(Source: The National Institute of Mental Health)
- Specific Phobias
- Generalized Anxiety Disorder (GAD)
- Role of Research in Improving the Understanding and Treatment of Anxiety Disorders
- Treatment of Anxiety Disorders
Anxiety disorders are serious medical illnesses that affect approximately 19 million American adults.1 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.
These information pages will
- help you identify the symptoms of anxiety disorders,
- explain the role of research in understanding the causes of these conditions,
- describe effective treatments,
- suggest ways to make treatment more effective.
Anxiety disorders include:
- panic disorder
- obsessive-compulsive disorder,
- post-traumatic stress disorder
- social phobia (or social anxiety disorder),
- specific phobias
- generalized anxiety disorder
Each anxiety disorder has its own distinct features, but they are all bound together by the common theme of excessive, irrational fear and dread.
Depression often accompanies anxiety disorders4 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
"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 Americans1 and are twice as common in women as in men.10 The causes of specific phobias are not well understood, though there is some evidence that these phobias may run in families.11 Specific phobias usually first appear during childhood or adolescence and tend to persist into adulthood.12
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.
Generalized Anxiety Disorder
"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 Americans1 and about twice as many women as men.2 The disorder comes on gradually and can begin across the life cycle, though the risk is highest between childhood and middle age.2 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.13
GAD is commonly treated with medications. GAD rarely occurs alone, however; it is usually accompanied by another anxiety disorder, depression, or substance abuse.2,4 These other conditions must be treated along with GAD.
Role of Research in Improving the Understanding and Treatment of Anxiety Disorders
Research has determined that several parts of the brain are key actors in a highly dynamic interplay that gives rise to fear and anxiety.14 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.15,16 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.17
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,18 perhaps a method will be found to stimulate growth of new neurons in the hippocampus in people with PTSD.
National Institute of Mental Health (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.
Treatment of Anxiety Disorders
Effective treatments for each of the anxiety disorders have been developed through research.19 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.
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.
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.
A number of medications that were originally approved for treatment of depression have been found to be very 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 (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa) and escitalopram oxalate (Lexipro) 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 (Effexor), a drug closely related to the SSRIs, is useful for treating GAD and OCD. Other newer antidepressants are under study in anxiety disorders, although one, bupropion (Wellbutrin), does not appear effective for these conditions. Buproprion (Wellbutrin) works well for treating depressive symptoms as apposed to anxiety symptoms. 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.
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 only 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 (Xanax), which is helpful for panic disorder and GAD; and lorazepam, which is also useful for panic disorder.
Buspirone (Buspar), 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.
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.
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.
Psychotherapy involves talking with a trained mental health professional, such as a psychologist, social worker, or counselor to learn how to deal with problems like anxiety disorders. Some psychiatrists also provide psychotherapy, but usually psychiatrists focus more on providing medication management.
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.
It is common for an anxiety disorder to be accompanied by another anxiety disorder or another illness.4,5,6 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.
1Narrow WE, Rae DS, Regier DA. NIMH epidemiology note: prevalence of anxiety disorders. One-year prevalence best estimates calculated from ECA and NCS data. Population estimates based on U.S. Census estimated residential population age 18 to 54 on July 1, 1998. Unpublished.
2Robins LN, Regier DA, eds. Psychiatric disorders in America: the Epidemiologic Catchment Area Study. New York: The Free Press, 1991.
3The NIMH Genetics Workgroup. Genetics and mental disorders. NIH Publication No. 98-4268. Rockville, MD: National Institute of Mental Health, 1998.
4Regier DA, Rae DS, Narrow WE, et al. Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders. British Journal of Psychiatry Supplement, 1998; (34): 24-8.
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6Wonderlich SA, Mitchell JE. Eating disorders and comorbidity: empirical, conceptual, and clinical implications. Psychopharmacology Bulletin, 1997; 33(3): 381-90.
7Davidson JR. Trauma: the impact of post-traumatic stress disorder. Journal of Psychopharmacology, 2000; 14(2 Suppl 1): S5-S12.
8Margolin G, Gordis EB. The effects of family and community violence on children. Annual Review of Psychology, 2000; 51: 445-79.
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16Stein MB, Hanna C, Koverola C, et al. Structural brain changes in PTSD: does trauma alter neuroanatomy? In: Yehuda R, McFarlane AC, eds. Psychobiology of posttraumatic stress disorder. Annals of the New York Academy of Sciences, 821. New York: The New York Academy of Sciences, 1997.
17Rauch SL, Savage CR. Neuroimaging and neuropsychology of the striatum. Bridging basic science and clinical practice. Psychiatric Clinics of North America, 1997; 20(4): 741-68.
18Gould E, Reeves AJ, Fallah M, et al. Hippocampal neurogenesis in adult Old World primates. Proceedings of the National Academy of Sciences USA, 1999, 96(9): 5263-7.
19Hyman SE, Rudorfer MV. Anxiety disorders. In: Dale DC, Federman DD, eds. Scientific American® Medicine. Volume 3. New York: Healtheon/WebMD Corp., 2000, Sect. 13, Subsect. VIII.
This brochure is a revision by Mary Lynn Hendrix of an earlier version written by Marilyn Dickey.
Scientific information and/or review for this revision were provided by Steven E. Hyman, M.D., Richard Nakamura, Ph.D., Matthew Rudorfer, M.D., Linda Street, Ph.D., and Elaine Baldwin, all of NIMH, and Una McCann, M.D., now of The Johns Hopkins University. Editorial assistance was provided by Clarissa Wittenberg, Margaret Strock, and Melissa Spearing of NIMH.