Anxiety Disorders
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Anxiety disorders are serious medical illnesses that affect approximately
19 million American adults. These disorders fill people's lives with overwhelming
anxiety and fear. Unlike the relatively mild, brief anxiety caused by a stressful
event such as a business presentation or a first date, anxiety disorders
are chronic, relentless, and can grow progressively worse if not treated.
Effective treatments for anxiety disorders are available, and research
is yielding new, improved therapies that can help most people with anxiety
disorders lead productive, fulfilling lives. If you think you have an anxiety
disorder, you should seek information and treatment.
Each anxiety disorder has its own distinct features, but they are
all bound together by the common theme of excessive, irrational fear and
dread.
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"It started 10 years ago, when I had just graduated from college
and started a new job. I was sitting in a business seminar in a hotel and
this thing came out of the blue. I felt like I was dying.
"For me, a panic attack is almost a violent experience. I feel
disconnected from reality. I feel like I'm losing control in a very extreme
way. My heart pounds really hard, I feel like I can't get my breath, and
there's an overwhelming feeling that things are crashing in on me.
"In between attacks there is this dread and anxiety that it's
going to happen again. I'm afraid to go back to places where I've had an
attack. Unless I get help, there soon won't be anyplace where I can go
and feel safe from panic."
People with panic disorder have feelings of terror that strike suddenly
and repeatedly with no warning. They can't predict when an attack will occur,
and many develop intense anxiety between episodes, worrying when and where
the next one will strike.
If you are having a panic attack, most likely your heart will pound
and you may feel sweaty, weak, faint, or dizzy. Your hands may tingle or
feel numb, and you might feel flushed or chilled. You may have nausea, chest
pain or smothering sensations, a sense of unreality, or fear of impending
doom or loss of control. You may genuinely believe you're having a heart
attack or losing your mind, or on the verge of death.
Panic attacks can occur at any time, even during sleep. An attack
generally peaks within 10 minutes, but some symptoms may last much longer.
Panic disorder affects about 2.4 million adult Americans and is twice
as common in women as in men. It most often begins during late adolescence
or early adulthood. Risk of developing panic disorder appears to be inherited.
Not everyone who experiences panic attacks will develop panic disorder—for
example, many people have one attack but never have another. For those who
do have panic disorder, though, it's important to seek treatment. Untreated,
the disorder can become very disabling.
Many people with panic disorder visit the hospital emergency room
repeatedly or see a number of doctors before they obtain a correct diagnosis.
Some people with panic disorder may go for years without learning that they
have a real, treatable illness.
Panic disorder is often accompanied by other serious conditions such
as depression, drug abuse, or alcoholism and may lead to a pattern of avoidance
of places or situations where panic attacks have occurred. For example, if
a panic attack strikes while you're riding in an elevator, you may develop
a fear of elevators. If you start avoiding them, that could affect your choice
of a job or apartment and greatly restrict other parts of your life.
Some people's lives become so restricted that they avoid normal, everyday
activities such as grocery shopping or driving. In some cases they become
housebound. Or, they may be able to confront a feared situation only if accompanied
by a spouse or other trusted person.
Basically, these people avoid any situation in which they would feel
helpless if a panic attack were to occur. When people's lives become so restricted,
as happens in about one-third of people with panic disorder, the condition
is called agoraphobia. Early treatment of panic disorder can often prevent agoraphobia.
Panic disorder is one of the most treatable of the anxiety disorders,
responding in most cases to medications or carefully targeted psychotherapy.
You may genuinely believe you're having a heart attack, losing your
mind, or are on the verge of death. Attacks can occur at any time, even during
sleep. Depression
Depression often accompanies anxiety disorders and, when it does,
it needs to be treated as well. Symptoms of depression include feelings of
sadness, hopelessness, changes in appetite or sleep, low energy, and difficulty
concentrating. Most people with depression can be effectively treated with
antidepressant medications, certain types of psychotherapy, or a combination
of both.
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"I couldn't do anything without rituals. They invaded every aspect
of my life. Counting really bogged me down. I would wash my hair three
times as opposed to once because three was a good luck number and one wasn't.
It took me longer to read because I'd count the lines in a paragraph. When
I set my alarm at night, I had to set it to a number that wouldn't add
up to a "bad" number.
"Getting dressed in the morning was tough because I had a routine,
and if I didn't follow the routine, I'd get anxious and would have to get
dressed again. I always worried that if I didn't do something, my parents
were going to die. I'd have these terrible thoughts of harming my parents.
That was completely irrational, but the thoughts triggered more anxiety
and more senseless behavior. Because of the time I spent on rituals, I
was unable to do a lot of things that were important to me.
"I knew the rituals didn't make sense, and I was deeply ashamed
of them, but I couldn't seem to overcome them until I had therapy."
Obsessive-compulsive disorder, or OCD, involves anxious thoughts or
rituals you feel you can't control. If you have OCD, you may be plagued by
persistent, unwelcome thoughts or images, or by the urgent need to engage
in certain rituals.
You may be obsessed with germs or dirt, so you wash your hands over
and over. You may be filled with doubt and feel the need to check things
repeatedly. You may have frequent thoughts of violence, and fear that you
will harm people close to you. You may spend long periods touching things
or counting; you may be pre-occupied by order or symmetry; you may have persistent
thoughts of performing sexual acts that are repugnant to you; or you may
be troubled by thoughts that are against your religious beliefs.
The disturbing thoughts or images are called obsessions, and the rituals
that are performed to try to prevent or get rid of them are called compulsions.
There is no pleasure in carrying out the rituals you are drawn to, only temporary
relief from the anxiety that grows when you don't perform them.
A lot of healthy people can identify with some of the symptoms of
OCD, such as checking the stove several times before leaving the house. But
for people with OCD, such activities consume at least an hour a day, are
very distressing, and interfere with daily life.
Most adults with this condition recognize that what they're doing
is senseless, but they can't stop it. Some people, though, particularly children
with OCD, may not realize that their behavior is out of the ordinary.
OCD afflicts about 3.3 million adult Americans. It strikes men and
women in approximately equal numbers and usually first appears in childhood,
adolescence, or early adulthood. One-third of adults with OCD report having
experienced their first symptoms as children. The course of the disease is
variable—symptoms may come and go, they may ease over time, or they can grow
progressively worse. Research evidence suggests that OCD might run in families.
Depression or other anxiety disorders may accompany OCD, and some
people with OCD also have eating disorders. In addition, people with OCD
may avoid situations in which they might have to confront their obsessions,
or they may try unsuccessfully to use alcohol or drugs to calm themselves.
If OCD grows severe enough, it can keep someone from holding down a job or
from carrying out normal responsibilities at home.
OCD generally responds well to treatment with medications or carefully
targeted psychotherapy.
The disturbing thoughts or images are called obsessions, and the rituals performed
to try to prevent or get rid of them are called compulsions. There is no pleasure
in carrying out the rituals you are drawn to, only temporary relief from the
anxiety that grows when you don't perform them.
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"I was raped when I was 25 years old. For a long time, I spoke
about the rape as though it was something that happened to someone else.
I was very aware that it had happened to me, but there was just no feeling.
"Then I started having flashbacks. They kind of came over me
like a splash of water. I would be terrified. Suddenly I was reliving the
rape. Every instant was startling. I wasn't aware of anything around me,
I was in a bubble, just kind of floating. And it was scary. Having a flashback
can wring you out.
"The rape happened the week before Thanksgiving, and I can't
believe the anxiety and fear I feel every year around the anniversary date.
It's as though I've seen a werewolf. I can't relax, can't sleep, don't
want to be with anyone. I wonder whether I'll ever be free of this terrible
problem."
Post-traumatic stress disorder (PTSD) is a debilitating condition
that can develop following a terrifying event. Often, people with PTSD have
persistent frightening thoughts and memories of their ordeal and feel emotionally
numb, especially with people they were once close to. PTSD was first brought
to public attention by war veterans, but it can result from any number of
traumatic incidents. These include violent attacks such as mugging, rape,
or torture; being kidnapped or held captive; child abuse; serious accidents
such as car or train wrecks; and natural disasters such as floods or earthquakes.
The event that triggers PTSD may be something that threatened the person's
life or the life of someone close to him or her. Or it could be something
witnessed, such as massive death and destruction after a building is bombed
or a plane crashes.
Whatever the source of the problem, some people with PTSD repeatedly
relive the trauma in the form of nightmares and disturbing recollections
during the day. They may also experience other sleep problems, feel detached
or numb, or be easily startled. They may lose interest in things they used
to enjoy and have trouble feeling affectionate. They may feel irritable,
more aggressive than before, or even violent. Things that remind them of
the trauma may be very distressing, which could lead them to avoid certain
places or situations that bring back those memories. Anniversaries of the
traumatic event are often very difficult.
PTSD affects about 5.2 million adult Americans. Women are more likely
than men to develop PTSD. It can occur at any age, including childhood, and
there is some evidence that susceptibility to PTSD may run in families. The
disorder is often accompanied by depression, substance abuse, or one or more
other anxiety disorders. In severe cases, the person may have trouble working
or socializing. In general, the symptoms seem to be worse if the event that
triggered them was deliberately initiated by a person—such as a rape or kidnapping.
Ordinary events can serve as reminders of the trauma and trigger flashbacks
or intrusive images. A person having a flashback, which can come in the form
of images, sounds, smells, or feelings, may lose touch with reality and believe
that the traumatic event is happening all over again.
Not every traumatized person gets full-blown PTSD, or experiences
PTSD at all. PTSD is diagnosed only if the symptoms last more than a month.
In those who do develop PTSD, symptoms usually begin within 3 months of the
trauma, and the course of the illness varies. Some people recover within
6 months, others have symptoms that last much longer. In some cases, the
condition may be chronic. Occasionally, the illness doesn't show up until
years after the traumatic event.
People with PTSD can be helped by medications and carefully targeted
psychotherapy.
Ordinary events can serve as reminders of the trauma and trigger flashbacks
or intrusive images. Anniversaries of the traumatic event are often very difficult.
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"In any social situation, I felt fear. I would be anxious before
I even left the house, and it would escalate as I got closer to a college
class, a party, or whatever. I would feel sick at my stomach—it almost
felt like I had the flu. My heart would pound, my palms would get sweaty,
and I would get this feeling of being removed from myself and from everybody
else.
"When I would walk into a room full of people, I'd turn red and
it would feel like everybody's eyes were on me. I was embarrassed to stand
off in a corner by myself, but I couldn't think of anything to say to anybody.
It was humiliating. I felt so clumsy, I couldn't wait to get out.
"I couldn't go on dates, and for a while I couldn't even go to
class. My sophomore year of college I had to come home for a semester.
I felt like such a failure."
Social phobia, also called social anxiety disorder, involves overwhelming
anxiety and excessive self-consciousness in everyday social situations. People
with social phobia have a persistent, intense, and chronic fear of being
watched and judged by others and being embarrassed or humiliated by their
own actions. Their fear may be so severe that it interferes with work or
school, and other ordinary activities. While many people with social phobia
recognize that their fear of being around people may be excessive or unreasonable,
they are unable to overcome it. They often worry for days or weeks in advance
of a dreaded situation.
Social phobia can be limited to only one type of situation—such as
a fear of speaking in formal or informal situations, or eating, drinking,
or writing in front of others—or, in its most severe form, may be so broad
that a person experiences symptoms almost anytime they are around other people.
Social phobia can be very debilitating—it may even keep people from going
to work or school on some days. Many people with this illness have a hard
time making and keeping friends.
Physical symptoms often accompany the intense anxiety of social phobia
and include blushing, profuse sweating, trembling, nausea, and difficulty
talking. If you suffer from social phobia, you may be painfully embarrassed
by these symptoms and feel as though all eyes are focused on you. You may
be afraid of being with people other than your family.
People with social phobia are aware that their feelings are irrational.
Even if they manage to confront what they fear, they usually feel very anxious
beforehand and are intensely uncomfortable throughout. Afterward, the unpleasant
feelings may linger, as they worry about how they may have been judged or
what others may have thought or observed about them.
Social phobia affects about 5.3 million adult Americans. Women and
men are equally likely to develop social phobia. The disorder usually begins
in childhood or early adolescence, and there is some evidence that genetic
factors are involved. Social phobia often co-occurs with other anxiety disorders
or depression. Substance abuse or dependence may develop in individuals who
attempt to "self-medicate" their social phobia by drinking or using drugs. Social phobia can be treated
successfully with carefully targeted psychotherapy or medications.
Social phobia can severely disrupt normal life, interfering with school, work,
or social relationships. The dread of a feared event can begin weeks in advance
and be quite debilitating.
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"I'm scared to death of flying,
and I never do it anymore. I used to start dreading a plane trip a month
before I was due to leave. It was an awful feeling when that airplane door
closed and I felt trapped. My heart would pound and I would sweat bullets.
When the airplane would start to ascend, it just reinforced the feeling that
I couldn't get out. When I think about flying, I picture myself losing control,
freaking out, climbing the walls, but of course I never did that. I'm not
afraid of crashing or hitting turbulence. It's just that feeling of being
trapped. Whenever I've thought about changing jobs, I've had to think,'Would
I be under pressure to fly?' These days I only go places where I can drive
or take a train. My friends always point out that I couldn't get off a train
traveling at high speeds either, so why don't trains bother me? I just tell
them it isn't a rational fear."
A specific phobia is an intense fear of something that poses little
or no actual danger. Some of the more common specific phobias are centered
around closed-in places, heights, escalators, tunnels, highway driving, water,
flying, dogs, and injuries involving blood. Such phobias aren't just extreme
fear; they are irrational fear of a particular thing. You may be able to
ski the world's tallest mountains with ease but be unable to go above the
5th floor of an office building. While adults with phobias realize that these
fears are irrational, they often find that facing, or even thinking about
facing, the feared object or situation brings on a panic attack or severe
anxiety.
Specific phobias affect an estimated 6.3 million adult Americans and
are twice as common in women as in men. The causes of specific phobias are
not well understood, though there is some evidence that these phobias may
run in families. Specific phobias usually first appear during childhood or
adolescence and tend to persist into adulthood.
If the object of the fear is easy to avoid, people with specific phobias
may not feel the need to seek treatment. Sometimes, though, they may make
important career or personal decisions to avoid a phobic situation, and if
this avoidance is carried to extreme lengths, it can be disabling. Specific
phobias are highly treatable with carefully targeted psychotherapy.
Phobias aren't just extreme fears; they are irrational fears. You may be able
to ski the world's tallest mountains with ease but feel panic going above the
5th floor of an office building.
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"I always thought I was just a worrier. I'd feel keyed up and
unable to relax. At times it would come and go, and at times it would be
constant. It could go on for days. I'd worry about what I was going to
fix for a dinner party, or what would be a great present for somebody.
I just couldn't let something go.
"I'd have terrible sleeping problems. There were times I'd wake
up wired in the middle of the night. I had trouble concentrating, even
reading the newspaper or a novel. Sometimes I'd feel a little lightheaded.
My heart would race or pound. And that would make me worry more. I was
always imagining things were worse than they really were: when I got a
stomachache, I'd think it was an ulcer.
"When my problems were at their worst, I'd miss work and feel
just terrible about it. Then I worried that I'd lose my job. My life was
miserable until I got treatment."
Generalized anxiety disorder (GAD) is much more than the normal anxiety
people experience day to day. It's chronic and fills one's day with exaggerated
worry and tension, even though there is little or nothing to provoke it.
Having this disorder means always anticipating disaster, often worrying excessively
about health, money, family, or work. Sometimes, though, the source of the
worry is hard to pinpoint. Simply the thought of getting through the day
provokes anxiety.
People with GAD can't seem to shake their concerns, even though they
usually realize that their anxiety is more intense than the situation warrants.
Their worries are accompanied by physical symptoms, especially fatigue, headaches,
muscle tension, muscle aches, difficulty swallowing, trembling, twitching,
irritability, sweating, and hot flashes. People with GAD may feel lightheaded
or out of breath. They also may feel nauseated or have to go to the bathroom
frequently.
Individuals with GAD seem unable to relax, and they may startle more
easily than other people. They tend to have difficulty concentrating, too.
Often, they have trouble falling or staying asleep.
Unlike people with several other anxiety disorders, people with GAD
don't characteristically avoid certain situations as a result of their disorder.
When impairment associated with GAD is mild, people with the disorder may
be able to function in social settings or on the job. If severe, however,
GAD can be very debilitating, making it difficult to carry out even the most
ordinary daily activities.
GAD affects about 4 million adult Americans and about twice as many
women as men. The disorder comes on gradually and can begin across the life
cycle, though the risk is highest between childhood and middle age. It is
diagnosed when someone spends at least 6 months worrying excessively about
a number of everyday problems. There is evidence that genes play a modest
role in GAD.
GAD is commonly treated with medications. GAD rarely occurs alone,
however; it is usually accompanied by another anxiety disorder, depression,
or substance abuse. These other conditions must be treated along with GAD.
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NIMH supports research into the causes, diagnosis, prevention, and
treatment of anxiety disorders and other mental illnesses. Studies examine
the genetic and environmental risks for major anxiety disorders, their course—both
alone and when they occur along with other diseases such as depression—and
their treatment. The ultimate goal is to be able to cure, and perhaps even
to prevent, anxiety disorders.
NIMH is harnessing the most sophisticated scientific tools available
to determine the causes of anxiety disorders. Like heart disease and diabetes,
these brain disorders are complex and probably result from a combination
of genetic, behavioral, developmental, and other factors.
Several parts of the brain are key actors in a highly dynamic interplay
that gives rise to fear and anxiety. Using brain imaging technologies and
neurochemical techniques, scientists are finding that a network of interacting
structures is responsible for these emotions. Much research centers on the
amygdala, an almond-shaped structure deep within the brain. The amygdala
is believed to serve as a communications hub between the parts of the brain
that process incoming sensory signals and the parts that interpret them.
It can signal that a threat is present, and trigger a fear response or anxiety.
It appears that emotional memories stored in the central part of the amygdala
may play a role in disorders involving very distinct fears, like phobias,
while different parts may be involved in other forms of anxiety.
Other research focuses on the hippocampus, another brain structure
that is responsible for processing threatening or traumatic stimuli. The
hippocampus plays a key role in the brain by helping to encode information
into memories. Studies have shown that the hippocampus appears to be smaller
in people who have undergone severe stress because of child abuse or military
combat. This reduced size could help explain why individuals with PTSD have
flashbacks, deficits in explicit memory, and fragmented memory for details
of the traumatic event.
Also, research indicates that other brain parts called the basal ganglia
and striatum are involved in obsessive-compulsive disorder.
By learning more about brain circuitry involved in fear and anxiety,
scientists may be able to devise new and more specific treatments for anxiety
disorders. For example, it someday may be possible to increase the influence
of the thinking parts of the brain on the amygdala, thus placing the fear
and anxiety response under conscious control. In addition, with new findings
about neurogenesis (birth of new brain cells) throughout life, perhaps a
method will be found to stimulate growth of new neurons in the hippocampus
in people with PTSD.
NIMH-supported studies of twins and families suggest that genes play
a role in the origin of anxiety disorders. But heredity alone can't explain
what goes awry. Experience also plays a part. In PTSD, for example, trauma
triggers the anxiety disorder; but genetic factors may explain why only certain
individuals exposed to similar traumatic events develop full-blown PTSD.
Researchers are attempting to learn how genetics and experience interact
in each of the anxiety disorders—information they hope will yield clues to
prevention and treatment.
Scientists supported by NIMH are also conducting clinical trials to
find the most effective ways of treating anxiety disorders. For example,
one trial is examining how well medication and behavioral therapies work
together and separately in the treatment of OCD. Another trial is assessing
the safety and efficacy of medication treatments for anxiety disorders in
children and adolescents with co-occurring attention deficit hyperactivity
disorder (ADHD)
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Effective treatments for each of the anxiety disorders have been developed
through research. In general, two types of treatment are available for an
anxiety disorder—medication and specific types of psychotherapy (sometimes
called "talk therapy"). Both approaches can be effective for most disorders. The choice of one or
the other, or both, depends on the patient's and the doctor's preference,
and also on the particular anxiety disorder. For example, only psychotherapy
has been found effective for specific phobias. When choosing a therapist,
you should find out whether medications will be available if needed.
Before treatment can begin, the doctor must conduct a careful diagnostic
evaluation to determine whether your symptoms are due to an anxiety disorder,
which anxiety disorder(s) you may have, and what coexisting conditions may
be present. Anxiety disorders are not all treated the same, and it is important
to determine the specific problem before embarking on a course of treatment.
Sometimes alcoholism or some other coexisting condition will have such an
impact that it is necessary to treat it at the same time or before treating
the anxiety disorder.
If you have been treated previously for an anxiety disorder, be prepared
to tell the doctor what treatment you tried. If it was a medication, what
was the dosage, was it gradually increased, and how long did you take it?
If you had psychotherapy, what kind was it, and how often did you attend
sessions? It often happens that people believe they have "failed" at treatment, or that the treatment has failed them, when in fact it was never
given an adequate trial.
When you undergo treatment for an anxiety disorder, you and your doctor
or therapist will be working together as a team. Together, you will attempt
to find the approach that is best for you. If one treatment doesn't work,
the odds are good that another one will. And new treatments are continually
being developed through research. So don't give up hope.
Medications
Psychiatrists or other physicians can prescribe medications for anxiety
disorders. These doctors often work closely with psychologists, social workers,
or counselors who provide psychotherapy. Although medications won't cure
an anxiety disorder, they can keep the symptoms under control and enable
you to lead a normal, fulfilling life.
The major classes of medications used for various anxiety disorders
are described below.
Antidepressants
A number of medications that were originally approved for treatment
of depression have been found to be effective for anxiety disorders. If your
doctor prescribes an antidepressant, you will need to take it for several
weeks before symptoms start to fade. So it is important not to get discouraged
and stop taking these medications before they've had a chance to work.
Some of the newest antidepressants are called selective
serotonin reuptake inhibitors, or SSRIs. These medications act in the brain on a chemical messenger called serotonin.
SSRIs tend to have fewer side effects than older antidepressants. People
do sometimes report feeling slightly nauseated or jittery when they first
start taking SSRIs, but that usually disappears with time. Some people
also experience sexual dysfunction when taking some of these medications.
An adjustment in dosage or a switch to another SSRI will usually correct
bothersome problems. It is important to discuss side effects with your
doctor so that he or she will know when there is a need for a change in
medication.
Fluoxetine, sertraline, fluvoxamine, paroxetine, and citalopram are
among the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social
phobia. SSRIs are often used to treat people who have panic disorder in combination
with OCD, social phobia, or depression. Venlafaxine, a drug closely related
to the SSRIs, is useful for treating GAD. Other newer antidepressants are
under study in anxiety disorders, although one, bupropion, does not appear
effective for these conditions. These medications are started at a low dose
and gradually increased until they reach a therapeutic level.
Similarly, antidepressant medications called tricyclics are
started at low doses and gradually increased. Tricyclics have been around
longer than SSRIs and have been more widely studied for treating anxiety
disorders. For anxiety disorders other than OCD, they are as effective as
the SSRIs, but many physicians and patients prefer the newer drugs because
the tricyclics sometimes cause dizziness, drowsiness, dry mouth, and weight
gain. When these problems persist or are bothersome, a change in dosage or
a switch in medications may be needed.
Tricyclics are useful in treating people with co-occurring anxiety
disorders and depression. Clomipramine, the only antidepressant in its class
prescribed for OCD, and imipramine, prescribed for panic disorder and GAD,
are examples of tricyclics.
Monoamine oxidase inhibitors,
or MAOIs, are the oldest class of antidepressant medications. The most commonly prescribed
MAOI is phenelzine, which is helpful for people with panic disorder and social
phobia. Tranylcypromine and isoprocarboxazid are also used to treat anxiety
disorders. People who take MAOIs are put on a restrictive diet because these
medications can interact with some foods and beverages, including cheese
and red wine, which contain a chemical called tyramine. MAOIs also interact
with some other medications, including SSRIs. Interactions between MAOIs
and other substances can cause dangerous elevations in blood pressure or
other potentially life-threatening reactions.
Anti-Anxiety Medications
High-potency benzodiazepines relieve
symptoms quickly and have few side effects, although drowsiness can be a
problem. Because people can develop a tolerance to them—and would have to
continue increasing the dosage to get the same effect—benzodiazepines are
generally prescribed for short periods of time. One exception is panic disorder,
for which they may be used for 6 months to a year. People who have had problems
with drug or alcohol abuse are not usually good candidates for these medications
because they may become dependent on them.
Some people experience withdrawal symptoms when they stop taking benzodiazepines,
although reducing the dosage gradually can diminish those symptoms. In certain
instances, the symptoms of anxiety can rebound after these medications are
stopped. Potential problems with benzodiazepines have led some physicians
to shy away from using them, or to use them in inadequate doses, even when
they are of potential benefit to the patient.
Benzodiazepines include clonazepam, which is used for social phobia
and GAD; alprazolam, which is helpful for panic disorder and GAD; and lorazepam,
which is also useful for panic disorder.
Buspirone, a member of a class of drugs called azipirones, is a newer
anti-anxiety medication that is used to treat GAD. Possible side effects
include dizziness, headaches, and nausea. Unlike the benzodiazepines, buspirone
must be taken consistently for at least two weeks to achieve an anti-anxiety
effect.
Other Medications
Beta-blockers, such as propanolol, are often used to treat heart conditions
but have also been found to be helpful in certain anxiety disorders, particularly
in social phobia. When a feared situation, such as giving an oral presentation,
can be predicted in advance, your doctor may prescribe a beta-blocker that
can be taken to keep your heart from pounding, your hands from shaking, and
other physical symptoms from developing.
Taking Medications Before
taking medication for an anxiety disorder:
- Ask your doctor to tell you about the effects and side effects
of the drug he or she is prescribing.
- Tell your doctor about any alternative therapies or over-the-counter medications
you are using.
- Ask your doctor when and how the medication will be stopped. Some drugs can't
safely be stopped abruptly; they have to be tapered slowly under a physician's
supervision.
- Be aware that some medications are effective in anxiety disorders only as long
as they are taken regularly, and symptoms may occur again when the medications
are discontinued.
- Work together with your doctor to determine the right dosage of the right medication
to treat your anxiety disorder.
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Psychotherapy involves talking with a trained mental health professional,
such as a psychiatrist, psychologist, social worker, or counselor to learn
how to deal with problems like anxiety disorders.
Cognitive-Behavioral and Behavioral Therapy
Research has shown that a form of psychotherapy that is effective
for several anxiety disorders, particularly panic disorder and social phobia,
is cognitive-behavioral therapy (CBT). It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming
their fears. For example, a person with panic disorder might be helped to
see that his or her panic attacks are not really heart attacks as previously
feared; the tendency to put the worst possible interpretation on physical
symptoms can be overcome. Similarly, a person with social phobia might be
helped to overcome the belief that others are continually watching and harshly
judging him or her.
The behavioral component of CBT seeks
to change people's reactions to anxiety-provoking situations. A key element
of this component is exposure, in which people confront the things they fear. An example would be a treatment
approach called exposure and response prevention for people with OCD. If the person has a fear of dirt and germs, the therapist
may encourage them to dirty their hands, then go a certain period of time
without washing. The therapist helps the patient to cope with the resultant
anxiety. Eventually, after this exercise has been repeated a number of times,
anxiety will diminish. In another sort of exposure exercise, a person with
social phobia may be encouraged to spend time in feared social situations
without giving in to the temptation to flee. In some cases the individual
with social phobia will be asked to deliberately make what appear to be slight
social blunders and observe other people's reactions; if they are not as
harsh as expected, the person's social anxiety may begin to fade. For a person
with PTSD, exposure might consist of recalling the traumatic event in detail,
as if in slow motion, and in effect re-experiencing it in a safe situation.
If this is done carefully, with support from the therapist, it may be possible
to defuse the anxiety associated with the memories. Another behavioral technique
is to teach the patient deep breathing as an aid to relaxation and anxiety
management.
Behavioral therapy alone, without a strong cognitive component, has
long been used effectively to treat specific phobias. Here also, therapy
involves exposure. The person is gradually exposed to the object or situation
that is feared. At first, the exposure may be only through pictures or audiotapes.
Later, if possible, the person actually confronts the feared object or situation.
Often the therapist will accompany him or her to provide support and guidance.
If you undergo CBT or behavioral therapy, exposure will be carried
out only when you are ready; it will be done gradually and only with your
permission. You will work with the therapist to determine how much you can
handle and at what pace you can proceed.
A major aim of CBT and behavioral therapy is to reduce anxiety by
eliminating beliefs or behaviors that help to maintain the anxiety disorder.
For example, avoidance of a feared object or situation prevents a person
from learning that it is harmless. Similarly, performance of compulsive rituals
in OCD gives some relief from anxiety and prevents the person from testing
rational thoughts about danger, contamination, etc.
To be effective, CBT or behavioral therapy must be directed at the
person's specific anxieties. An approach that is effective for a person with
a specific phobia about dogs is not going to help a person with OCD who has
intrusive thoughts of harming loved ones. Even for a single disorder, such
as OCD, it is necessary to tailor the therapy to the person's particular
concerns. CBT and behavioral therapy have no adverse side effects other than
the temporary discomfort of increased anxiety, but the therapist must be
well trained in the techniques of the treatment in order for it to work as
desired. During treatment, the therapist probably will assign "homework"—specific problems that the patient will need to work on between sessions.
CBT or behavioral therapy generally lasts about 12 weeks. It may be
conducted in a group, provided the people in the group have sufficiently
similar problems. Group therapy is particularly effective for people with
social phobia. There is some evidence that, after treatment is terminated,
the beneficial effects of CBT last longer than those of medications for people
with panic disorder; the same may be true for OCD, PTSD, and social phobia.
Medication may be combined with psychotherapy, and for many people
this is the best approach to treatment. As stated earlier, it is important
to give any treatment a fair trial. And if one approach doesn't work, the
odds are that another one will, so don't give up.
If you have recovered from an anxiety disorder, and at a later date
it recurs, don't consider yourself a "treatment failure." Recurrences can be treated effectively, just like an initial episode. In fact,
the skills you learned in dealing with the initial episode can be helpful
in coping with a setback.
Coexisting Conditions
It is common for an anxiety disorder to be accompanied by another
anxiety disorder or another illness. Often people who have panic disorder
or social phobia, for example, also experience the intense sadness and hopelessness
associated with depression. Other conditions that a person can have along
with an anxiety disorder include an eating disorder or alcohol or drug abuse.
Any of these problems will need to be treated as well, ideally at the same
time as the anxiety disorder.
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If you, or someone you know, has symptoms of anxiety, a visit to the
family physician is usually the best place to start. A physician can help
determine whether the symptoms are due to an anxiety disorder, some other
medical condition, or both. Frequently, the next step in getting treatment
for an anxiety disorder is referral to a mental health professional.
Among the professionals who can help are psychiatrists, psychologists,
social workers, and counselors. However, it's best to look for a professional
who has specialized training in cognitive-behavioral therapy and/or behavioral therapy, as appropriate, and
who is open to the use of medications, should they be needed.
As stated earlier, psychologists, social workers, and counselors sometimes
work closely with a psychiatrist or other physician, who will prescribe medications
when they are required. For some people, group therapy is a helpful part
of treatment.
It's important that you feel comfortable with the therapy that the
mental health professional suggests. If this is not the case, seek help elsewhere.
However, if you've been taking medication, it's important not to discontinue
it abruptly, as stated before. Certain drugs have to be tapered off under
the supervision of your physician.
Remember, though, that when you find a health care professional that
you're satisfied with, the two of you are working together as a team. Together
you will be able to develop a plan to treat your anxiety disorder that may
involve medications, cognitive-behavioral or other talk therapy, or both,
as appropriate.
You may be concerned about paying for treatment for an anxiety disorder.
If you belong to a Health Maintenance Organization (HMO) or have some other
kind of health insurance, the costs of your treatment may be fully or partially
covered. There are also public mental health centers that charge people according
to how much they are able to pay. If you are on public assistance, you may
be able to get care through your state Medicaid plan.
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Many people with anxiety disorders benefit from joining a self-help
group and sharing their problems and achievements with others. Talking with
trusted friends or a trusted member of the clergy can also be very helpful,
although not a substitute for mental health care. Participating in an Internet
chat room may also be of value in sharing concerns and decreasing a sense
of isolation, but any advice received should be viewed with caution.
The family is of great importance in the recovery of a person with
an anxiety disorder. Ideally, the family should be supportive without helping
to perpetuate the person's symptoms. If the family tends to trivialize the
disorder or demand improvement without treatment, the affected person will
suffer. You may wish to show this booklet to your family and enlist their
help as educated allies in your fight against your anxiety disorder.
Stress management techniques and meditation may help you to calm yourself
and enhance the effects of therapy, although there is as yet no scientific
evidence to support the value of these "wellness" approaches to recovery from anxiety disorders. There is preliminary evidence
that aerobic exercise may be of value, and it is known that caffeine, illicit
drugs, and even some over-the-counter cold medications can aggravate the
symptoms of an anxiety disorder. Check with your physician or pharmacist
before taking any additional medicines.
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Most people experience feelings of anxiety before an important event
such as a big exam, business presentation, or first date. Anxiety disorders,
however, are illnesses that fill people's lives with overwhelming anxiety
and fear that are chronic, unremitting, and can grow progressively worse.
Tormented by panic attacks, obsessive thoughts, flashbacks of traumatic events,
nightmares, or countless frightening physical symptoms, some people with
anxiety disorders even become housebound. Fortunately, through research supported
by the National Institute of Mental Health (NIMH), there are effective treatments
that can help.
How Common Are Anxiety Disorders?
Anxiety disorders, as a group, are the most common mental illness
in America. More than 19 million American adults are affected by these debilitating
illnesses each year. Children and adolescents can also develop anxiety disorders.
What Are the Different Kinds of Anxiety Disorders?
- Panic Disorder—Repeated episodes of intense fear that strike often
and without warning. Physical symptoms include chest pain, heart palpitations,
shortness of breath, dizziness, abdominal distress, feelings of unreality,
and fear of dying.
- Obsessive-Compulsive Disorder—Repeated, unwanted thoughts or compulsive
behaviors that seem impossible to stop or control.
- Post-Traumatic Stress Disorder—Persistent symptoms that occur after
experiencing or witnessing a traumatic event such as rape or other criminal
assault, war, child abuse, natural or human-caused disasters, or crashes.
Nightmares, flashbacks, numbing of emotions, depression, and feeling angry,
irritable or distracted and being easily startled are common. Family members
of victims can also develop this disorder.
- Phobias—Two major types of phobias are social phobia and specific
phobia. People with social phobia have an overwhelming and disabling fear
of scrutiny, embarrassment, or humiliation in social situations, which leads
to avoidance of many potentially pleasurable and meaningful activities.
People with specific phobia experience extreme, disabling, and irrational
fear of something that poses little or no actual danger; the fear leads
to avoidance of objects or situations and can cause people to limit their
lives unnecessarily.
- Generalized Anxiety Disorder—Constant, exaggerated worrisome thoughts
and tension about everyday routine life events and activities, lasting at
least six months. Almost always anticipating the worst even though there
is little reason to expect it; accompanied by physical symptoms, such as
fatigue, trembling, muscle tension, headache, or nausea.
Treatments have been largely developed through research conducted
by NIMH and other research institutions. They help many people with anxiety
disorders and often combine medication and specific types of psychotherapy.
A number of medications that were originally approved for treating
depression have been found to be effective for anxiety disorders as well.
Some of the newest of these antidepressants are called selective serotonin
reuptake inhibitors (SSRIs). Other antianxiety medications include groups
of drugs called benzodiazepines and beta-blockers. If one medication is not
effective, others can be tried. New medications are currently under development
to treat anxiety symptoms.
Two clinically-proven effective forms of psychotherapy used to treat
anxiety disorders are behavioral therapy and cognitive-behavioral therapy.
Behavioral therapy focuses on changing specific actions and uses several
techniques to stop unwanted behaviors. In addition to the behavioral therapy
techniques, cognitive-behavioral therapy teaches patients to understand and
change their thinking patterns so they can react differently to the situations
that cause them anxiety.
Do Anxiety Disorders Co-Exist with Other Physical or Mental Disorders?
It is common for an anxiety disorder to accompany depression, eating
disorders, substance abuse, or another anxiety disorder. Anxiety disorders
can also co-exist with illnesses such as cancer or heart disease. In such
instances, the accompanying disorders will also need to be treated. Before
beginning any treatment, however, it is important to have a thorough medical
examination to rule out other possible causes of symptoms.
Anxiety Disorders
One-Year Prevalence (Adults)
| |
Percent |
Population Estimate*
(Millions) |
| Any Anxiety Disorder |
13.3 |
19.1 |
| Panic Disorder |
1.7 |
2.4 |
| Obsessive-Compulsive Disorder |
2.3 |
3.3 |
| Post-Traumatic Stress Disorder |
3.6 |
5.2 |
| Any Phobia |
8.0 |
11.5 |
| Generalized Anxiety Disorder |
2.8 |
4.0 |
| * Based on 7/1/98 U.S. Census resident
population estimate of 143.3 million, age 18-54 |
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Alzheimer's Disease
