Arousal and stress reactions are essential for human survival; they enable people to pursue important goals and to respond appropriately to danger. In a healthy individual, the stress response (fight, fright, or flight) is provoked by a genuine threat or challenge and is used as a spur for appropriate action. Anxiety, however, is excessive or inappropriate arousal characterized by feelings of apprehension, uncertainty, and fear. The word is derived from the Latin, angere, which means to choke or strangle. It is often not attributable to a real or appropriate threat and can paralyze the individual into inaction or withdrawal. Anxiety can also be a symptom of other psychologic or medical problems, such as depression, substance abuse, or thyroid disease.
Anxiety disorders are the most common psychiatric condition in the United States. About 25 million Americans experience anxiety disorders at some time during their lives; the lifetime risk for an anxiety disorder is nearly 25%. Nevertheless, only about a quarter of those who experience this problem seek help. In recent years, a number of different anxiety disorders have been classified; the two primary ones are generalized anxiety disorder (GAD), which is long-lasting and low-grade, and panic disorder, which has more dramatic symptoms. Other anxiety disorders include phobias, performance anxiety, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). Anxiety disorders are usually caused by a combination of psychological, physical, and genetic conditions, and treatment is, in general, very effective.
Physically, anxiety is usually expressed through a series of responses that include a rise in blood pressure, a fast heart rate, rapid breathing, and an increase in muscle tension; intestinal blood flow decreases, sometimes resulting in nausea or diarrhea. Specific anxiety disorders are diagnosed based on the severity and duration of symptoms and on additional behavioral characteristics that accompany the symptoms of anxiety.
Generalized anxiety disorder (GAD), which affects about 10 million Americans, is characterized by a more-or-less constant state of tension and anxiety over various situations; this state lasts more than six months despite the lack of an obvious or specific stressor. It is very difficult to control worry. (For a clear diagnosis of GAD, the worries are not those of other anxiety disorders, such as fear of panic attacks or appearing in public, nor are they obsessive as in obsessive-compulsive disorder. It should be noted, however, that over half of those with GAD also have another anxiety disorder or depression.) Given these conditions, a diagnosis of GAD is confirmed if three or more of the following symptoms are present (only one for children): feeling on edge or very restless; feeling tired; having difficulty with concentration; feeling irritable; having muscle tension; experiencing sleep disturbances. Some of these symptoms occur on most days for six months. Symptoms should cause significant distress and impair normal functioning and not be due to a medical condition or other mood disorder or psychosis.
Panic disorder is characterized by periodic attacks of anxiety or terror, which usually last 15 to 30 minutes, although residual effects can persist much longer. The frequency and severity of acute states of anxiety determine the diagnosis. During a panic attack a person feels intense fear or discomfort with at least four or more of the following symptoms: rapid heart beat, sweating, shakiness, shortness of breath, a choking feeling, dizziness, nausea, feelings of unreality, numbness, either hot flashes or chills, chest pain, fear of dying, and fear of going insane. A diagnosis of panic disorder is made when a person experiences at least two recurrent, unexpected panic attacks followed by at least one month of fear that another will occur. Frequency of attacks can vary widely. Some people have frequent attacks (for example, every week) that occur for months; others may have clusters of daily attacks followed by week or months of remission. Panic attacks may occur spontaneously or in response to a particular situation. If the patient associates fear with harmless circumstances surrounding the original attack, similar circumstances later on may recall the anxiety and trigger additional panic attacks. Panic attacks that include only one or two symptoms, such as dizziness and heart pounding, are known as limited-symptom attacks; these may be either residual symptoms after a major panic attack or precursors to full-blown attacks. (It should be noted that panic attacks occur with other anxiety disorders, including phobias and posttraumatic stress disorder.)
Phobiasoverwhelming and irrational fearsare common, but they vary in severity. In most cases, people can avoid or at least endure phobic situations, but in some cases, as with agoraphobia, the anxiety associated with the feared object or situation can be incapacitating.
Agoraphobia. About half of people with panic disorders develop agoraphobia, which has been somewhat misleadingly described as fear of open spacesthe term having been derived from the Greek word agora meaning marketplace. In its severest form, agoraphobia is characterized by a paralyzing terror of being in places or situations from which the patient feels there is no escape or accessible help in case of an attack. (One patient described the terror of going outside as opening a door onto a landscape filled with snakes.) Consequently, agoraphobes confine themselves to places in which they feel safe, usually at home. The patient with agoraphobia often makes complicated plans in order to avoid confronting feared situations and places.
Social Phobia and Performance Anxiety. Social phobia is the fear of being publicly scrutinized and humiliated. The associated symptoms vary in intensity, ranging from mild and tolerable anxiety to a full-blown panic attack. Usually, the fear is directed at a particular activity, such as writing in the presence of others or urinating in a public bathroom. Sometimes social phobia is manifested by extreme shyness and discomfort in social settings; frequent blushing, trembling, and sweating are typical symptoms. Performance anxiety, or stage fright, is a subset of social phobia that occurs when a person must perform in public; symptoms include pounding heart, dry mouth, and tremor.
Simple Phobias. A simple phobia is an irrational fear of specific objects or situations. The most common phobias are fear of animals (usually spiders, snakes, or mice), flying (pterygophobia), heights (acrophobia), water, public transportation, confined spaces (claustrophobia), dentists (odontiatophobia), storms, tunnels, and bridges. When confronting the object or situation, the phobic person experiences panicky feelings, sweating, rapid heart beat, avoidance behavior, and difficulty breathing. Most phobic individuals are aware of the irrationality of their fear, and many endure intense anxiety rather than disclose their disorder. Simple phobias are among the most common medical disorders; in many mild cases, however, they are not significant enough to require treatment.
Obsessive-compulsive disorder (OCD) has been described as hiccups of the mind. Obsessions are recurrent or persistent mental images, thoughts, or ideas, which may result in compulsive behaviorsrepetitive, rigid, and self-prescribed routines that are intended to prevent the manifestation of the obsession. Although individuals recognize that the obsessive thoughts and ritualized behavior patterns are senseless and excessive, they cannot stop them in spite of strenuous efforts to ignore or suppress the thoughts or actions. Obsessions and compulsions do not always coexist; however, over half of OCD sufferers have obsessive thoughts without ritualistic behavior.
OCD is time-consuming, distressing, and can disrupt normal functioning. The obsessive thoughts or images can range from mundane worries about whether one has locked a door to bizarre and frightening fantasies of behaving violently toward a loved one. The compulsive acts triggered by such obsessions might include repetitive checking for locked doors or unlit stove burners or calls to loved ones at frequent intervals to be sure they are safe. Some people are compelled to wash their hands every few minutes or spend inordinate amounts of time cleaning their surroundings in order to subdue the fear of contagion. Certain other obsessive disorders, including body dysmorphic disorder (BDD), trichotillomania, and Tourette's syndrome, may be part of the OCD spectrum. In BDD, people are obsessed with the belief that they are extremely ugly. People with trichotillomania continually pull their hair, leaving bald patches. Symptoms of Tourette's syndrome include jerky movements, tics, and uncontrollably uttering obscene words. OCD should not be confused with obsessive-compulsive personality, which defines certain character traits (e.g., being a perfectionist, excessively consciousness, morally rigid, and preoccupied with rules and order). These traits do not necessarily occur in people with obsessive-compulsive disorder, which is a psychiatric condition.
Although post-traumatic stress disorder (PTSD) is primarily a reaction to a traumatic event, it is classified as an anxiety disorder because of the similarity of symptoms. The event that precipitates PTSD is usually thought to be outside the norm of human experience, such as sexual assault or combat. Studies indicate, however, that the condition may be very common. It may develop in people who witness accidents, who or are involved with rescues, or who lose loved ones suddenly. It may also occur in people who have serious illness and receive aggressive treatments or who have close family members or friends with such conditions. Symptoms can occur weeks, months, or even years after the traumatic event. The patient struggles to forget the traumatic event and frequently develops emotional numbness and event-related amnesia. Often, however, the PTSD patient suffers a mental flashback and re-experiences the painful circumstance in the form of intrusive dreams or disturbing thoughts and memories, which resemble or recall the trauma. They are often quick to startle or be angry, even from minor matters. Other symptoms may include emotional withdrawal, hopelessness, mood swings, sleep disorders, guilt over surviving the event, inability to concentrate, and an excessive startle response to noise.
A person's genetics, biochemistry, environment, and psychologic profile all seem to contribute to the development of anxiety disorders. Most people with these disorders seem to have a biological vulnerability to stressmaking them more susceptible to environmental stimuli than the normal population.
Abnormalities in the Brain. Studies suggest that an imbalance of certain substances called neurotransmitters (chemical messengers in the brain) may contribute to anxiety disorders. Advanced imaging techniques have revealed over-activity in the locus ceruleusthe part of the brain important in triggering a response to dangerin people experiencing anxiety, indicating that some people's brains may be more vulnerable to the disorder. Scientists are now beginning to identify the different areas of the brain associated with specific anxiety responses. For example, mechanisms causing OCD may be generated in part by the striatum, the portion of the brain involved with motor control. Generalized anxiety and panic disorder, however, are associated with the amygdala, a part of the brain that regulates fear, memory, and emotion and coordinates them with heart rate, blood pressure, and other physical responses to stressful events.
Chemical Hypersensitivity. Some people have panic attacks after exposure to certain foods or chemicals, such as those contained in perfumes or hair sprays. Some studies have indicated that many children and adults with anxiety disorders may have a hypersensitive response to high levels of carbon dioxide, which can occur in crowded spaces, such as airplanes or elevators. Injections of lactic acid have also been known to set off panic attacks in people with anxiety, but not in people without it.
Genetic Factors. About 20% to 25% of close relatives of people with panic disorder or obsessive-compulsive disorder experience these disorders. Researchers have identified a gene associated with people who have personality traits that include anxiety, anger, hostility, impulsiveness, pessimism, and depression. The gene produces reduced amounts of a protein that transports serotonin, an important neurotransmitter for maintaining positive emotions. (This gene, however, would account for only a very small fraction of people with anxiety disorders.) Genetic mutations that affect other neurotransmitters have also been identified that contribute to obsessive-compulsive disorder. The importance of genetics in GAD is still being investigated. Some experts have identified a genetic defect that affects dopamine, another important neurotransmitter, which appears to cause a syndrome that includes migraine headaches, anxiety, and depression.
Panic Disorder and Family Influence. Psychodynamic theories suggest
that panic disorder is caused by the inability to solve the early childhood
conflict of dependence vs. independence. (This theory is backed up by one study
reporting that young adults who had experienced childhood anxiety were more
likely to live with their parents until their early to mid-twenties.) Many people
with panic disorder perceive their
parents as being frightening and extremely controlling. One study reported, however, that the
incidence of inconsistent, neglectful, or abusive parenting was higher than average in panic disorder patients
only if they also had agoraphobia. In fact, people who have severe agoraphobia with or without panic
disorder generally report less parental affection and more strictness, overprotection, and encouragement
of dependence than those without these disorders.
Phobias and Family Influence. Several studies show a strong correlation between a parent's fears and those of the offspring. Although an inherited trait may be present, some researchers believe that many children can even "learn" fears and phobias just by observing a parent or loved one's phobic or fearful reaction to an event.
Obsessive Compulsive Disorder and Family Influence. One recent study found that parental influence played no part in obsessive-compulsive disorder when the patient was also not suffering from depression. (Patients who had both OCD and depression reported lower levels of parental care and overprotectiveness.)
Specific traumatic events in childhood, including abusesexual, physical, or bothcan later on cause anxiety and other emotional disorders. Some individuals may even have a biological propensity for specific fears, for instance of spiders or snakes, that can be triggered and perpetuated after a single first exposure. A number of studies have reported a strong link between childhood rheumatic fever, which is caused by a streptococcal infection, and the development of tic-related disorders, including OCD and Tourette's syndrome. The effects of alcohol on the developing fetus now appear to increase the risk for mental disorders as well as birth defects.
Anxiety disorders affect more than 23 million Americans, and as many as 25% of all American adults experience intense anxiety at sometime in their lives. Anxiety disorders run in families and genetic or biological factors play a role in most forms.
Worry is very common among children and is often intense, but only about 5% have anxiety that can be classified as a disorder; moreover, depression is a common companion in such children. Studies have suggested that extremely shy children and those likely to be the target of bullies are at higher risk for developing anxiety disorders later in life. One study suggests that such children could be identified as early as two years of age and possibly treated to avoid later anxiety disorders. Prolonged television viewing also puts children at risk for anxiety, depression, and behavioral problems. Panic disorders tend to begin in late adolescence and peak at around 25 years of age. Signs of obsessive-compulsive disorder (OCD) can occur in childhood but usually develops fully in adulthood. The risk for generalized anxiety disorder spans a lifetime although it appears to be the most common form of anxiety at older ages. One study reported that depression in adolescence was a strong predictor of generalized anxiety disorder (GAD) in adulthood.
Women have twice the risk for most anxiety disorders that men do, although obsessive-compulsive disorder occurs equally in both genders. A number of factors may increase the risk in women, including hormonal factors, cultural pressures to meet everyone else's needs except their own, and less self-restrictions on reporting anxiety to physicians.
A study of Mexican adults living in California reported that native-born Mexican-Americans were three times more likely to have anxiety disorders (and even more likely to be depressed) as those who had recently immigrated to American. And the longer the immigrants lived in the U.S. the greater was their risk for psychiatric problems. Traditional Mexican cultural effects and social ties, then, appear to protect newly arrived immigrants from mental illness, even when they are poor. Eventually, however, the consequences of Americanization lead to depression and anxietyprobably resulting from feelings of alienation and inferioritynot only in many Mexican Americans, but in other impoverished minority groups.
Simply experiencing a traumatic event does not predict post-traumatic stress
disorder. Studies estimated that between 6% to 28% of trauma survivors develop
PTSD. A number of factors increase vulnerability to
catastrophic events, include having a psychiatric illness, drug or alcohol abuse, a family history of
anxiety, a history of physical or sexual abuse, and an early separation from parents. One study reported that
having a pre-existing emotional disorder, particularly depression, before the traumatic event most often
predicted PTSD in women. In a study of female veterans, sexual harassment was four times more likely to
cause PTSD than was exposure to military action. Some research suggests that having higher heart rates after
a traumatic event may be an indicator of future PTSD.
Studies report that 25% to 30% of people with panic disorder harbor suicidal thoughts at some point. Studies have also reported that 18% of people with panic disorder, 12% of those with social phobias, and 13% of patients with OCD had attempted suicide. Often, these patients had major depression along with their anxiety disorders. Adolescent girls with panic disorders have nearly three times the risk of those without anxiety.
People with panic disorder perceive their own physical and emotional well being as poor and seek medical help more often than do those in the general population. Studies, in fact, have reported that between 25% and 60% of patients with chest pain who see a physician for possible heart problems suffer instead from panic disorder. Any causal connection between anxiety and medical disorders is unclear. Although a 1998 study found no association between coronary artery disease and anxiety in either men or women, anxiety itself may trigger acute events, such as asthma or chest pain. In fact, panic disorders and phobias have been associated with a higher rate of sudden death from cardiac events. Some researchers speculate that intense anxiety might trigger an abnormal and dangerous heart rhythm, called ventricular fibrillation. Another study indicated that people who experience anxiety are more likely to develop high blood pressure than are those who are not anxious. Both anxiety and depression have been associated with a poor response to treatment in heart patients. Anxiety frequently accompanies medical conditions; for example, half the cases of irritable bowel syndrome are related to anxiety. One study reported that 32% of people with chronic tension headaches met criteria for anxiety; it isn't clear whether the psychologic disorder preceded or followed the onset of headaches. Similarly, another study reported that young girls with anxiety disorder were three times more likely to have chronic headaches than those without the disorder. (Headaches in both these studies were also strongly associated with depression.) No hard evidence exists, however, that anxiety causes these physical problems or that treating anxiety alone will benefit the patient's physical health.
People with obsessive-compulsive disorders can experience skin problems from excessive washing, injuries from repetitive physical acts, and hair loss from repeated hair-pulling, a specific OCD known as trichotillomania.
People with untreated anxiety are at risk for severe depression and for self-medication with alcohol or drugs. More than two-thirds of OCD patients also suffer from depression. In one survey, 40% of OCD sufferers reported that they had to stop working because of the disorder; only 40% worked full-time, and only half were married. In another, nearly half of those who suffered from psychiatric disorders before or during their first marriage were divorced compared to a divorce rate of 36% in those who those who never suffered from emotional disorders.
The long-term impact of a traumatic event is uncertain. In one study of people
who survived a mass killing spree in Texas, nearly less than half of those who
suffered PTSD (28% of all survivors) had recovered after a year. Survivors of
natural catastrophes, such as earthquakes and hurricanes, appear to have an
impaired immune response, which may cause problems over time. Some studies on
people, including military veterans, who have endured major traumatic events
have found a higher risk for health problems. A recent study of Vietnam veterans
reported that PTSD was associated with greater physical limitations, poorer
physical health, and a lower quality of life than in those in the normal population,
regardless of other accompanying emotional or medical disorders. One study of
twins, however, reported that among those
who had served in Vietnam, combat stress increased some hearing and skin problems but had no
major impact on health. Certainly PTSD in adolescence poses real dangers, particularly increasing the risk
for drugs, alcohol, and eating disorders. Of additional concern is recent study reporting that most
adolescents at risk for PTSD are not treated. PTSD may cause actual physical changes in the brain. Two
studies reported that Vietnam veterans and women with PTSD who had been sexually abused displayed a
7% to 8% shrinkage in the hippocampusthe part of the brain important for memory and learning.
Studies of animals indicate that such damage may result from long term exposure to cortisolthe major
stress hormone. Groups who had suffered severe trauma also scored 40% lower in tests of verbal
memory than the general population. There was no difference in IQ or in scores of other types of memory.
Because anxiety accompanies so many medical conditions, some serious, it is extremely important for the physician to uncover any medical problems or medications that might underlie or be masked by an anxiety attack. A physical examination and medical and personal history is essential. The patient should describe any occurrence of anxiety disorders or depression in the family and mention any other contributing factors, such as excessive caffeine use, recent life changes, or stressful events. It is very important to be honest with the physician about all conditions, including excessive drinking, substance abuse, or other psychologic or mood states, that might contribute to or result from the anxiety disorder.
Anxiety attacks can mimic or accompany nearly every acute disorder of the heart or lungs, including heart attacks and angina. One study reported that 25% of patients entering the emergency room with chest pain were actually suffering from panic attacks, which were diagnosed correctly by cardiologists in only 2% of cases. It is often difficult to distinguish between a heart condition and a panic attack. Mitral valve prolapse, a common and usually mild heart problem, may have symptoms that are nearly identical to those of panic disorder and the two conditions frequently occur together. Two-thirds of people with a heart-rhythm disturbance called paroxysmal supraventricular tachycardia have the same symptoms as those with panic attacks. Women who are having actual heart events are much more likely to be misdiagnosed as having an anxiety attack than men with similar problems. Asthma attacks and panic attacks have similar symptoms and can also coexist. In addition, anxiety-like symptoms are seen in many other medical problems, including epilepsy, hypoglycemia, adrenal-gland tumors, and hyperthyroidism. Women can also experience intense anxiety attacks with hot flashes during menopause.
Many drugs, including some for high blood pressure, diabetes, and thyroid disorders, can produce symptoms of anxiety. Withdrawal from certain drugsoften those used to treat sleep disorders or anxietycan also precipitate anxiety reactions.
Overuse of caffeine or abuse of amphetamines can cause symptoms resembling a panic attack. People with anxiety disorders often drink alcohol or abuse drugs in order to conceal or ameliorate symptoms, but substance abuse and dependency can also cause anxiety. In addition, withdrawal from alcohol can produce physiologic symptoms similar to panic attacks. Clinicians often have difficulty determining whether alcoholism or anxiety is the primary disorder.
Depression affects as many as 40% of patients with panic disorder. It is sometimes difficult to distinguish from anxiety disorders because depression is often accompanied by anxious feelings, agitation, insomnia, and problems with concentration. (Because of the confusion in making a diagnosis between the two disorders, the American Psychiatric Association is considering a new classificationmixed anxiety and depression.)
Although most family physicians can identify panic disorder, very few (10%
in one study) recognize social phobias. Clinicians can use various tests to
determine the causes, type, severity, and frequency of anxiety. Such tests include
the Beck Anxiety Inventorya self-administered test, the Hamilton Anxiety
Rating Scale, and the Anxiety Disorders Interview Schedule.
It is also possible to detect correlates of anxiety by assessment of the autonomic nervous system functions, e.g., heart rate, blood pressure, muscle tension, and respiratory rate. These measurements can help gauge the severity of a person's anxiety.
Anxiety disorders require treatment; simply trying to talk oneself out of anxiety is as futile as trying to talk oneself out of a heart or stomach problem. Most anxiety disorders, especially the phobias, respond well to treatment. At present, the most effective approach for most anxiety disorders is a combination of cognitive-behavior therapy (CBT) and medication. The effects of CBT may be relatively short-lived, however, and it should be noted that most anxiety disorders are chronic and often recur after treatments. Treatments are equally effective in men and women, although women are at much higher risk for recurrence of panic attacks. Some studies indicate that between 30% and 82% of people with panic disorder and phobias have a recurrence of attacks at an average of nine months after successful short-term therapy. Obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are particularly hard to treat.
Until recently, the anti-anxiety drugs known as benzodiazepines were the primary medications for anxiety. Increasingly, antidepressants, particularly the selective serotonin-reuptake inhibitors (SSRIs), are being used as the initial treatment. They are proving to be effective, to be less addictive, and to have fewer side effects than the standard anti-anxiety drugs. No one should give up if one drug treatment fails; another may prove to be very effectiveeven a drug of a similar type. Drug combinations should be tried generally only if a single drug and cognitive-behavior therapy have failed. Because many anxiety disorders are chronic, drug therapy sometimes is needed for prolonged period--seven years.
| Anxiety Disorder | Drug Treatment Options | Cognitive-Behavioral and other Non-Drug Therapies |
| Generalized Anxiety Disorder | Benzodiazepines; buspirone; tricyclics (TCAs) for patients who also are depressed. | Cognitive-behavioral, interpersonal therapy, stress management, biofeedback |
| Panic Attacks | SSRIs; benzodiazepines; TCAs, MAO inhibitors. | Cognitive-behavioral therapy |
| Phobias | Benzodiazepines; beta-blockers; SSRIs. | Cognitive-behavioral therapy (desensitization therapy), hypnosis |
| Obsessive Compulsive Disorder | SSRIs as first choice, except if tics are present (neuroleptics for tics); clomipramine (a tricyclic); MAO inhibitors for those who do not respond to other drugs. | Cognitive-behavioral therapy (Exposure and response prevention) |
| Post-traumatic Stress Disorder | Antidepressants, particularly SSRIs; clonidine | Cognitive-behavioral therapy (Group therapy) |
Antidepressants. Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and fluvoxamine (Luvox) are antidepressant drugs known as selective serotonin reuptake inhibitors (SSRIs). They are recommended as the first line of treatment for obsessive-compulsive disorder, and appear to reduce symptoms by 25% to 35% in about half of all patients. Low-dose maintenance therapy may be sufficient for patients who respond well to initial therapy, although most patients do not have a fully adequate response and require high doses. (SSRIs are less effective in OCD patients with tics, for whom small doses of drugs known as neuroleptics may be helpful.) Both fluvoxamine and sertraline are also beneficial in treating of patients with panic disorder and agoraphobia. SSRIs may be helpful for social phobias, particularly when combined with behavioral treatment. Studies have also indicated that fluvoxamine and paroxetine may even help some people with post-traumatic stress disorder (PTSD). (Victims of child abuse tend to respond poorly, whether or not the abuse was the specific trauma triggering PTS.) SSRIs can cause agitation, nausea, and sexual dysfunction, including delay in or loss of orgasm and low sexual drive. (Taking a supervised drug "holiday" on the weekend may improve sexual function during that time, although it may also cause dizziness, exhaustion, and depression.) Some patients, during the first few weeks of treatment, lose a small amount of weight but generally regain it. Elderly people taking these drugs should take the lowest effective dose possible, and those with heart problems should be monitored closely. Newer antidepressants are being specifically designed to target mechanisms that elevate serotonin and other neurotransmitters in the brain; some showing promise for anxiety are venlafaxine (Effexor) and nefazodone (Serzone).
The antidepressant drugs known as tricyclic antidepressants (TCA) have also been effective in treating panic and obsessive-compulsive disorders. The most common TCA used for the treatment of panic disorder is imipramine (Tofranil, Janimine); it is also effective in treating agoraphobia. For people with a mix of generalized anxiety disorder and depression, doxepin (Adapin, Sinequan) has been beneficial. Clomipramine (Anafranil) has been approved for OCD; the drug causes significant reduction in symptoms for patients who can tolerate it. In one study, however, almost half of the patients dropped out because of side effects and even half of those who stayed on the drug experienced adverse effects. Anafranil has more adverse side effects than the SSRIs; both appear to be equally effective over time. (The other tricyclics do not appear to benefit OCD patients.) Elderly patients and those with a history of seizures, cardiac problems, closed-angle glaucoma, and urinary retention or obstruction should be closely supervised when taking tricyclics.
Monoamine oxidase inhibitors (MAOIs), typically phenelzine (Nardil) or tranylcypromine (Parnate), are antidepressants used for panic disorder or OCD that does not respond to other treatments. MAOIs commonly cause weight gain, drowsiness, dizziness, sexual dysfunction, and insomnia. They can also cause birth defects and should not be taken by pregnant women. Hypertension, a potentially serious side effect, can be brought on by eating certain foods, including cheese, red wine, vermouth, dried meats and fish, canned figs, and fava beans, that have a high tyramine content. MAOIs can have serious interactions with certain drugs, including some common over-the-counter cough medications and decongestants. Fatal reactions have occurred when SSRIs and MAOIs were taken at the same time. There should be at least a two to three-week break if a patient is changing from one type of antidepressant to the other. (There should be a five-week break after taking Prozac and before taking an MAOI.)
Several antidepressants are useful in the treatment of post-traumatic stress disorder; still, this is the only anxiety disorder without an effective overall treatment strategy.
One problem with antidepressants is the long delay before they are fully effectiveusually two to four weeksand sometimes up to 12 weeks. People who take them may also experience a temporary period of increased anxiety. Consequently, about a third of patients stop taking antidepressants for anxiety disorders before the initial phase of therapy has been completed. A combination of the anti-anxiety drugs alprazolam (Xanax) or clonazepam (Klonopin) [see below] and an antidepressant is sometimes used to avoid the initial anxiety symptoms and to hasten control of panic symptoms. Xanax can then be withdrawn and the antidepressant, with its negligible chance for long-term abuse, is continued.
Benzodiazepines. Benzodiazepines have, until recently, been the standard treatment of most anxiety disorders; these drugs reinforce a chemical in the brain that inhibits nerve-cell excitability. Alprazolam (Xanax) and clonazepam (Klonopin) are effective for panic disorder, agoraphobia, and generalized anxiety disorder. Other benzodiazepines, including diazepam (Valium), lorazepam (Ativan), halazepam (Paxipam), and chlordiazepoxide (Librium), are used mainly for generalized anxiety.
Common side effects of benzodiazepines are daytime drowsiness and a hung-over feeling. Respiratory problems may be exacerbated. The drugs appear to stimulate eating and can cause weight gain. Benzodiazepines can interact with certain drugs, including cimetidine (Tagamet) and antihistamines. Benzodiazepines are potentially dangerous when used in combination with alcohol. Overdoses are serious, although very rarely fatal. Elderly people are more susceptible to side effects and should usually start at half the dose prescribed for younger people. Of great concern are studies showing automobile accidents and a high risk for hip fractures from falls in older people who take benzodiazepines. They are associated with birth defects, and should not be used by pregnant women or nursing mothers.
The primary problem with the these drugs is their loss of effectiveness over time with continued use at the same dosage. As a result, patients may require increasing doses to prevent anxiety. Dependence is a common danger, which can occur after as short a time as three months. People who discontinue benzodiazepines after taking them for long periods may experience rebound symptomssleep disturbance and anxietywhich can develop within hours or days after stopping the medication. Some patients experience withdrawal symptoms, including stomach distress, sweating, and insomnia, that can last from one to three weeks.
Azapirones. Buspirone (BuSpar) is an azapirone, a class of drugs showing promise for generalized anxiety disorder. Unfortunately, it usually takes several days to weeks for the drug to be fully effective, and it is not useful against panic attacks. Unlike the benzodiazepines, buspirone is not addictive, even with long-term use, and it seems to have less pronounced side effects and no withdrawal effects, even when the drug is discontinued quickly. The drug does not produce any immediate euphoria or change in sensation, so some people believe, erroneously, that the drug doesn't work. Because it has a low potential for abuse, buspirone is useful in persons whose anxiety disorder coexists with alcoholism. Some experts also think it may useful for adolescents and children. Common side effects include dizziness, drowsiness, and nausea. Patients who have recently been taking benzodiazepines may respond less well to buspirone than others. BuSpar should not be used with monoamine oxidase inhibitors (MAOIs).
Beta-Blockers. Beta-blockers, including propranolol (Inderal) and atenolol (Tenormin), block the nerves that stimulate the heart to beat faster. They affect only the physiologic symptoms of anxiety and are most helpful for phobias, particularly performance anxiety. Beta-blockers are less successful for other forms of anxiety.
Clonidine. Clonidine, a drug that relaxes blood vessels, has been used to treat children with post-traumatic stress disorder. Anxiety was reduced and behavior improved, and some experts believe it should be tried if other therapies fail. The drug can have severe side effects.
Pagoclone. Pagoclone is a new drug known as a gamma amino butyric acid (GABA) receptor modulator. It is showing promise in trials for significantly reducing panic attacks with few side effects.
Substance P. Substance P is a brain chemical that is believed to have a role in increasing mood disorders. In one investigative trial of patients with major depression, a substance-P blocker termed MK-869 reduced anxiety as well as depression.
Combining medications, usually SSRIs, and cognitive-behavioral therapies (CBT) are proving to be the best treatment options for panic disorders, phobias, and obsessive-compulsive disorder (OCD). Behavioral therapy alone may be as effective as medications for some children with OCD. CBT and especially group therapy for children may even help people with post-traumatic stress syndrome. The goal is to regain control of reactions to stress and stimuli, thus reducing the feeling of helplessness that often accompanies anxiety disorders. A number of approaches have been designed to treat both the general symptoms of anxiety and specific disorders. Treatment usually takes about 12 to 20 weeks; additional treatments may be necessary to prevent relapse. Because there are not enough trained professionals, particularly in remote areas, researchers are investigating the use of a touch-tone telephone service that provides a voice response path, leading patients through behavioral methods for self-treatment. In one study, 71% of OCD patients said the service had helped them.
Cognitive Therapy. Cognitive therapy works on the principle that the thoughts that produce and maintain anxiety can be recognized objectively and altered, thereby changing the response and eliminating the anxiety reaction. First, the patient must learn how to recognize anxious reactions and thoughts as they occur. These entrenched and automatic reactions and thoughts must be challenged and understood. As the patient begins perceiving that false assumptions underlie the anxiety, he or she can begin substituting new ways of coping with the feared objects and situations. The essential goal of cognitive therapy is to understand the realities of an anxiety-provoking situation and to respond to reality with new actions based on reasonable expectations. A small study compared cognitive therapy with emotional supportive therapy; after two months, 70% of those using cognitive therapy but only 25% of the other group were free of panic attacks. It may even help OCD with compulsive thinking. Techniques for this disorder include keeping a diary of repetitive thinking events, using an audio tape to "over-expose" the patient to repetitive thoughts, and self-observation to reduce unrealistic ideassuch as perfectionismand to restructure thought process.
Systematic Desensitization. Systematic desensitization breaks the link between the anxiety-provoking stimulus and the anxiety response; this treatment requires the patient to gradually confront the object of fear. There are three main elements to the process: relaxation training; a list composed by the patient that prioritizes anxiety-inducing situations by degree of fear; and the desensitization procedure itselfconfronting each item on the list, starting with the least stressful. This treatment is especially effective for simple phobias, social phobias, agoraphobia, and post-traumatic stress syndrome.
Exposure and Response Treatment. Unlike the desensitization process, which emphasizes a relaxed approach and allows the patient to gradually confront the sources of anxiety, exposure treatment purposefully generates anxiety. By repeatedly exposing the patient to the feared object or situation, either literally or using imagination, the patient experiences the anxiety over and over until the stimulating event eventually loses its effect.
Two variants of exposure treatments are flooding and graduated exposure. Flooding, which exposes the person to the anxiety-producing stimulus for as long as one or two hours, has been helpful for some patients with most types of anxiety disorders. Graduated exposure, which can also be successful, gives the patient a greater degree of control over the length and frequency of exposures. Both types of exposure treatment use the most fearful stimulus first, unlike systematic desensitization, which begins with the least fearful.
Modeling Treatment. Phobias can be treated successfully with modeling treatment; the patient observes an actor approach an anxiety-producing object or engage in a fear-provoking activity that is similar to the patient's specific problem. The goal is to learn how to behave in comparable circumstances. Either a live or video-taped situation may be used, but the live model is considered more effective. Recently, a psychologist used virtual reality (three-dimensional, computer-generated images) to cure a woman of arachnophobia (fear of spiders). More research is needed.
Breathing Retraining.
Many people with panic disorders experience hyperventilationrapid, tense breathing that expels too much carbon dioxide, resulting in chest pain, dizziness, tingling of the mouth and fingers, muscle cramps, and even fainting. Hyperventilation is one of the primary physical manifestations of panic disorders. By practicing measured, controlled breathing at the onset of a panic attack, patients may be able to prevent full attacks. This technique is frequently used in conjunction with other treatments for anxiety disorders.
Other forms of psychotherapycommonly called "talk" therapies deal more with childhood roots of anxiety and usually, although not always, require longer treatments. They include interpersonal therapy, supportive psychotherapy, attention intervention, and psychoanalysis. All work is done during the sessions. Some experts believe that such therapies might be more useful for generalized anxiety, which may require more sustained work to process and recover from early traumas and fears.
A surgical technique called cingulotomy involves interrupting the cingulate gyrus, a bundle of nerve fibers in the front of the brain. It is sometimes used as a last resort for patients with severe OCD. A recent variation of this procedure using magnetic resonance imaging (MRI) to guide the surgeon is resulting in long-term improvement in about one-quarter to one-third of OCD patients in whom it is performed. The procedure is generally safe with few serious complications and does not affect intellect or memory.
A healthy lifestyle that includes exercise, adequate rest, and good nutrition can help to reduce the impact of anxiety attacks. Rhythmic aerobic and yoga exercise programs lasting for more than 15 weeks have been found to help reduce anxiety. Strength, or resistance, training does not seem to help anxiety.
National Institute of Mental Health
5600 Fishers Lane
Parklawn Building
Rockville, MD 20857
call (800-64-PANIC) or on the Internet (http://www.nimh.nih.gov/)
The organization is part of the National Institutes of Health. It provides an
important and useful hotline for information on panic disorder. They also provide
a Mental Health Fax (call 301-443-5158) from the headset on your fax machine.
First request their coded sheet for information items, then request two items
per call using code. On the Internet net the report can be accessed directly
(http://www.nimh.nih.gov/publicat/anxiety.htm)
Anxiety Disorders Association of American (ADAA)
11900 Parklawn Drive, Suite 100
Rockville, MD 20852
call (301-231-5484)
On the Internet (http://www.adaa.org/)
This the major anxiety association; it provides information and lists of professionals
and self-help groups.
International Society for Traumatic Stress Studies
60 Revere Dr.
Suite 500
Northbrook, IL 60062 USA
call (847-480-9028) (http://www.istss.com/)
National Anxiety Foundation
3135 Custer Drive
Lexington, KY 40517-4001
call (606-272-7166) or on the Internet (http://lexington-on-line.com/nafmasthead.html)
The Obsessive Compulsive Foundation, Inc.
PO Box 70
Milford, CT 06460
call (203-878-5669) or the information line (203-874-3843) or
on the Internet (http://www.ocfoundation.org/)
Provides information and support to people and families with OCD, as well as
referrals, two newsletters, videos, and support groups.
A.I.M. (Agoraphobic in Motion)
1719 Crooks Rd.
Royal Oak, MI 48067-1305
call (248-547-0400)
Hotline refers people to volunteers and gives information
Phobics Anonymous
PO Box 1180
Palm Springs, CA 92263
call (760-322-COPE)
Send self- addressed stamped envelope for support groups and information.
National Alliance for the Mentally Ill (NAMI)
200 N. Glebe Rd.
Arlington, VA 22203-3754
call (800-950-6264) or on the Internet (http://www.nami.org/)
NAMI is a national grass roots organization providing ways for self-help and
support organizations to individuals and families of people with psychologic
disorders.
National Mental Health Association
1021 Prince St.
Alexandria, VA 22314-2971
call (800-969-6642) or on the Internet (http://www.nmha.org)
This organization will give the names and numbers of regional chapters and provides
information on 200 mental health topics.
Emotions Anonymous
PO Box 4245
St. Paul, MN 55104
call (612-647-9712) or on the Internet (http://www.mtn.org/EA/)
Offers a 12-step program to help people experiencing emotional difficulties.
Has 1,400 groups worldwide.
Expert Knowledge Systems
PO Box 917
Independence VA 23248
fax (540-773 2347) or on the Internet (www.psychguides.com)
Provides in-depth information for OCD.
American Institute for Cognitive Therapy
call (212-308-2440)
Association for the Advancement of Behavior Therapy
call (212-647-1890) or (800-685-AABT)
The American Psychiatric Association
call (202-682-6000) or on the Internet (www.psych.org)
The American Psychological Association
call (800-964-2000) or on the Internet (www.apa.org)
The National Association of Social Workers
call (202-408-8600) or on the Internet (www.naswdc.org)
The American Psychiatric Nurses Association
call (202-857-1133) or on the Internet (www.apna.org)
On the Internet
Mental Health Net (http://www.cmhc.com/)
American Academy of Child and Adolescent Psychiatry (http://www.aacap.org/)
Information on cognitive therapy (http://www.cognitivetherapy.com/)
Internet Mental Health (http://www.mentalhealth.com/)
is a free encyclopedia of mental health information.
Chronic anxiety: How to stop living on the edge. Harvard Health Letter, July 1998, p. 1
Cognitive-behavioral treatment of obsessive thoughts: A controlled study. J Consult Clin Psychol 1997: 65:405-13
Is the course of panic disorder the same in women and men? American Journal of Psychiatry, May 1998, Vol 155, p. 596
Fighting phobias. The things the go bump in the night. FDA Consumer, March 1997
Full and partial posttraumatic stress disorder; findings from a community survey. American Journal of Psychiatry. August 1997
Living without anxiety. Johns Hopkins Medical Letter, August 1997
Mental health affects response to heat treatment. HealthNews, 1/27/98, p. 6
Obsessive-compulsive disorder? Giving up the secret. Harvard Health Letter, March 1998
One-year follow-up of survivors of a mass shooting. American Journal of Psychiatry. December 1997, Vol. 154, p. 1696
Panic attacks. Harvard Men's Health Watch, June 1997
Post-traumatic stress disorder and qualify of life outcomes in a nationally representative sample of male Vietnam veterans. American Journal of Psychiatry, December 1997, Vol. 154, p. 1690
Shaking up immunity; psychological and immunologic changes after a natural disaster. Psychomsomatic Medicine March/April 1997
The trauma of serious illness. HealthNews, 6/25/98, page 1
Well-Connected reports are written and updated by experienced medical writers and reviewed and edited by the in-house editors and a board of physicians at Harvard Medical School and Massachusetts General Hospital. The reports are distinguished from other information sources available to patients and health care consumers by their quality, detail of information and currency. These reports are not intended as a substitute for medical professional help or advice but are to be used only as an aid in understanding current medical knowledge. A physician should always be consulted for any health problem or medical condition. The reports may not be copied without the express permission of the publisher.
Board of Editors
Harvey Simon, M.D., EditorinChief
Massachusetts Institute of Technology; Physician, Massachusetts General Hospital
Masha J. Etkin, M.D., Gynecology
Harvard Medical School; Physician, Massachusetts General Hospital
John E. Godine, M.D., PhD, Metabolism
Harvard Medical School; Associate Physician, Massachusetts General Hospital
Daniel Heller, M.D., Pediatrics
Harvard Medical School; Associate Pediatrician, Massachusetts General Hospital;
Active Staff, Children's Hospital
Irene Kuter, M.D., D. Phil, Oncology
Harvard Medical School; Assistant Physician, Massachusetts General Hospital
Paul C. Shellito, M.D., Surgery
Harvard Medical School; Associate Visiting Surgeon, Massachusetts General Hospital
Theodore A. Stern, M.D., Psychiatry
Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation Service,
Massachusetts General Hospital
Carol Peckham, Editorial Director
Cynthia Chevins, Publisher
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