Treatment-Resistant Anxiety

The diversity of anxiety disorders are the most prevalent of the DSM-IV-classified psychiatric conditions as a group (estimated lifetime prevalence of 24.9% according to an early nineties survey). As a widely under-diagnosed and under-evaluatedcondition, most of its economic impact on health care systems comeswith the associated physical symptoms rather than with the (generallyinadequate) treatment itself.

As a media subject,anxiety disorders doesn’t have neither the “flavour” of bipolar’selated euphoric mania (which apparently generates a huge number ofstupid young people who “secretly” self-diagnosed themselves wanting tolive an Andy Behrman story),nor the excrutiating pain of clinical, neurologic-based deep majordepression. There’s somewhat of a jest in media descriptions of peoplewho can’t do a number of minor daily tasks such as drive a car or leavethe house, and also a general sense that that’s a quite manageablecondition easily solvable with few sessions of cognitive-behavioraland exposure therapies. Nevertheless, some patients remain refractoryeven to various combinations and doses of pharmacologic drugs. A commonproblem in patients with “treatment-resistant” anxietyis the use of inadequate doses and treatment duration with specificmedications. SSRIs (Selective Serotonin Reuptake Inhibitors) and otherdrugs claim to work by correcting chemical imbalances,but without accurate tools to measure neurotransmitter levels it’sdifficult to know if one’s correctly targeting a defficientneurotransmitter, reaching a desirable level, or even introducing a new chemical imbalance and abnormal brain states – resulting, e.g., in persistent sexual dysfunction. Hence, diagnosis may need to be periodically reconsidered, and comorbid diagnoses carefully accessed.

Meanwhile, there’s a small series of known or promising powerfull therapeutic alternatives (i.e. non-pharmacological) that it’s not first-, second-, or even third-line treatment options at this point – e.g. vagal nerve (electrical) stimulation.Think of all the suffering and impaired functioning of a (traditional)treatment-resistant patient with, e.g., 20 years of illness, 18different combinations of medications with all sorts of mainly unpredictable side-effect and interactions profiles. I.e., 20 years during which the patient was busy running away from the pain – a life organized around the not so simple task of not feeling pain. A patient who eventually will consider suicide as a serious (self-)”treatment” option, because of all the treatment-resistant doctors.

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