The Endowment for the Advancement of Psychotherapy

Anxiety Disorders Module

What are anxiety disorders?

Anxiety disorders comprise a broad range of psychological problems that affect more people in the United States than any other mental disorder.1 Not only are anxiety disorders common, they will effect approximately one in five of all people in their lifetime representing an enormous burden.2 Anxiety can be helpful in that it protects us from danger, prepares us for important events, and warns our bodies when immediate actions are needed to ensure our safety. While anxiety can be adaptive, for many people it becomes so severe and uncontrollable that it is overwhelming, even in everyday situations. When anxiety becomes disabling enough to interfere with daily activities, mental health clinicians may help to diagnosis an anxiety disorder. Even with proper diagnoses, only about one-third of those suffering from an anxiety disorder receive treatment despite effective treatments being available.

[emaillocker]

Anxiety disorders include various psychiatric illnesses including generalized anxiety disorder (GAD), panic disorder, obsessive-compulsive disorder (OCD), social anxiety, and specific phobias, all of which will be described more in depth below. It is also common for those suffering from anxiety to have other types of psychological problems further leading to more profound impact. One study found that almost three of every four people who suffer from an anxiety disorder will also have an episode of depression in their lifetime while another study found almost one in every 10 people with an anxiety disorder will also have problems with substances.3,4 Despite the significant burden of anxiety on people and their family members, treatments are effective when utilized, most often including medications and psychotherapy.

What are the types of anxiety disorders?

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is characterized by excessive or persistent worry that is difficult to control. Often people will experience significant worries that are often caused by the common concerns of everyday life including family problems, difficulties at work, health issues, or financial issues. As a result of excessive worrying, people may have difficulty concentrating, problems with sleep, fatigue, sweating, nausea, irritability, and muscle tension. What sets apart the normal experience of worrying is that the anxiety is so severe that it impairs a person’s ability to work or maintain relationships with friends, family, or loved ones.

Panic Disorder

For some people, anxiety occurs in relatively brief, intense episodes rather than prolonged excessive worrying. In panic disorder, people experience panic attacks that are characterized by sudden periods of intense anxiety, usually accompanied by sweating, dizziness, shortness of breath, racing heart, and sometimes chest pain. When panic attacks are severe, one may also fear that they are losing control of their mind while having a sense of impending doom. Some individuals believe they are having a cardiac event and are only reassured after seeing their physician or going to the Emergency Room where tests are conducted. Panic attacks are often sudden, without a precipitant that the patient is aware of and usually peak within 10 minutes. For some people, the experience of having a panic attack is so severe that they may even be afraid to leave their homes or be in public (called agorophobia).

Social Anxiety

Social anxiety disorder is characterized by intense anxiety and self-consciousness while in everyday social situations. As opposed to minor anxiety experienced by everyone when meeting new people or even speaking in public, those with social anxiety disorder have an intense fear that they are being judged negatively by others or that they may do things to embarrass themselves. Physical symptoms may accompany their anxiety including trembling, nausea, shortness of breath, difficulty speaking, and sweating. Like other psychiatric disorders, symptoms are severe enough that they may interfere with school, work, or maintaining relationships.

Specific Phobia

A specific phobia is characterized by a persistent fear that is excessive and brought on by a specific situation or object. Situations may include flying, fear of heights, seeing blood, receiving an injection, or seeing a certain animal such as a spider. As opposed to normal fears, a specific phobia is marked by an intense and irrational anxiety that is inconsistent with the level of danger presented by the situation. People with specific phobia disorder may also experience intense anxiety in anticipation of a situation involving the feared object which may lead to a pattern of avoidance or even panic attacks.

Obsessive-Compulsive Disorder

Obessive-compulsive disorder is characterized by persistent and recurrent thoughts, urges or impulses (obsessions) that generate anxiety often coupled with associated behaviors or mental acts that attempt to reduce distress (compulsions). For example, one may have an intense fear their hands or their thoughts are dirty or dangerous with subsequent compulsion to wash one’s hands throughout the day or to avoid leaving one’s home. Other examples may include obsessions with certain numbers and associated compulsion to count or add numbers. While many people check locks before leaving their home or wash their hands throughout the day, people with OCD may spend multiple hours per day engaged in these types of behaviors which interferes with work and relationships. Often people with OCD are distressed by their symptoms and are able to realize their behaviors may be excessive. However, despite this realization, they are unable to stop their obsessions and compulsions and in severe cases, their lives are crippled as a result.

What does psychodynamic psychotherapy look like for anxiety disorders?

As is consistent with psychodynamic psychotherapy, the person will meet with a psychotherapist at least once a week for an extended period during which time the person will be encouraged to speak openly about their anxiety symptoms, past history of anxiety, prior and current relationships, and often their life history in their family of origin. As opposed to other types of psychotherapy, the exploration of anxiety symptoms and their psychological meaning are often the focus of the treatment. Anxiety can be seen as a signal that a situation, thought or wish is threatening and an awareness of the source of the threat can lead to increased mastery and a decrease in symptoms. Psychodynamic psychotherapy may be particularly helpful with anxiety disorders as an insight-oriented psychotherapy serves to understand one’s patterns in relationships or thought processes that are often at the center of anxiety symptoms. Often, anxiety disorders may result from our patterns of coping with stressful situations. In addition, the exploration of the role of anxiety in a person’s life is encouraged along with how one’s upbringing may have contributed to present symptoms of anxiety.

Does psychodynamic psychotherapy work for anxiety disorders?

There have been numerous studies evaluating the efficacy of psychodynamic psychotherapy for anxiety disorders with primarily positive findings. For generalized anxiety disorder described above, there have been several studies with evidence of improvement in anxiety symptoms but no comprehensive, large scale study of psychodynamic psychotherapy has been performed. However, one smaller study with less than 30 subjects conducted by Leichsenring in 2009 showed that a course of psychodynamic psychotherapy for 30 weekly sessions was as effective as cognitive behavior therapy (another form of psychotherapy) in the treatment of generalized anxiety disorder.5 This study clearly shows that short-term psychodynamic psychotherapy is beneficial in treating generalized anxiety disorder but a larger study is needed to further support these findings. Psychodynamic psychotherapy may be a well-suited treatment for generalized anxiety disorder as often anxiety may be worsened by difficulty in relationships or problems coping with stress, both of which can be addressed in a psychodynamic psychotherapy. Future research may help to clarify the specific role of psychodynamic psychotherapy in the treatment of generalized anxiety disorder.

There have been several rigorous studies showing that psychodynamic psychotherapy is an effective treatment for panic disorder. In a recent study published in 2013, a 3-month dose of twice weekly psychodynamic psychotherapy lead to resolution of symptoms of panic disorder in 44% of patients.6 Furthermore, at six months after treatment concluded, 55% of persons showed resolution of panic disorder. In a similar study published in 2007, intensive twice-weekly psychodynamic psychotherapy for 12 weeks conducted by psychoanalysts was more effective than relaxation techniques in reducing severity of panic symptoms.7 When compared to medication treatment alone for panic disorder, psychodynamic psychotherapy coupled with medications showed a significantly lower rate of relapse into panic disorder.8 This suggests that psychodynamic psychotherapy can be effective at reducing the recurrence of panic symptoms both alone and in combination with medications.

In regards to evidence for the treatment of social anxiety disorder, there is a substantial body of research that psychodynamic psychotherapy is an effective treatment. In a study published in 2014, psychodynamic psychotherapy was just as effective as cognitive behavioral therapy and showed remission rates of close to 50% after 3 months of treatment.9 One year after treatment ended, 75% of those receiving psychodynamic psychotherapy showed resolution of symptoms. In an even larger study conducted in 2014 by Leichsenring et al., similar results of psychodynamic psychotherapy were observed after 25 sessions of psychotherapy.10 More recently, a study from 2015 by Moghadam et al. showed that 25 sessions of psychodynamic psychotherapy was as effective as medication (sertraline) in the treatment of social anxiety. Results from this study also showed a statistically significant improvement in symptoms of social anxiety as compared to patients who had not begun treatment while on a wait list.11

Often, medications may be recommended in treating social anxiety. When compared to taking medications alone, medications with group psychodynamic psychotherapy for 3 months was shown to be significantly more effective.12 Accordingly, psychodynamic psychotherapy is viewed as an effective treatment for social anxiety disorder.

In regards to evidence for treatment in obsessive-compulsive disorder, there have been no rigorous studies examining the efficacy of psychodynamic psychotherapy. However, there has been one smaller study examining the effect of psychodynamic psychotherapy with medications versus medications alone. The study found no benefit with the addition of psychotherapy to medications alone suggesting psychodynamic psychotherapy may have little efficacy in OCD.13 In the future, more research is needed to improve our understanding of the role of psychodynamic psychotherapy for obsessive-compulsive disorder.

  1. Fonagy P, Roth A, Higgitt A. Psychodynamic psychotherapies: evidence-based practice and clinical wisdom. Bull Menninger Clin. 2005;69(1):1–58.
  2. Somers JM, Goldner EM, Waraich P, Hsu L. Prevalence and incidence studies of anxiety disorders: a systematic review of the literature. Can J Psychiatry. 2006;51(2):100–13.
  3. Moffitt TE, Harrington HL, Caspi A, Kim-Cohen J, Goldberg D, Gregory AM, et al. Depression and generalized anxiety disorder: cumulative and sequential comorbidity in a birth cohort followed prospectively to age 32 years. Arch Gen Psychiatry. 2007;64:651–60.
  4. Andrews G, Slade T, Issakidis C. Deconstructing current comorbidity: data from the Australian national survey of mental health and well-being. Br J Psychiatry. 2002;181:306–14.
  5. Leichsenring F, Walzer S, Jaeger U, Kachele H, et. al. Short-term psychodynamic psychotherapy and cognitive-behavioral therapy in generalized anxiety disorder: a randomized control trial. 2009; 166(8): 875-81.
  6. Beutel M, Scheurich V, Psych D. et. al. Implementing panic-focused psychodynamic psychotherapy into clinical practice. Can J Psychiatry. 2013; 58(6)326-34.
  7. Milrod B, Leon AC, Rudden M, et. al. A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. Am J Psychiatry. 2007; 164(2): 265-72.
  8. Wiborg IM, Dahl AA. Does brief dynamic psychotherapy reduce relapse rate of panic disorder. Arch Gen Psychiatry. 1996; 53(8): 689-94.
  9. Bogels SM, Wijts P, Oort FJ, Sallaerts SJ. Psychodynamic psychotherapy vs cognitive behavioral therapy for social anxiety disorder: an efficacy and partial effectiveness trial. Depress Anxiety. 2014; 31(5): 363-73.
  10. Leichsenring F, Salze S, Beutel M, et. al. Long-term outcome of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder. Am J Psychiatry. 2014; 171(10): 107-82.
  11. Moghadan MN, Atef-Vahid MK, Asgharenejad-Farid AA, et. al. Effectiveness of Short-term Dynamic Pyschotherapy versus Sertraline in Treatment of Social Phobia. Iran J Psychiatry Behav Sci. 2015; June; 9(2):e228.
  12. Knijnik DZ, Blanco C, Salum GA, et al. A pilot study of clonazepam versus psychodynamic group plus clonazepam in the treatment of generalized anxiety disorder. Eur Psychiatry. 2008; 23(8): 567-74.
  13. Maina G, Rosso G, Rigardetoo S, et al. No effect of adding brief dynamic therapy to pharmacotherapy in the treatment of obsessive-compulsive disorder with concurrent major depression. Psychotic Psychosom. 2010; 79(5): 295-302.

[/emaillocker]