The perception of bodily states depends to a large degree on the mood of a person and the attention paid to bodily states rather than on the actual physiological state.6 Therefore, improvement of anxiety lessens the perception of physical symptoms irrespective of the effect of medication on the bodily state. Treatment of physical symptoms without concomitant treatment of anxiety is usually insufficient but, when combined with a benzodiazepine or an anxiolytic such as buspirone, can help reduce the dose of the latter.
Frequency of distress
Few patients are anxious all the time, but some patients experience symptoms regularly (most of the day) while others only episodically (during demanding times). In the latter, only short-term use of benzodiazepines or antihistamines is needed. However, because of the potential for habituation, long-term use of benzodiazepines should be avoided.
Psychological treatments not only reduce psychic but also somatic symptoms; the latter diminish with reduction of worries irrespective of the patient's physical condition. Psychotherapy should be planned according to the needs and expectations of the patients. Milder cases may require only supportive therapy. More severely ill patients may need CBT with greater emphasis on relaxation when physical symptoms predominate and with more emphasis on cognitive aspects when strong psychic symptoms are present.7
Antidepressants with serotonin- inhibiting properties have anxiolytic effects on psychic symptoms and are indicated in patients who have difficulties in coping with pathological fears and worries. The effect of antidepressants is not immediate, and medications must be taken regularly for several weeks. The choice of the antidepressant depends on how a patient tolerates adverse effects and on possible physical comorbidity. Generally, it is best to start with a low dose and titrate the dose until a therapeutic effect is achieved or until poor tolerance necessitates a change in medication.
Tolerance to the anxiolytic effects does not develop, and there is no abuse potential. Plasma levels are of little clinical help except to assess a lack of response caused by low levels or toxic effects produced by excessive levels. The duration of treatment has to be individualized; some patients improve within a few months and the dosage of the medication can be reduced and eventually stopped, while others have to take medication indefinitely.
Hyperarousal
Hyperarousal may manifest itself in tension lasting throughout the day and as insomnia at night. Patients may have difficulty in falling asleep or may wake up in the middle of the night, or both. Proper sleep hygiene and relaxation exercises help milder forms of insomnia. Alcohol in the evening should be avoided, because its sedative effect is brief and patients tend to wake up in the middle of the night. Antidepressants with sedative properties, such as mirtazapine or the sedating tricyclic antidepressants (TCAs) amitriptyline, doxepin, or clomipramine, may suffice. SSRIs have little or no sedative properties and additional sedative medication may have to be prescribed.
Benzodiazepines, zaleplon, zolpidem, eszopiclone, and sedating antihistamines such as diphenhydramine effectively induce sleep. Compared with benzodiazepines, zaleplon, zolpidem, and eszopiclone are less habit-forming; for instance, eszopiclone has been found effective for 12 months without causing tolerance.8 Patients who wake up at night need longer-acting sedatives. Trazodone and the long-acting benzodiazepine, flurazepam, induce long-lasting sleep; the former is not habit-forming but sometimes induces a hangover. To reduce daytime arousal, sedative antidepressants, benzodiazepines, and antihistamines are useful.
Muscular symptoms
Increased muscle tension is the most consistent physiological finding in anxious patients.9 However, many patients are unaware of increased muscle tension until they undergo relaxation exercises. While increased muscle tension affects the whole body, it can focus on specific groups of muscles, causing tension headache, writer's cramp, or globus hystericus. General muscle tension is a peripheral manifestation of central arousal; therefore, treatments that reduce hyperarousal also reduce general muscle tension. Spasms that affect specific muscle groups respond acutely to benzodiazepines but may need specific behavioral interventions.
