THERAPEUTIC STRATEGIES FOR THE PATIENT WITH TREATMENT-RESISTANT ANXIETY

Outcome of anxiety disorder treatment with psychotherapy and medicatio n is generally as good as or better than that of other psychiatric ill nesses. Nevertheless, refractory cases occur. The first step in approa ching the treatment-resistant patient with an anxiety disorder is to b e certain that the treatment has been adequate. Failure to provide an adequate dose of medication for adequate periods of time may be the mo st common cause of ''treatment resistance.'' The second step is to rec onsider the diagnosis and/or determine if new diagnoses have emerged s ince the original consultation. Depression and substance abuse are esp ecially likely to complicate anxiety disorders. Several studies have s hown that concomitant personality disorders (axis II) increase the occ urrence of resistance to standard treatment and must be addressed thro ugh psychotherapy. Last, a variety of possible underlying medical cond itions, including thyroid disorder, arrhythmia, and complex partial se izure, should be considered. Then, the clinician should consider a var iety of pharmacologic approaches that are specific to each anxiety dis order. Panic disorder patients who are refractory to imipramine freque ntly respond to high-potency benzodiazepines, monoamine oxidase (MAO) inhibitors, serotonin reuptake inhibitors, or various combinations. Ge neralized anxiety disorder, if unresponsive to benzodiazepines, may re spond to buspirone or a tricyclic antidepressant. Patients with obsess ive compulsive disorder who have failed to respond to clomipramine or fluoxetine and other serotonin reuptake blockers may benefit from augm entation strategies using combination therapies including buspirone, f enfluramine, and neuroleptics. Social phobia refractory to beta-blocke rs and MAO inhibitors may benefit from buspirone, fluoxetine, or alpra zolam.