How is it that anti-anxiety drugs can cause anxiety and insomnia, sometimes within the first day or two of treatment? This effect is repeatedly noted in the Physicians' Desk Reference for most selective serotonin reuptake inhibitors such as fluoxetine (Prozac) and sertraline (Zoloft). Anxiety reactions occurred in 14% of patients given fluoxetine for obsessive-compulsive disorder versus 7% on placebo (PDR, 2003a). Similarly, insomnia occurred in 33% of patients with bulimia treated with fluoxetine versus 13% on placebo (PDR, 2003a). Fluoxetine and sertraline induced tremor in about 10% to 11% of patients with major depression compared to 3% for placebo (PDR, 2003a, 2003b); these are not the soothing qualities we expect for anti-anxiety medications.
Different Types of Anxiety
A simple explanation is that there are two (or more) separate types of anxiety, and a drug can affect them differently. Specifically, SSRIs reliably decrease psychological anxiety but not somatic anxiety. Somatic anxiety is primarily a tension phenomenon, with restlessness, agitation, impatience, hyperreactivity and irritability. It is largely but not entirely observable. Tension is associated with high epinephrine or norepinephrine activity and activation of the sympathetic nervous system. Drug-induced akathisia is usually described as a tension phenomenon.
In contrast, psychological anxiety is largely comprised of worry, repetitive thoughts and dissatisfaction. Because it is subjective, understanding its presence and severity requires description by the patient. Psychological anxiety is apparently related to low serotonergic activity. The separation between somatic anxiety and psychological anxiety has been observed in symptom cluster analysis (Watson et al., 1995) and suggested by pharmaceutical response (Fogari et al., 1992). This separation implies that the evaluation of anxiety involves specific assessments of somatic anxiety and psychological anxiety. Because pain, dizziness and disassociation can respond to hypnosis therapy, they might be considered additional types of anxiety.
Different types of anxiety can provoke each other in a circular loop, but this does not make them inseparable. Although pain causes anxiety, when pain remits, anxiety can persist if an anxiety disorder has developed. Similarly, worry can induce somatic anxiety, but restless tension can persist after worry has faded. Tension can begin with worry, yet it can eventually be autonomous from worry. This concept resembles phantom pain that persists after the physical cause of the pain is removed.
Somatic anxiety is sometimes mislabeled as psychological disinhibition. Inappropriate conduct that appears when irritability or hyperreactivity overcome self-control does not illustrate psychological disinhibition. Analogously, pain can cause patients to scream; this is bodily discomfort, not psychological disinhibition. The discomfort is the same, with or without the scream. Tension is also a bodily discomfort. Another inconsistency between tension and disinhibition is shown by the effect of benzodiazepines--they diminish tension but actually increase disinhibition.
Mythology in DSM Anxiety
The DSM formulation of anxiety disorders contains the belief that the mind controls bodily tension. This is done by combining tension and psychological anxiety together in the diagnostic criteria. Surely psychotherapy can relieve psychological anxiety. The problem is that after successful psychotherapy relieves the psychological anxiety, the patient may no longer meet anxiety disorder diagnostic criteria but might still suffer from somatic anxiety. This inconsistency is resolved only by believing that psychotherapy also reliably treats somatic anxiety.
However, besides muscle movement, body control by the mind is indirect, incomplete, highly variable and largely speculative. It is not right to base our professional diagnosis and treatment on the assumption that psychotherapy can control bodily function. The alternative to this belief is once tension has become persistent and intrusive, it no longer depends on worry in order to continue. Worry provokes bodily tension, and it also predisposes to infections, injuries and substance abuse. The bodily consequences of these problems are not reasonably curable by psychotherapy alone, but require medical treatment of the body.
Psychiatrists might be able to occasionally decrease persistent tension or other somatic conditions with psychotherapy. Still, it is not appropriate for DSM to require the belief that psychotherapy (or pharmacotherapy) reliably relieves somatic anxiety as it diminishes psychological anxiety. The myth that psychological anxiety and somatic anxiety are the same condition probably pervades DSM because it is a widely accepted belief. This belief may predispose to violent consequences from not treating somatic anxiety in patients on SSRIs.
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