What does it mean to be treatment-resistant
when it comes to anxiety?
That's what I'm talking about today.
I'm going to define four terms for you.
Treatment resistance, treatment refractory,
medication intolerance and target symptoms.
I'm Dr. Tracey Marks, a psychiatrist
and I make mental health education videos.
We usually refer to treatment resistance
when we talk about other disorders
like schizophrenia and depression.
And with those disorders,
treatment resistance is failing to respond adequately
to two medications used at different times.
So you take one and it didn't work well enough or at all,
and then you take another one and still no luck.
But it's a little different with anxiety.
With anxiety, some experts consider treatment resistance
to mean that you failed two rounds of medication
and a course of cognitive behavior therapy.
Actually, the more effective treatment
for anxiety is cognitive behavior therapy
when it's delivered properly,
but the more common treatment that people get is medication.
Why?
Because therapy is time-intensive, which is usually weekly,
and not everyone can afford
to spend a hundred dollars or more per week
if your insurance doesn't cover it.
And then there's the issue
of finding a therapist trained to do CBT.
Here's the gist of CBT.
CBT approaches your anxiety from three angles.
One is your physical response to anxiety
like chest tightness or nausea.
You learn exercises to reduce those symptoms
such as deep breathing from your diaphragm
or progressive muscle relaxation just as an example.
A second component is correcting faulty thinking
that keeps your anxiety going
like decatastrophizing your expectations
or challenging inaccurate assumptions.
Then a third component is changing the things
that you do to cope with anxiety like avoiding things.
I talk about avoidance in my video on Safety Behaviors.
Exposure therapy with response prevention teaches you
how to allow yourself to face the feared object or situation
and manage your anxious feelings
without engaging in the compulsive rituals
that you would normally use to reduce your anxiety.
Exposure can also serve to desensitize you
to things like avoiding social criticism
if you have social anxiety,
or internal sensations if you have health anxiety.
CBT has been well-studied
and shown to be superior over medication,
but the results depend
on the skill of the therapist delivering the treatment
and your commitment to completing the exercises
and using the techniques on your own.
So if you don't do well with therapy,
it's more like you have a pseudo-resistance
because other factors kept you from benefiting
and it's not because you're such a difficult case
that you can't be helped.
Medication treatment is much more accessible
because you don't always have to see a psychiatrist.
It's fairly common for primary care doctors
to prescribe medication for anxiety.
The first choice of medications used
is selective serotonin reuptake inhibitors
like Prozac and Lexapro,
and then the serotonin norepinephrine reuptake inhibitors
like Effexor and Cymbalta.
Benzodiazepines like Klonopin and Xanax
are used at the beginning
while you're ramping up on the antidepressant,
but they're not recommended for long-term use
because of their habit-forming potential
and their long-term effects on slow thinking
when you take them regularly for years.
It's like they make you not as sharp.
If we go back to using medication treatment resistance
for depression as a reference,
it's a failure to respond
to an adequate trial of two antidepressants.
What's an adequate trial?
It's six to eight weeks at a dose that's usually higher
than what you would use to treat depression.
For example, a typical depression dose of Prozac
is 40 to 60 milligrams.
Some people can get better on less,
but this is the most common range.
Usually, anxiety responds better
to 60 to 80 milligrams.
I've seen people who've come to me saying
that their medication doesn't work.
Their family doctor started them on Prozac
and they've been taking 40 milligrams
for the past six months.
In this case, it's not a treatment failure
until you've tried a higher dose,
especially if the lower dose helped a little,
but not enough.
If that's the case, you should expect
that if you increase the dose, you'll see an improvement.
Another way you can experience a pseudo failure
or of the appearance that nothing is working
is if you have to stop taking a medication
because of side effects.
These medications can cause a lot of nausea or weight gain,
or sexual side effects.
If you've taken six different medications
that all cause problems for you that made you stop them,
you're not treatment resistant.
We call this medication intolerance
when you can't reap the benefits from a medication
because the side effects get in the way.
Medication intolerance can be a reason
that you can't find a medication that works,
but it doesn't mean your anxiety
is treatment refractory.
Refractory means the condition doesn't respond
to the expected treatments.
We generally use refractory
to refer to the condition
and resistant to refer to the patient response
to the treatment.
But sometimes people just use the terms interchangeably.
How do you know if the medication is working?
What do you look for?
Sometimes it's hard to tell when you've got a lot going on.
The way you tell
is to focus on target symptoms.
Target symptoms are the things
that you notice that are not right with you.
You want to look at the way
you feel physically and emotionally,
what you're thinking about,
and the things that you do that are a deviation
from your usual.
Write these things down,
preferably in a journal or something that you can keep
and refer to later.
Also think about how often you have these experiences.
You may say, "I have no idea."
Well start with, does it happen daily?
Does it happen multiple times a day?
Is it frequent enough to happen weekly?
Or is it more like a few times a month?
And you're estimating. You don't have to be exact.
But once you have a sense
of how often you have these symptoms,
you can then see if the symptoms lessen in frequency
or intensity after you start the medications.
Here's an example.
Let's say on most mornings you feel fine,
but maybe once a week or so,
you wake up feeling on edge,
with a headache from grinding your teeth during the night.
You work remotely at home and sudden loud sounds,
like your neighbor banging the trash can or a car honking,
startles you,
but then you can't seem to come down from that state,
and you spend hours irritated and unfocused.
If you're really aggravated, you feel chest pain.
Every night, you have trouble falling asleep before midnight
because of feeling wired and worrying about things.
Notice how I laid at out.
I started with how you wake up,
what your daytime experiences are like,
and then what it's like at bedtime for you.
If you think about your day like that,
you can identify how your target symptoms look
throughout the day.
So from this example, here are your target symptoms:
Morning anxiety experience as mental and physical tension
and sometimes headaches;
attacks of irritability and poor focus triggered
by loud unexpected sounds;
trouble falling asleep with worry.
I start you on Lexapro five milligrams,
which is a very low dose,
but since people with anxiety or more prone
to feel more anxious when you start the medicine,
it's best to ease you onto the medicine with a low dose.
My target dose for you
is 20 milligrams,
but sometimes people with anxiety need 30 to 40 milligrams.
If you have a positive response to the Lexapro,
you may notice that you go a couple of weeks
without a headache in the morning.
If you do have one, you can barely feel it.
Looking back over your month,
you remember that your neighbor
was doing some very loud yard work
but you don't even remember it bothering you.
You still have trouble falling asleep,
but you do have nights
where you feel sleepy around 10:00 pm.
It's not every night but a few nights out of the week,
and those few nights are improvement.
Because we all can have some amount
of normal reactionary anxiety,
I think it's hard to judge just how much your medication
should be doing for you.
I usually tell patients not to expect to be anxiety-free
because there will always be something that can wind you up.
But with normal everyday anxiety reactions,
the anxiety shouldn't interfere with your daily functions.
So I think a best case scenario is
that the medication brings the intensity and frequency
of your anxiety experiences down several levels
to where you can still function in your usual way.
But then you need to implement other cognitive, behavioral,
or lifestyle practices
to manage the remaining symptoms that are still present
even though you're taking medication.
Using the previous example,
that may mean integrating breathing and meditation exercises
into your evening wind down to help you sleep,
or journaling to address your worry thoughts.
Take a look at this video
that talks about how to manipulate your vagus nerve
to reduce anxiety
and this video on why antidepressants
can make you feel worse at first
when you first start taking them.
And that video explains why people
with anxiety should start at a lower dose of antidepressant.
Thanks for watching.
See you next time.