll through psychological theory, neurobiology and chemistry is to bring an appreciation for the crossroads of art and science that is psychology. I also want to give hope that professional understanding is growing and help is possible in dealing with anxiety. I further believe, in the sense that knowledge is power, that understanding the basis of anxiety not only legitimizes this problem but helps in the recovery process. If you are looking to engage in talk therapy for your anxiety, find someone whom you feel able to talk with openly who is capable of personalizing your therapy based on the factors with which you present. If you have children who are anxious, treat early to prevent chronic and potentially disabling mental illness.
Meanwhile, know that scientists continue to untangle the web of brain and emotion toward bettering treatment options for anxiety and other mental health problems.