Behavioral interventions are extremely useful in managing anxiety disorders without problematic side effects. They include hypnosis, desensitization, and relaxation techniques (152– 163). These techniques provide a patient with tools to cope with her own anxiety. Specialists in behavioral medicine, usually psychologists, are expert in these techniques. A local medical school department of psychiatry or behavioral medicine is a good source for referrals. Interested gynecologists can master some of the techniques.
It is easy to be trapped into a cat-and-mouse game with an anxious and needy patient who has an anxiety or personality disorder (153). Faced with an obsessive or anxious, talkative, and needy patient in the midst of bedside rounds, clinic, or office hours, the clinician can develop a pattern of avoidance, sometimes alternating with overindulgence stemming from feelings of guilt. This kind of behavior results in sporadic, unpredictable reinforcement of the patient’s symptoms and demands for attention and is very likely to increase them. Attempting to escape by appearing distracted or harassed or yielding with despair to the destruction of the day’s schedule and the care of other patients simply heightens the patient’s anxiety (154–160).
It is preferable to develop a prospective approach (153,162,163). Gynecologists tend to underrate the power of their personal interactions with patients and their own ability to structure and limit those interactions appropriately. A patient with a long list of symptoms can be informed at the beginning of the visit how much time is available and asked to focus on her most important problem, with other problems to be discussed at future, scheduled appointments (162). Instead of scheduling appointments and returning telephone calls grudgingly in response to patient demands, the gynecologist should inform the patient that her condition requires brief regular scheduled visits. If she is contacting the office more often than visits can reasonably be scheduled, she should be asked to call between visits, at prearranged times, to advise the staff of her progress. There are useful self-help groups for patients with various psychiatric conditions and their families. Although groups focused only on victimization can validate patients’ experiences and pain and help them build new lives, they may interfere with their motivation to find other ways to identify themselves and obtain gratification (159). The gynecologist can monitor the patient’s responses to the self-help group interaction.
Medication does have a place in the management of anxiety disorders (164–166). Table 12.5 describes many of these agents. SSRIs are effective for a variety of anxiety disorders, sometimes
Table 12.5 Compounds Used for Anxiety aLong ≥2 hours; Intermediate = 1–2 hours; Short ≤1 hour. bLong >20 hours; Intermediate = 6–20 hours; Short <6 hours. From Gilman AG, Rall TW, Nies AS, et al. The pharmacological basis of therapeutics. 8th ed. New York: McGraw-Hill, 1990; Stotland NL. Psychiatric and psychosocial issues in primary care for women. In: Seltzer VL, Pearse WH, eds. Women’s primary health care: office practice and procedures. New York: McGraw-Hill, 1995.
in different dosage regimens than those used for depression. Benzodiazepines are effective when taken for acute anxiety or during relatively brief, time-limited (several days) stressful situations. The specific agent should be chosen on the basis of onset of action and half-life. The patient must be admonished to avoid concomitant use of alcohol and to exercise extreme care about driving or engaging in other activities requiring attention, concentration, and coordination.
Patients who fail to respond to a trial of office counseling or medication, who are unable to fulfill their responsibilities, who exhaust the patience and resources of significant others, who pose a diagnostic dilemma, who consume inordinate quantities of medical resources, or whose symptoms are becoming increasingly worse should be evaluated by a psychiatrist (166).