Anxiety Disorders

The most common anxiety disorders are specific phobias. Specific phobias are an excessive fear of a specific object or situation, such as spiders (arachnophobia), heights (acrophobia), flying, or closed spaces (claustrophobia).

Anxiety can be described as the response to a future or possible threat. It is closely related to fear, which is the response to a real or perceived immediate threat.

• Fear and anxiety are normal evolved responses in both humans and animals, and physical responses are linked to the "fight-or-flight" system.
• The autonomic nervous system controls the fight-or-flight response in the body, and this response generally includes dilation of the pupils in the eyes, increased heart rate, and increased respiration/breathing.

Anxiety responses can include increased vigilance (paying attention to one's surroundings) and muscle tension. It can be constructive, such as improving performance on a test, sporting event, or public speaking. Although these are normal responses and often helpful responses to danger, anxiety can cause problems when it is turned on too easily, not turned off when danger is absent, or when the response is too strong.

Excessive anxiety that causes distress or impairment, interferes with normal function, or causes avoidance of important activities and people in life, is considered an anxiety disorder.

Anxiety disorders are differentiated based on the type of object or situation that causes fear, anxiety, or avoidance as well as the thought patterns associated with the fear or anxiety. To be considered an anxiety disorder, the fear or anxiety also has to be persistent (lasting usually six months or more), and not a normal developmental phase (for example a young child being afraid of being away from their parent). Anxiety disorders commonly start in childhood but persist into adulthood.

The most common anxiety disorders are specific phobias. Specific phobias are an excessive fear of a specific object or situation, such as:

• Spiders (arachnophobia)
• Heights (acrophobia)
• Flying
• Closed spaces (claustrophobia)

Most people are aware that their fears (phobias) are excessive, but they often feel powerless to control them. Sometimes a phobia may start after a traumatic event (for example being stuck in a small space or seeing someone injured by an animal), but the symptoms are related to the fear and not related to re-experiencing the trauma (for example the symptoms don't better fit a post-traumatic stress disorder [PTSD] diagnosis).

In social anxiety disorder (social phobia or performance anxiety), people are excessively fearful or anxious about social interactions or situations that may involve being observed or scrutinized. Self-consciousness about being observed by others, or performing in front of others, is normal. However, social anxiety is much more extreme and gets in the way of completing normal (and often necessary) activities successfully. Social phobia may be limited to performance situations (such as speaking, singing, or acting in front of others), or it may be more general and related to many (or all) situations around other people.

Generalized anxiety disorder (GAD) is characterized by persistent and excessive anxiety and worry about many different areas that are hard to control. Other anxiety disorders include separation anxiety disorder, selective mutism, agoraphobia (fear of being outside of the home in various situations), and panic disorder (recurring unexpected panic attacks and fear of having more panic attacks).

While there is no single cause of GAD, some people are more at risk for developing anxiety than others. Women tend to develop this condition and most other anxiety disorders more often than men, and individuals with a family history of anxiety and depression are more at risk for having GAD. Genetic factors (for example, a family history of anxiety and/or depression) are thought to explain about one-third of the risk for GAD. Younger adults are more likely to have GAD or social anxiety disorder compared to older adults. Other risk factors for developing social anxiety disorder include being of Native-American ethnicity and having a low income. Being of Asian, Hispanic, or black ethnicity, as well as residing in a more populated region, seems to reduce the risk of social anxiety disorder.

Inhibited temperament, parental anxiety, and having family and friends who somehow support avoidant coping mechanisms are risk factors for developing an anxiety disorder. Adolescents who smoke tobacco are at risk of developing anxiety. In children, girls, particularly those who begin puberty early, seem to be more likely to develop anxiety than their age peers of both genders.

Life stress, involving health problems and family disagreements, is associated with developing an anxiety disorder. Certain other life stresses put people at risk for developing anxiety, as well. For example, in a study of African-American, Afro-Caribbean, and non-Hispanic white individuals, non-race-based discrimination was found to be a risk factor for developing anxiety in each of those groups while race-based discrimination was found to increase the likelihood of only the African-American people in developing anxiety.

Anxiety disorders may also be caused by drugs, medications, or other substances (including stimulants, caffeine, and corticosteroids).

• Stimulant medications and herbal preparations include common over-the-counter drugs such as cold medicine and decongestants, ephedra or ephedrine-containing products, diet pills, or energy drinks.
• Prescription stimulants are sometimes used to treat ADHD/ADD (attention deficit hyperactivity disorder or attention deficit disorder) and include methylphenidate (Ritalin, Concerta), and amphetamine salts (Adderall), lisdexamfetamine (Vyvanse), and others.
• Withdrawal from alcohol and certain drugs (including benzodiazepines [medicines sometimes used to treat acute anxiety, such as alprazolam (Xanax), lorazepam (Ativan), or clonazepam (Klonopin), barbiturates, or newer seizure medications such as gabapentin (Neurontin)]) can also cause anxiety-like symptoms.

When a medication or drug is the primary cause of the anxiety, it is diagnosed as a medication or substance-induced anxiety disorder. Medical illnesses or conditions (such as thyroid conditions, breathing problems [such as asthma or COPD (chronic obstructive pulmonary disease), or rare adrenal gland tumors (pheochromocytoma)]) can also cause anxiety disorders and/or anxiety-like symptoms.

Common symptoms and signs of anxiety disorder can include:

• restlessness or feeling edgy
• becoming tired easily, fatigue
• trouble concentrating, which may also appear as memory or attention problems
• feeling as if the mind is going "blank"
• irritability
• muscle tension
• headaches
• sleep problems (trouble falling or staying asleep or having sleep that is not restful)

Anxiety that is associated with specific (specific or simple phobia) or social fears (social phobia) may also result in avoidance of certain situations or an elevation of symptoms to trigger a panic attack.

Panic attacks are sudden episodes of intense fear and/or physical discomfort that reach a peak within minutes. Specific signs and symptoms of a panic attack include both physical and emotional symptoms such as:

• palpitations (feelings of rapid and/or irregular heartbeats)
• chest pain, chest tightness, or other discomforts, feeling like one is having a heart attack
• shortness of breath or trouble breathing
• sweating of the palms
• nausea or other stomach upset
• trembling or shaking
• feeling dizzy, unsteady, lightheaded, or faint
• derealization (feelings of unreality) or depersonalization (feeling detached from oneself)
• fear of losing control or going insane
• numbness or tingling sensations
• chills or hot flashes
• feeling like one is choking
• a sense of impending doom
• feeling like one is dying

According to the DSM-5, the diagnosis of GAD requires the following criteria, which must be present for at least six months for more than half of the time:

• Excessive anxiety and worry. Worry is about several events or activities (for example, work or school performance, relationships, and social functioning; worry is not limited just to one topic).
• The worry is difficult to control.
• The anxiety and worry are associated with at least three of the following symptoms:
  • Restlessness or feeling keyed up or on edge
  • Easily fatigued
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance (difficulty falling or staying asleep; or restless, unsatisfying sleep)
• The anxiety, worry, and/or physical symptoms cause significant distress and/or impairment. Impairment may be in social, occupational, or other important aspects of life.
• The anxiety and worry are not better explained by a medical condition, a substance (drug of abuse or medication). They are also not better explained by a different psychiatric diagnosis.

If a health care professional suspects that you have GAD, you will likely undergo an extensive medical interview and physical examination. As part of this examination, you may be asked a series of questions from a standardized questionnaire or self-test to help assess your risk of anxiety. The answers to these questions will help assess whether you meet the diagnostic criteria for GAD (as described above).

Because anxiety may be associated with several other medical illnesses or can be a side effect of various medications, routine laboratory tests are often performed during the initial evaluation to rule out other causes of your symptoms. Occasionally, an X-ray, scan, or another imaging study may be needed.

SRI medications for anxiety

There are a variety of treatments available for controlling anxiety, including several effective anti-anxiety medications and specific forms of psychotherapy.

In terms of medications, buspirone (BuSpar) is known to be quite effective for treating GAD. However, it seems to be less effective in managing many other disorders that often co-occur (are comorbid) with GAD. Therefore, specific members of the serotonin reuptake inhibitor (SRI) and the serotonin and norepinephrine reuptake inhibitor (SNRI) classes of drugs, are also approved by the U.S. Food and Drug Administration (FDA) for effective treatment of GAD and are prescribed more often.

Examples of SRI medications include:

• fluoxetine (Prozac),
• sertraline (Zoloft),
• paroxetine (Paxil),
• citalopram (Celexa), and
• escitalopram (Lexapro).

Examples of SNRI medications are:

• duloxetine (Cymbalta),
• venlafaxine (Effexor), and
• desvenlafaxine (Pristiq).

Some of the newer antidepressants work in a similar way to SRI and SNRI medications but do not yet have FDA approval for the treatment of GAD. Some of these newer medications are mirtazapine (Remeron), levomilnacipran (Fetzima), vilazodone (Viibryd), and vortioxetine (Brintellix).

Benzodiazepine medications for anxiety

Benzodiazepine medications like clonazepam (Klonopin) and lorazepam (Ativan) are sedatives sometimes used for treating anxiety. They may be more effective for short-term use (for example, weeks to months), or occasional use in stopping severe anxiety symptoms, like those that occur in panic attacks, rather than the ongoing worry that is usually associated with GAD.

• Although alprazolam (Xanax) is often used to treat panic attacks, its short duration of action can sometimes result in having to take it several times per day, increasing the risk of tolerance and addiction.
• Another benzodiazepine, diazepam (Valium), tends to be used less often due to concerns about its long duration of action and addiction potential.

The use of benzodiazepines is somewhat controversial; many doctors are reluctant to use them because of the risk of abuse and dependence, and/or withdrawal. There is also some clinical research that suggests PTSD and anxiety disorders may be harder to control later if benzodiazepines are used.

Beta-blocker medications for anxiety

Because of the link between the autonomic nervous system and the fight-or-flight response in anxiety, medications that block this response may be helpful. One example is the beta-blocker family of medications usually used for high blood pressure. Beta-blockers stop some of the effects of epinephrine (adrenaline) which also is involved in anxiety and fear responses.

Beta-blockers such as propranolol (Inderal) are sometimes used to decrease episodic anxiety (for example, performance anxiety or test anxiety), and may also relieve some of the physical symptoms associated with a panic attack.

Other medications for anxiety

In addition to these medications, a variety of other medication classes are sometimes used to help treat anxiety. Although they don't have specific approval for treating anxiety from the FDA, people may discuss the risks and benefits with their prescribing doctor and decide which medications may be right for them.

• Gabapentin (Neurontin) is a medication developed as a seizure medication but has been found to help some individuals with severe anxiety symptoms. Gabapentin may be a less addictive option compared to benzodiazepines.
• Older sedating antihistamine medications, such as hydroxyzine (Vistaril), are another non-addictive type of medication that may be useful for panic attacks or severe episodes of anxiety.

Newer antipsychotic medications for anxiety

When anxiety disorders are difficult to treat, or an individual has side effects with an SRI/SNRI, they may decide with their doctor to try one of the newer antipsychotic (neuroleptic) medications. This class includes:

• risperidone (Risperdal),
• olanzapine (Zyprexa),
• quetiapine (Seroquel),
• aripiprazole (Abilify),
• ziprasidone (Geodon),
• paliperidone (Invega), and
• lurasidone (Latuda).

Several clinical trials are showing some reduction of anxiety symptoms from these medications. However, they also have significant possible side effects and require ongoing monitoring by the patient and their doctor.

Zolpidem (Ambien) and trazodone (Desyrel) have been found helpful in treating insomnia that can often be a symptom of anxiety.

Before SRIs and SNRIs became available, older antidepressant medications including the tricyclic antidepressant (TCA) and monoamine oxidase inhibitor (MAOI) classes were often used to treat anxiety disorders. Although both of these medication classes are effective in treating anxiety disorders, the newer classes of medications (SRIs and SNRIs) have been proven to be safer and better tolerated. Therefore, TCAs and MAOIs are used much less often than they used to be. When used in the appropriate person with close monitoring, these medications can be quite effective as part of treatment for panic disorder.

Alternative, natural, and complementary treatments for anxiety

For people who may be wondering how to treat anxiety without prescribed medications, natural remedies available over the counter may be an option. Alternative and complementary treatment methods such as hypnosis, acupuncture, and herbal supplements (such as kava, valerian, or passionflower) are helpful for some people with some anxiety disorders, but the research data are still considered to be too limited for many physicians to recommend them. Also, care should be taken when taking any dietary supplements, since dietary supplements and "natural" remedies are not regulated in terms of quality, content, or effectiveness.

Psychotherapy treatments for anxiety

The psychotherapy component of treatment for anxiety disorders is at least as important as the medication treatment. Research shows that counseling alone or the combination of medication and psychotherapy treatment is more effective than medication alone in overcoming anxiety for both adults and children. It has also been found to be potentially effective for people with autism in addition to anxiety. The most common type of therapy used to treat anxiety is cognitive behavioral therapy (CBT). This form of therapy seeks to help those with an anxiety disorder identify and decrease the irrational thoughts and behaviors that reinforce anxiety symptoms and can be administered either individually, in group therapy, or even in partner-assisted therapy. Recently, there have also been more online options for CBT available to treat both anxiety and depression. CBT which seeks to help the anxiety sufferer decrease the tendency to pay excessive attention to potential threats has also been found to be helpful.

Behavioral techniques that are often used to decrease anxiety include relaxation techniques and gradually increasing exposure to situations that may have previously precipitated anxiety in the individual. Another name for this type of psychotherapy is exposure therapy. Helping the anxiety sufferer to understand and how to handle the emotional forces that may have contributed to developing symptoms (anxiety-focused psychodynamic psychotherapy) has also been found to be effective in teaching an individual with panic disorder how to prevent an anxiety attack or to decrease or stop a panic attack once it starts. Other commonly available psychotherapy approaches can also improve symptoms of anxiety. Therapies focused on well-being, including mindfulness-based individual or group therapies, are widely available options.

Often, a combination of psychotherapy and medications produces good results. Improvement is usually noticed in a fairly short period, about two to three months, although a full response (or remission of symptoms) usually takes longer. Thus, appropriate treatment for anxiety can prevent symptoms or at least substantially reduce their severity and frequency, bringing significant relief to many people with anxiety.

There are also self-care measures that people with anxiety can do to help make treatment more effective. Since substances like caffeine, alcohol and illicit drugs can worsen anxiety, those things should be avoided. Other tips to prevent or manage anxiety symptoms include engaging in aerobic exercise and stress-management techniques like deep breathing, massage therapy, and yoga since these self-help and well-being activities have also been found to help decrease the frequency and severity of symptoms. Although many people breathe into a paper bag when afflicted by the hyperventilation that can be associated with panic, the benefit received may be the result of the individual believing it will remedy the symptoms (placebo effect). Also, breathing into a paper bag when one is having trouble breathing can make matters worse when the hyperventilation is the result of conditions of oxygen deprivation, as occurs with an asthma attack or a heart attack.

People with an anxiety disorder may also need treatment for other emotional problems. Depression has often been associated with anxiety, as has alcohol and drug abuse. Recent research also suggests that suicide attempts are more frequent in people with an anxiety disorder. Fortunately, these problems associated with panic disorder can be overcome effectively, just like panic disorder itself. Sadly, many people with anxiety do not seek or receive treatment.

Just as inhibited temperament, parental anxiety, and family and friends supporting avoidant coping mechanisms are risk factors for developing an anxiety disorder, encouraging the use of healthier ways to deal with stress can be of great help in the prevention of anxiety. Educating parents on how anxiety fits into their understanding of childhood development and the role of overprotecting parents in developing anxiety disorders have been found to help prevent anxiety disorders in children. Maintaining a healthy lifestyle, including a regular exercise program, eating a balanced diet, and getting adequate sleep can be key to minimizing and perhaps preventing anxiety.

Generalized anxiety disorder is often longstanding or lifelong, particularly without treatment. It can significantly interfere with the lives of individuals who have it and usually requires treatment for it to resolve. Therefore, people with generalized anxiety disorder are usually thought to need treatment for at least a year to prevent its recurrence, and some individuals may need to stay in treatment over the long term.

There are many possible complications associated with anxiety. Mothers who struggle with anxiety during pregnancy are more likely to have babies who are of low birth weight. Children with anxiety often also suffer from depression, behavioral problems like attention deficit hyperactivity disorder (ADHD), or oppositional defiant disorder (ODD), as well as substance abuse. They are at risk of having anxiety as adults, as well as attempting suicide and becoming psychiatrically hospitalized. In terms of achievement, children, and teens with anxiety experience a higher rate of failing in school and having low-paying jobs as adults.

The following are examples of support groups for anxiety disorders:

ABIL, Inc. (Agoraphobics Building Independent Lives)
[email protected]

A.I.M. (Agoraphobics in Motion)
[email protected]

Association for Anxiety and Depression in America (ADAA) has an online listing of support groups by region: http://www.adaa.org/supportgroups

Freedom From Fear
http://www.freedomfromfear.org

Phobics Anonymous
619-322-COPE

Reliable information about GAD, other anxiety disorders and psychiatric diagnoses can be found at

• National Alliance for Mental Illness (NAMI) and
• National Institute of Mental Health (NIMH).

American Academy of Child and Adolescent Psychiatry
http://www.aacap.org

American Counseling Association
http://www.counseling.org

American Psychiatric Association
http://www.psych.org

American Psychological Association
http://helping.apa.org

Anxiety Disorders Association of America
http://www.adaa.org/

National Anxiety Foundation
3135 Custer Dr.
Lexington, KY 40517-4001
606-272-7166

National Association of Social Workers
http://www.naswdc.org

National Mental Health Association
http://www.nmha.org

National Panic/Anxiety Disorder News, Inc.
http://www.npadnews.com