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Friday, November 22, 2019

Multiple Anxiety Disorders

A common characteristic of the clinical picture of patients with anxiety disorders is the simultaneous presence of a secondary anxiety disorder alongside the primary anxiety disorder. A classic example is that of the concurrent diagnosis of:

  1. Panic disorder with agoraphobia and
  2. Generalized anxiety disorder.

In these cases, the effective and complete treatment of the first disorder ALWAYS depends on the effective treatment of the second disorder. If the secondary anxiety disorder is not properly diagnosed and if the clinical severity and the specific characteristics of each diagnostic entity are not fully explained to the patient, both in terms of their symptoms and in terms of their causes, then one of the following may happen:

  1. The disorder for which the patient complained may be treated only partially and relapse is almost certainly a matter of time. In this case, the lifespan perpetuation of the clinical problem is progressively introduced into the organism of the patient.
  2. The therapy may be ineffective, as a result of the second disorder’s obstructing interference with the effective treatment of the first.

We may see in detail an example that highlights the first possibility of only a partial response to treatment. A patient is diagnosed with panic disorder with agoraphobia (1) and generalized anxiety disorder (2). The successful treatment of the panic attacks, which is the central characteristic of panic disorder, and their lessening or complete alleviation is the encouraging initial step from which therapy may move forward to addressing the agoraphobic element. The therapy for the agoraphobic symptomatology is more difficult for the patient, from an experiential viewpoint and equally difficult for the therapist, from a technical viewpoint.

However, the parallel presence of the second disorder (the social anxiety disorder) may decisively prevent the reduction of the agoraphobic symptomatology and ultimately block the complete therapy of the first disorder, namely the panic disorder with agoraphobia. This is possible to happen, particularly in this case, because some clinical criteria of agoraphobia and social anxiety disorder are very closely related and differential diagnosis requires advanced attention. 

In cases such as these, the patient may decide that s/he will never get completely well from panic disorder and agoraphobia (especially if exposed to the uncritical information available at non-professional web sites and online fora). The usual consequence is that the therapy presented only partial improvement. This is not attributable to the inherent characteristics of the diagnoses but to the fragmentary understanding of the patient regarding the nature of the problem. The patient’s understanding about his/her difficulty incorporated the fear that s/he will never get fully well. This fear remained outside the therapeutic protocol.

The absence of the decisive information permitted the uncontrolled activation of the belief that there is no complete cure for anxiety disorders, especially when the therapy focused on the difficult agoraphobic domain. In other words, when the therapy attempted to address the agoraphobic symptomatology, the presence of the social anxiety (the secondary diagnosis) made the treatment of agoraphobia  (the first diagnosis) far more difficult than what it would have been, had the agoraphobia been the only clinical problem.

In cases of multiple anxiety disorders it is far more critical for the outcome of therapy to comprehensively inform the patient about the nature of the problem and the possible obstacles to therapy. This is particularly so when the diagnostic criteria of comorbid disorders are interrelated and are likely to negatively affect the effect of treatment.

Ask your therapist:

  1. If your diagnosis expresses the full extend of your symptoms or if s/it would be more appropriate to consider your diagnosis from a multiple anxiety viewpoint.
  2. What might be the difficulties you will experience during your treatment.
  3. What should be your reaction when your therapy reaches the difficult areas.

Let your therapist know:

  1. If you often think that your therapy might not be met with success.
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