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Running head: Anxiety diorders therapy and medication

Anxiety Disorders: Medication and Cognitive Behavioral Therapy


Hector Orendain Licn
City University of Seattle

Anxiety diorders therapy and medication

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Abstract

This paper intends to elucidate anxiety disorders main treatments, one being
psychopharmacological treatment and the other cognitive behavioral treatment, in order for the
reader to comprehend its main differences and how using them individually or combined can
change the course of the disorders course of action. This essay will also introduce the
benzodiazepine course in the GABA receptor system for it to understand how is that
neurochemicals act in behaviors related to anxiety. Finally, aspects of substance abuse will be
commented briefly for the reader to understand some side-effects of pharmacological treatment.
Keywords: anxiety disorder, medication, CBT, benzodiazepines, GABA, substanceabuse.

Anxiety diorders therapy and medication

Anxiety Disorders: Medication and Cognitive Behavioral Therapy


According to the National Institute of Mental Health (as cited in Anxiety and Depression
Association of America [ADAA], 2014), anxiety disorders are the most present mental illness in
the United States; this disorder affects 40 million adults age 18 and older, or in other terms, 18%
of the population are submerged in this anguishing pathology. This disorder costs the U.S. more
than 42 billion dollars a year, reaching one-third of the nations total mental health bill (The
Journal of Clinical Psychiatry, 1999).
Anxiety disorders are highly treatable often with a good prognosis; however, only about
one third of those suffering it receive the treatment (ADAA, 2014). Anxiety and fear happen to
be confused often in many places of the world, with population with a scarce education in mental
health treating these two variables in the same way or ignoring the fact that there is something
called anxiety. This can impact socially the lives of many people who happen to have
pathological distress, because they cant treat their mental health issue the correct way.
Fear is a healthy adaptive response to a threat or a danger perceived by the human for
them to run or confront the dangerous stimuli with the objective to ensure their integrity and feel
safe. However, fear can be maladaptive or pathological when its produced during a neutral
situation or a non-threatening event that is perceived as dangerous or a representation of a
potential threat (Beck & Clark, 2010). This means that fear is a primitive and automatic
neurophysiological state of alarm that contains a cognitive evaluation of a threat or an imminent
danger for the persons integrity and personal security being that physical or psychological (Beck
& Clark, 2010). Anxiety is a complex cognitive, behavioral, emotional and physiological system
that activates when the person anticipates events or circumstances that are perceived or judged as

Anxiety diorders therapy and medication

threatening or extremely disturbing because they seem unpredictable, incontrollable, and may
potentially damage the patients most vital interests (Beck & Clark, 2010)
Neurochemical basis of anxiety
Neuroanatomic circuits that trigger fear and anxiety behaviors are modulated by a range
of chemical neurotransmitter systems which include the peptidergic neurotransmitters, the
monoaminergic transmitters, serotonin (5-hydroxytryptamine or 5-HT) and dopamine (DA), and
the amino acid transmitters GABA and glutamate which will be commented shortly. These
chemical systems are important in regulating the adaptive functions of preparing an organism for
a response to threat or stress, this behaviors or actions can be in the form of increased vigilance,
modulating memory, storing energy and elevating the cardiovascular system. However, these
responses can become pathological if they are activated inappropriately.
Gamma-aminobutyric acid, or GABA is one of the most abundant neurotransmitters of
the central nervous system and act as a neve transmission inhibitory calming the nervous activity
(Denver Naturopathic Clinic, n.d.). This can be related to anxiety disorder and their high physical
activation, people with a neuropsychological originated anxiety disorder can be found in a
decrease in the GABA receptor system, this means that medication related to this neurochemical
channels are essential in order to reduce the anxiety symptomatic picture. This is where
benzodiazepines show up as the neurochemical that reduces anxiety which is also called
anxiolytic. Benzodiazepines are prescribed often through the name of Valium, Xanax and
Klonopin. These are often used as tranquilizers or anxiolytics for people to cope with major life
stress events.

Anxiety diorders therapy and medication

Central Benzodiazepine-GABA-Receptor system


Anxiolytic drugs affect directly the GABA receptor in which chlorine ions (Cl-) are most
abundant. First, the GABA

excites the receptor which produces an influx of CI- ions

through synaptic pore that hyperpolarizes the receptor making it hard for it to propagate an
action potential effectively inhibiting or decreasing the neurons firing rate affecting directly the
patients behavior.
The GABA

receptors have binding sites for other chemicals other than GABA, one

site is special for barbiturates which are prescribed as a sleeping medication but is used mainly
for anesthesia before surgery. And another site is special for benzodiazepines. An activation of
each site promotes the influx of chlorine ions, but in different ways. Activating the
benzodiazepine site promotes the natural action of GABA by increasing the frequency that the
ion pore opens in response to the GABA chemical (Kolb & Whishaw, 2014). This is extremely
important to notice because having this two sites that can be triggered with external elements like
alcohol (barbiturate) and anxiolytics (benzodiazepines) we must educate the patient not just with
the right dosage but also with the right use of the medication, this is why is strictly prohibited to
drink alcohol or take sleeping pills during a benzodiazepine treatment and vice-versa; this can
react as a hyper sedative effect that can lead to a coma or even death.
Treatment: BZD vs CBT
Benzodiazepines abuse
This treatment can be subjected to an abuse for people that arent using them for
legitimate reasons, and can produce a physical addiction for patients that have been using
tranquilizers all their lives and are beginning to generate tolerance to the medication, needing
more dosage every time to fulfill the therapeutic objectives. The wide availability of these

Anxiety diorders therapy and medication

tranquilizing medications can become very alarming due to the increasing overdose deaths
consumers have reached.
The National Institute on Drug Abuse (2015) had gather data regarding overdose deaths
from benzodiazepines.

This graph elucidates the number of deaths from benzodiazepines, the chart shows the
total number of overdose deaths from 2001 to 2014. The chart is overlayed by a line graph that
differentiates the deaths by females and males (NIDA, 2015).
Also, benzodiazepines withdrawal has similar effects of those from the alcohol
withdrawal syndrome that has to be medically supervised because of the extremely painful
effects this can have. Benzodiazepine withdrawal must be managed by administrating long acting
benzodiazepines at a dose high enough to abort the symptoms with gradual suspension when the
patient has regained control of the cravings (Marin & Escobar, 2013).

Anxiety diorders therapy and medication

Benzodiazepine abuse symptoms


High doses of benzodiazepines can produce dangerous side effects. Signs and symptoms
that relate to those of a BZD overdose include: Drowsiness, confusion, dizziness, blurred vision,
weakness, slurred speech, coordination issues, breathing deficiencies and even coma. (WebMD,
n.d.)
BZD treatment can be extremely helpful in severe cases of anxiety or epileptic seizures
however, this treatment must be used with caution because of the physical dependence that can
result and the withdrawal symptoms this produces.
Cognitive behavioral therapy (CBT) for anxiety disorders
Beck and Clark (2010) state that strategies for cognitive treatment base on the cognitive
model of anxiety that has been described at the beginning in this paper. This treatment is
designed to treat the thought process, evaluations and anxiety triggering beliefs. The strategies
function as a modifier of the cognitive perspective the client perceives from danger to reduce it
to an acceptable minimum level and offer to the client a wide set of strategies to face new danger
in an adaptive way. The authors also mention that cognitive therapy must focus on these 6
interventions.
1.
2.
3.
4.
5.
6.

Change the threat focus


Attention directed to the evaluation and belief processes
Modify the biased belief and perception of the threat.
Normalize fear and anxiety
Strengthen personal effectiveness
Adaptive focus towards seeking security

Mental health facilitator often think that medication is necessary in order to reduce
anxiety disorders, and this can be accurate, some anxiety disorders can be effectively treated with
benzodiazepines, however some studies have concluded that exposure based CBT plus BZD is

Anxiety diorders therapy and medication

superior to using psychopharmacological monotherapy, especially if used at the end of an acute


treatment Marks et al, (1993) (as cited in Wurz & Sungur, 2009).
However, this study states that at the end of the acute treatment combining BZD and
exposure-based CBT the benefits may not persist and possibly even be counterproductive during
the follow-up of 6 to 12 months after the treatment termination. A short-term advantage of
combination therapy (BZD and CBT) over exposure based CBT alone may result in a worse
long-term outcome of combination therapy compared to CBT monotherapy (Wurz & Sungur,
2009).
An important conclusion to this clinical approach of understanding the diverse treatments
a disorder so common like anxiety is that pharmacological treatments must be used with extreme
caution. Overdosing is a very important factor in possibly reducing the amount of prescriptions a
psychiatrist gives to their patients; instead we must challenge the patients to undergo a
psychological treatment like CBT or other therapies that can reduce the symptomatic picture
without having side-effects or possibly a physical dependence issue. Research has stated that
maybe CBT monotherapy is even better than combined therapy, however more research has to be
done in order to effectively conclude that psychological treatment is better in the long term than
medical treatment. This is a very difficult research topic because various interests like those from
the pharmaceutical industry is involved. For now, we must focus our work in educating the users
of prescription drugs the best way to use this treatment and treating non-prescription users to
reduce a possible addiction problem.
References
Anxiety and Depression Association of America. (2014). Facts and Statistics. ADAA. Retrieved
from: http://www.adaa.org/about-adaa/press-room/facts-statistics

Anxiety diorders therapy and medication

Denver Naturopathic Clinic. (n.d.). GABA: Gamma-Amino Butyric Acid. Retrieved from:
http://www.denvernaturopathic.com/news/GABA.html
Marin, H., Escbar, J. (2013). Clinical Psychopharmacology: A Practical Approach.
Singapore: World Scientific Publishing Company.
National Institute on Drug Abuse. (2015). Overdose Death Rates. Retrieved from:
https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
Kolb B., Whishaw I. (2014) An introduction to Brain and behavior. Worth Publishers:
New York
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Last Name, F. M. (Year). Book Title. City Name: Publisher Name.
Wrz, A., & Sungur, M. Z. (2009). Combining Cognitive Behavioural Therapy and
Pharmacotherapy in the Treatment of Anxiety Disorders: True Gains or False Hopes?. Klinik
Psikofarmakoloji Bulteni, 19(4), 436-446.