Panic Anxiety Education
Management Services

The Politics of Anxiety Disorder Treatments - Who suffers?

TREATMENT : THE MEDICAL MODEL

Prescribed Medication
Besides the lack of diagnosis, the current medical paradigm for Anxiety Disorders is a major contributing factor in the long term reliance on Health Services. Whether diagnosed or not, medication is in many cases, the only form of treatment offered. The biological model with its biological interventions for mental disorders is the leading paradigm for General Practitioners and Psychiatrists. Irrespective of the latest research detailing effective Cognitive Behavioural Treatments for Anxiety Disorders our clients group is and has been a main target of the biological approach

The biological model, ('chemical imbalance theory') for Anxiety Disorders has never been proven despite the myriad of biological studies . If the Disorders, particularly Panic Disorder, Social Phobia and Generalised Anxiety Disorder are a result of a biological factors one would assume there would now be specific tests to prove this. Even though there are now drugs approved specifically for Panic Disorder, they are not effective in the long term. (16) Not only this, the sometimes serious side effects can be worse than the original presenting Disorder.(Ibid) Unfortunately these effects are denied and clients' experience in many instances are ignored by their treating Health Professional. The view being the client's Disorder is the problem not the medication. The detriment to our clients and to the Economy of this model is rarely questioned.

The most dramatic example of the biological model for Panic Disorder is the marketing campaign for the benzodiazepine Alprazolam, brand name Xanax. Until recently Xanax was the only drug approved by the Commonwealth for use in Panic Disorder. Our clients are still experiencing the effects, physically and psychologically of this campaign, and is one of the major problems we are dealing with on a daily basis..

Xanax was approved for use in the treatment of Panic Disorder, despite the literature which shows the high rate of dependence of this drug. This includes the drug manufacturer's own study for the USA Food and Drug Administration (FDA) which showed 'at eight weeks most patients were better off if they had never taken the drug.' The study at eight weeks showed 'severe withdrawal and rebound reactions, including an increase in anxiety and in phobic responses, plus a 350 percent greater number of panic attacks." Only the first four weeks of the study was ultimately presented. (22 )

A leading international expert Professor Isaac Marks plus ten other psychiatrists and psychologists took the unusual step of publicly criticising the study. For further detailed information see the British Journal of Psychiatry June 1993. This edition of the Journal is dedicated to this issue. (23)

This drug is now prescribed on 'authority' and despite the warnings listed in various publications about the level of dependence, many clients are taking this drug on a long term basis. Many are being told by their health professional they will be on this drug for the rest of their life. Any breakthrough withdrawal is being assessed as part of the original Disorder by the treating health professional and client complaints about the withdrawal symptoms are being ignored.

A report in the form of a booklet 'Guidelines for the prevention and management of benzodiazapine dependence' by the Australian Health Care Committee Expert Advisory Panel on Alcohol and Drug use (24) confirms the addictive nature of Xanax and other minor tranquillisers and sets out guidelines for their use. The problem is many General Practitioners or Psychiatrists appear not to have read this or other publications regarding this drug.

The chemical imbalance theory for the use of Xanax is alive and well in private practice. When clients challenge their treating therapist after speaking with us, they are told we have no 'idea of what we are talking about'. Although prescriptions for Xanax now need to authorised, clients can be on this medication for years and any breakthrough withdrawal is written off as part of the patient's original Disorder. In many cases the dosage of the drug is increased. Despite the evidence, General Practitioners and Psychiatrists continue to prescribe these drugs and some still deny these drugs are addictive.

The Xanax campaigns of 1987 & 1992 advocated the use of Cognitive Behaviour Therapy in conjunction with the medication. In reality this does not happen and in most cases clients are not told of this other treatment.

There is lack of trained Cognitive Behavioural Therapists in Australia. Trying to find sufficient therapists for our client group is an ongoing nightmare for our Association and our clients. Although many psychologists are trained in the newer Cognitive Behavioural Therapies, a large number of people are unable to afford the fees charged by private psychologists. They have no alternative but to stay within a system which disempowers and contributes to their Disorder. Even if there were sufficient Cognitive Behaviour Therapists it is doubtful clients would be given this option.

An Australian psychiatrist who is this country's leading advocate for the use of Xanax in Panic Disorder told a group of Anxiety Disorder consumer representatives in October 1996, that the drug does not cause dependence and that Cognitive Behaviour Therapy does not work. Interesting comments, considering the above and that most of the representatives themselves had not only gone through benzodiazapine withdrawal but had recovered using Cognitive Behaviour Therapy. When challenged he spoke of Biological genetic Panic Disorder that runs in families for which the drug is approved. Most people with Panic Disorder show a family history of the Disorder, including the consumer representatives he was addressing.

The growing trend is the prescribing of anti depressants.(25 p 78) Over the last twelve months the current trend is to prescribe Serotonin Re-uptake Inhibitors (SSRIs), primarily Zoloft and Prozac. Over the last twelve months, Zoloft appears to have become the main drug now prescribed for our clients. The Commonwealth has recently approved Aropax, another SRI, for the treatment of Panic Disorder. Until recently SSRIs were restricted to major depressive disorders 'where other therapy is inappropriate'. (25 p 191) We question why this drug has now been classified as suitable for Panic Disorder, especially as there is a much more appropriate therapy in the form of Cognitive Behaviour Therapy which is not even considered by most Health Professionals.

As with the effects of benzodiazepines, clients' subjective experiences of an increase in symptoms or new symptoms when taking SSRIs or other antidepressants are usually rejected by the treating health professional. The new or increased symptoms are attributed to the client's Disorders. Clients are usually told their drugs have no or minimal side effects.

What tranquillisers were to Anxiety Disorders in the 1970s & 1980s, the SSRIs appear poised to become the alternative in the 1990s. We are getting reports from clients that medication is being prescribed even though they may have had only one or two Panic Attacks. In most of these cases clients do not need medication if they are given an adequate explanation of what is happening to them, and if indicated, short term Cognitive Behavioural Therapy. The publicity campaign for Aropax in the last week of October 1996 appears to herald yet another cycle of health care dependence for our current and future clients.

There is a time and place for medication in some cases, including tranquillisers, as long as they are prescribed as per the guidelines set our by the NHMRC (24 ). Irrespective of whether a biological cause is eventually found, clients can recover without medication. As some people can control their diabetes through diet without medication, why can't our client group do the same through Cognitive Behaviour skills?

Behavioural Therapy
Another form of therapy some clients have received has been the older style graded exposure/desensitisation programs which do not have any Cognitive component to them. Along with medication this may be the only other form of treatment people have received. Graded exposure/desensitisation does not cover the strategies used in Cognitive Behaviour Therapy and is simply exposure to situations and/ or places people avoid. This type of treatment has been given to people even if they do not have any associated avoidance behaviour (Agoraphobia). This has been particularly so in relation to people with Panic Disorder.

The question many of our clients with Panic Disorder/Agoraphobia ask is, 'exposure to what'? Many graded exposure programs treat the avoidance behaviour (Agoraphobia) in Panic Disorder as though it was the situation or place which triggered the attack. Also much to their confusion, clients who have Panic Disorder without any form of avoidance behaviour have been given such a program.

The rationale behind graded exposure programs is that when the individual goes into avoided situations /or places and stays in that situation or place, the anxiety and/or panic attack will peak and slowly ebb away. In other words the person will habituate to the anxiety and panic attack in that situation or place. As many clients say even though the panic attack does subside, if they are not directly frightened of the situation /or place why would the anxiety 'ebb away' when it has never done so before.

In the case of Panic Disorder the 'uncued' or 'spontaneous' Panic Attack (1) is the root cause of the Disorder Yet despite the latest literature, detailed and qualified in the Diagnostic and Statistical Manual No 4, this is still not being recognised by some Mental Health Professionals. DSM 4 states that Panic Disorder with Agoraphobia is not a fear of situations and places, but is a fear of the spontaneous Panic Attack, i.e. the trigger of the attack is internal and is not based on external factors. The older style graded exposure programs focus on external factors; and in thousands of cases does not resolve the 'internal trigger' of the spontaneous panic attack.

We are aware that a few Mental Health Professionals are skeptical about this criteria for Panic Disorder. From a client perspective, DSM 4 (1) is the most accurate description of the Disorder ever presented. While debates may continue on whether the cause of Panic Disorder is biological or behavioural, DSM 4 clearly states our clients' experience. Unfortunately clients' experiences are not taken into account if they do not fit other treatment paradigms.

Clients frustration with this type of treatment was highlighted during a pilot study two years ago. The pilot study was a prelude to a formal study to evaluate the effectiveness of our Panic Anxiety Management Workshops. Part of the pilot study involved clients filling out a 'Fear Questionnaire', listing fears associated to their Disorder. Some Panic Disorder clients expressed anger over the questionnaire and its relevance to their Disorder. As a result of their comments the 'Fear Questionnaire' was excluded from the formal study. (26)

Many older style graded exposure programs are built around clients answers to this questionnaire. In some cases the list of fears include specific fears which predate the clients Panic Attacks and have no relevance to their Disorder , yet they were incorporated or became the main feature of the graded exposure program. This little known but crucial fact has also been noted by researchers. One such study showed, "half the simple (specific) phobias in Panic Disorder had childhood onset and half had onset associated with the onset of Panic Disorder". (27) Short term Cognitive Behavioural Therapy addresses the spontaneous panic attacks much more effectively than these older style programs.

SUMMARY
Medication is a reactive measure. It does not give people control over their lives in the long term, nor does it prevent future episodes or reliance on health care services. Cognitive Behaviour Therapy is proactive as it enables people to participate in their treatment and enables them to take control of their lives. This can prevent future episodes with substantial benefits to people with the Disorder and the health care budgets.

The perception of the 'worried well' is compounded when the Medical or 'Behavioural only' models fail. The perception can be that people have too many secondary gains to want to recover from their Disorder. This is unfounded and unjust. What is not understood is that people can't recover when there is minimal or no understanding of the dynamics of the Disorders by both the treating therapists and by the patient themselves. The horrific personal costs bear this out. As one client once said, 'Why would we do this to ourselves; we are not masochists.'

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