Featured Article: Treatment resistance in the anxiety disorders

by Fiona Challacombe

Anxiety disorders are amongst the most prevalent mental health problems both in adulthood and childhood, with up to one in three people meeting a diagnosis at some point in their lifetime [1]. People often suffer from more than one disorder, and many also have depression. Anxiety disorders impair functioning, curtail plans, steal goals and dreams; they can be disabling and severe and can become chronic conditions [2].

Messages about treatment are therefore crucial. Current first line treatments for most anxiety disorders are Serotonin Reuptake Inhibitors (SRIs) and cognitive-behaviour therapy, which have been found effective for a range of anxiety problems. However, 30-60% of people do not make significant gains with these treatments. ‘Treatment resistance’ will be a familiar term to many clinicians and service users. For example, in the context of OCD, the UK consensus definition is that a person has tried two types of SRIs and two courses of CBT without success. Uncritical use of the term is problematic and can locate the problem within the individual in terms of low motivation or fixed biological factors. These implications, whether explicit or not, can decrease engagement with treatment on both sides. Beliefs about what can change, that is to say, hope, underpins outcome. However, some would argue that this needs to be balanced by realistic expectations, that management of a disorder is the best that can be achieved.

It is worth examining what treatment resistance actually means. Studies have shown that sub therapeutic doses of pharmacology and CBT are commonplace [3]. Furthermore, people may have received a range of interventions under the banner of CBT that would not be recognised as such [4]. Given the common overlap between anxiety disorders, more recent studies are examining the interface and interaction between disorders, leading to promising treatment developments, for example in mental contamination or compassion focused therapy [5]. Innovations in delivery such as internet-delivered and time-intensive therapy may help overcome practical barriers to treatment [6]. Let us hope that treatments can continue to catch up to be of help to all.

Dr Fiona Challacombe is a clinical psychologist and researcher in the field of anxiety disorders at the Institute of Psychiatry, Psychology & Neuroscience and the South London and Maudsley NHS Trust.

Co-authored with Victoria Bream, Asmita Palmer, and Paul Salkovskis,Cognitive Behaviour Therapy for OCD, is available now in print, and coming soon to Oxford Clinical Psychology.

Further Reading
Oxford Guide to Surviving as a CBT Therapist
Case Studies in Clinical Psychological Science: Bridging the Gap from Science to Practice

1. Kessler, R.C., et al., Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 2012. 21(3): p. 169-184. 
2. Lochner, C., et al., Quality of Life in Anxiety Disorders: A Comparison of Obsessive-Compulsive Disorder, Social Anxiety Disorder, and Panic Disorder. Psychopathology, 2003. 36(5): p. 255-262. 
3. Bystritsky, A., Treatment-resistant anxiety disorders. Mol Psychiatry, 2006. 11(9): p. 805-814. 
4. Stobie, B., et al., "Contents may vary": A pilot study of treatment histories of OCD patients. Behavioural and Cognitive Psychotherapy, 2007. 35(3): p. 273-282. 
5. Badour, C.L., et al., Disgust, mental contamination, and posttraumatic stress: Unique relations following sexual versus non-sexual assault. Journal of Anxiety Disorders, 2013. 27(1): p. 155-162. 
6. Andrews, G., et al., Computer Therapy for the Anxiety and Depressive Disorders Is Effective, Acceptable and Practical Health Care: A Meta-Analysis. PLOS ONE, 2010. 5(10): p. e13196.

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