Anxiety Disorder - NIMH

8/11/2019 Anxiety Disorder - NIMH

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AnxietyDisordersNationalInstituteofMentalHealth

U.S.DEPARTMENTOFHEALTHANDHUMANSERVICES National InstitutesofHealth


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NationalInstituteofMentalHealth

AnxietyDisorders

AnxietyDisordersaffectabout40millionAmericanadultsage18

yearsandolder(about18%)inagivenyear,1 causingthemtobefilled

withfearfulnessanduncertainty.Unliketherelativelymild,briefanxi

etycausedbyastressfulevent(suchasspeakinginpublicorafirst

date),anxietydisorderslastatleast6monthsandcangetworseif

theyarenottreated.Anxietydisorderscommonlyoccuralongwith

othermentalorphysicalillnesses,includingalcoholorsubstanceabuse,

whichmaymaskanxietysymptomsormakethemworse.Insome

cases,theseotherillnessesneedtobetreatedbeforeapersonwill

respondtotreatmentfortheanxietydisorder.

Effectivetherapiesforanxietydisordersareavailable,andresearch

isuncoveringnewtreatmentsthatcanhelpmostpeoplewithanxiety

disordersleadproductive,fulfillinglives.Ifyouthinkyouhaveananxiety

disorder,youshouldseekinformationandtreatmentrightaway.


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This

booklet

will:

describe

the

symptoms

of

anxiety

disorders,

explain

the

role

of

research

in

understanding

the

causes

of

these

conditions,

describeeffectivetreatments,

help

you

learn

how

to

obtain

treatment

and

work

with

a

doctor

or

therapist,

and

suggestwaystomaketreatmentmoreeffective.

The

following

anxiety

disorders

are

discussed

in

this

brochure:

panicdisorder,

obsessive-compulsivedisorder(OCD),

post-traumaticstressdisorder(PTSD),

socialphobia(orsocialanxietydisorder),

specific

phobias,

and

generalized

anxiety

disorder

(GAD).

Each

anxiety

disorder

has

different

symptoms,

but

all

the

symptoms

cluster

around

excessive,

irrational

fear

and

dread.


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p an i c d i sord e r 3

PanicDisorder

Forme,apanicattack

is

almost

a

violent

experience.Ifeel

disconnectedfrom

reality.IfeellikeI'm

losingcontrolina

veryextremeway.

Myheartpounds

really

hard,

I

feel

likeIcantgetmy

breath,andtheresan

overwhelmingfeeling

thatthingsarecrash-

inginonme.

Itstarted10yearsago,whenIhad

just

graduated

from

college

and

startedanewjob.Iwassittingin

abusinessseminarinahoteland

thisthingcameoutoftheblue.

IfeltlikeIwasdying.

In

between

attacks,

there

is

thisdreadandanxietythat

itsgoingtohappenagain.

Imafraidtogobacktoplaces

whereIvehadanattack.

UnlessIgethelp,theresoon

wontbeanyplacewhereIcan

goandfeelsafefrompanic.

Panicdisorder

isarealillnessthatcanbesuccessfullytreated.Itis

characterizedbysuddenattacksofterror,usuallyaccompaniedbya

poundingheart,sweatiness,weakness,faintness,ordizziness.During

theseattacks,peoplewithpanicdisordermayflushorfeelchilled;

theirhandsmaytingleorfeelnumb;andtheymayexperience

nausea,

chest

pain,

or

smothering

sensations.

Panic

attacks

usually

produceasenseofunreality,afearofimpendingdoom,orafear

oflosingcontrol.

Afearofonesownunexplainedphysicalsymptomsisalsoasymptom

ofpanicdisorder.Peoplehavingpanicattackssometimesbelieve

theyarehavingheartattacks,losingtheirminds,oronthevergeof

death.Theycantpredictwhenorwhereanattackwilloccur,and

between

episodes

many

worry

intensely

and

dread

the

next

attack.

Panicattackscanoccuratanytime,evenduringsleep.

Anattackusuallypeakswithin10minutes,butsomesymptoms

maylastmuchlonger.


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4 na t i ona l i n s t i t u t e of mental heal th

Panicdisorderaffectsabout6millionAmericanadults1andistwice

ascommoninwomenasmen.2Panicattacksoftenbegininlate

adolescenceorearlyadulthood,2 butnoteveryonewhoexperiences

panic

attacks

will

develop

panic

disorder.

Many

people

have

just

oneattackandneverhaveanother.Thetendencytodevelop

panicattacksappearstobeinherited.3

Peoplewhohavefull-blown,repeatedpanicattackscanbecome

verydisabledbytheirconditionandshouldseektreatmentbefore

theystarttoavoidplacesorsituationswherepanicattackshave

occurred.Forexample,ifapanicattackhappenedinanelevator,

someone

with

panic

disorder

may

develop

a

fear

of

elevators

that

couldaffectthechoiceofajoboranapartment,andrestrictwhere

thatpersoncanseekmedicalattentionorenjoyentertainment.

Somepeopleslivesbecomesorestrictedthattheyavoidnormal

activities, suchasgroceryshoppingordriving.Aboutone-third

becomehouseboundorareabletoconfrontafearedsituationonly

whenaccompaniedbyaspouseorothertrustedperson.2When

the

condition

progresses

this

far,

it

is

called

agoraphobia,

or

fear

of

openspaces.

Earlytreatmentcanoftenpreventagoraphobia,butpeoplewith

panicdisordermaysometimesgofromdoctortodoctorforyears

andvisittheemergencyroomrepeatedlybeforesomeonecorrectly

diagnosestheircondition.Thisisunfortunate,becausepanicdisor-

der

is

one

of

the

most

treatable

of

all

the

anxiety

disorders,

responding

in

most

cases

to

certain

kinds

of

medication

or

certain

kindsofcognitivepsychotherapy,whichhelpchangethinkingpat-

ternsthatleadtofearandanxiety.

Panicdisorderisoftenaccompaniedbyotherseriousproblems,such

asdepression,drugabuse,oralcoholism.4,5Theseconditionsneedto

betreatedseparately.Symptomsofdepressionincludefeelingsofsad-

nessorhopelessness,changesinappetiteorsleeppatterns,low

energy,anddifficultyconcentrating.Mostpeoplewithdepression

can

be

effectively

treated

with

antidepressant

medications,

certain

typesofpsychotherapy,oracombinationofthetwo.


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obs e ss i v e-compu l s i v e d i sord e r 5

Obsessive-CompulsiveDisorder(OCD)

Icouldntdoanythingwithoutrituals.

Theyinvadedeveryaspectofmylife.

Counting

really

bogged

me

down.

I

would

wash

my

hair

three

times

as

opposed

to

once

because

three

was

a

good

luck

number

and

one

wasnt.

It

took

me

longer

to

read

because

Idcountthelinesinaparagraph.WhenIset

myalarmatnight,Ihadtosetittoanumber

that

wouldn't

add

up

to

a

bad

number.

Iknewtherituals

didntmakesense,

andIwasdeeply

ashamedofthem,

butIcouldntseem

toovercomethem

untilIhadtherapy.

Gettingdressedinthemorn-

ing

was

tough,

because

I

had

a

routine,

and

if

I

didnt

followtheroutine,Idget

anxiousandwouldhaveto

get

dressed

again.

I

always

worried

that

if

I

didn't

do

something,myparentswere

going

to

die.

Id

have

these

terrible

thoughts

of

harming

my

parents.That

was

com-

pletely

irrational,

but

the

thoughts

triggered

more

anxiety

and

more

senseless

behavior.Becauseofthe

timeIspentonrituals,

I

was

unable

to

do

a

lot

of

things

that

were

important

tome.

Peoplewithobsessive-compulsivedisorder(OCD)havepersist-

ent,upsettingthoughts(obsessions)anduserituals(compulsions)to

controltheanxietythesethoughtsproduce.Mostofthetime,the

ritualsendupcontrollingthem.

Forexample,ifpeopleareobsessedwithgermsordirt,theymay

developacompulsiontowashtheirhandsoverandoveragain.If

they

develop

an

obsession

with

intruders,

they

may

lock

and

relock

theirdoorsmanytimesbeforegoingtobed.Beingafraidofsocial

embarrassmentmaypromptpeoplewithOCDtocombtheirhair

compulsivelyinfrontofamirrorsometimestheygetcaughtin

themirrorandcantmoveawayfromit.Performingsuchritualsis

notpleasurable.Atbest,itproducestemporaryrelieffromthe

anxietycreatedbyobsessivethoughts.

Other

common

rituals

are

a

need

to

repeatedly

check

things,

touchthings(especiallyinaparticularsequence),orcountthings.Some

commonobsessionsincludehavingfrequentthoughtsofviolence

andharminglovedones,persistentlythinkingaboutperforming

sexualactsthepersondislikes,orhavingthoughtsthatare


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6 nat ional i n s t i t u t e of mental heal th

prohibitedbyreligiousbeliefs.PeoplewithOCDmayalsobe

preoccupiedwithorderandsymmetry,havedifficultythrowing

thingsout(sotheyaccumulate),orhoardunneededitems.

Healthypeoplealsohaverituals,suchascheckingtoseeifthestove

isoffseveraltimesbeforeleavingthehouse.Thedifferenceisthat

peoplewithOCDperformtheirritualseventhoughdoingso

interfereswithdailylifeandtheyfindtherepetitiondistressing.

AlthoughmostadultswithOCDrecognizethatwhattheyare

doingissenseless,someadultsandmostchildrenmaynotrealize

thattheirbehaviorisoutoftheordinary.

OCDaffectsabout2.2millionAmericanadults,1 andtheproblem

canbeaccompaniedbyeatingdisorders,6otheranxietydisorders,or

depression.2,4 Itstrikesmenandwomeninroughlyequalnumbers

andusuallyappearsinchildhood,adolescence,orearlyadulthood.2

One-thirdofadultswithOCDdevelopsymptomsaschildren,

andresearchindicatesthatOCDmightruninfamilies.3

Thecourseofthediseaseisquitevaried.Symptomsmaycomeand

go,

ease

over

time,

or

get

worse.

If

OCD

becomes

severe,

it

can

keep

apersonfromworkingorcarryingoutnormalresponsibilitiesat

home.PeoplewithOCDmaytrytohelpthemselvesbyavoiding

situationsthattriggertheirobsessions,ortheymayusealcoholor

drugstocalmthemselves.4,5

OCDusuallyrespondswelltotreatmentwithcertainmedications

and/orexposure-basedpsychotherapy,inwhichpeopleface

situations

that

cause

fear

or

anxiety

and

become

less

sensitive

(desensitized)tothem.NIMHissupportingresearchintonew

treatmentapproachesforpeoplewhoseOCDdoesnotrespond

welltotheusualtherapies.Theseapproachesincludecombination

andaugmentation(add-on)treatments,aswellasmodern

techniquessuchasdeepbrainstimulation.


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pos t-t raumat i c s t r e s s d i sord e r 7

Post-TraumaticStressDisorder(PTSD)

IwasrapedwhenIwas25yearsold.Foralongtime,I

spokeabouttherapeasthoughitwassomethingthat

happened

to

someone

else.

I

was

very

aware

that

it

hadhappenedtome,buttherewasjustnofeeling.

ThenIstartedhavingflashbacks.Theykindofcame

overmelikeasplashofwater.Iwouldbeterrified.

SuddenlyIwasrelivingtherape.Everyinstantwas

startling.Iwasn'tawareofanythingaroundme,Iwas

inabubble, justkindoffloating.Anditwasscary.

Havingaflashbackcanwringyouout.

TherapehappenedtheweekbeforeThanksgiving,

andIcantbelievetheanxietyandfearIfeeleveryyear

aroundtheanniversarydate.ItsasthoughIveseena

werewolf.Icantrelax,cantsleep,dontwanttobewith

anyone.IwonderwhetherIlleverbefreeofthisterrible

problem.

Post-traumatic

stress

disorder

(PTSD)

develops

after

a

terrifyingordealthatinvolvedphysicalharmorthethreatofphysi-

calharm.ThepersonwhodevelopsPTSDmayhavebeentheone

whowasharmed,theharmmayhavehappenedtoalovedone,or

thepersonmayhavewitnessedaharmfuleventthathappenedto

lovedonesorstrangers.

PTSDwasfirstbroughttopublicattentioninrelationtowarvet-

erans,

but

it

can

result

from

a

variety

of

traumatic

incidents,

such

asmugging,rape,torture,beingkidnappedorheldcaptive,child

abuse,caraccidents,trainwrecks,planecrashes,bombings,ornatural

disasterssuchasfloodsorearthquakes.

PeoplewithPTSDmaystartleeasily,becomeemotionallynumb

(especiallyinrelationtopeoplewithwhomtheyusedtobeclose),

loseinterestinthingstheyusedtoenjoy,havetroublefeeling

affectionate,

be

irritable,

become

more

aggressive,

or

even

becomeviolent.Theyavoidsituationsthatremindthemoftheoriginal

incident,andanniversariesoftheincidentareoftenverydifficult.

PTSDsymptomsseemtobeworseiftheeventthattriggered

themwasdeliberatelyinitiatedbyanotherperson,asinamugging

orakidnapping.


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8 na t i ona l i n s t i t u t e of mental heal th

MostpeoplewithPTSDrepeatedlyrelivethetraumaintheir

thoughtsduringthedayandinnightmareswhentheysleep.

Thesearecalledflashbacks.Flashbacksmayconsistofimages,

sounds,

smells,

or

feelings,

and

are

often

triggered

by

ordinary

occurrences,suchasadoorslammingoracarbackfiringonthe

street.Apersonhavingaflashbackmaylosetouchwithrealityand

believethatthetraumaticincidentishappeningalloveragain.

Noteverytraumatizedpersondevelopsfull-blownorevenminor

PTSD.Symptomsusuallybeginwithin3monthsoftheincident

butoccasionallyemergeyearsafterward.Theymustlastmorethan

a

month

to

be

considered

PTSD.The

course

of

the

illness

varies.

Somepeoplerecoverwithin6months,whileothershavesymptoms

thatlastmuchlonger.Insomepeople,theconditionbecomes

chronic.

PTSDaffectsabout7.7millionAmericanadults,1 butitcanoccur

atanyage,includingchildhood.7Womenaremorelikelytodevelop

PTSDthanmen,8 andthereissomeevidencethatsusceptibilityto

the

disorder

may

run

in

families.9

PTSD

is

often

accompanied

by

depression,substanceabuse,oroneormoreoftheotheranxiety

disorders.4

Certainkindsofmedicationandcertainkindsofpsychotherapy

usuallytreatthesymptomsofPTSDveryeffectively.


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soc i a l phob i a 9

Social

Phobia

(SocialAnxietyDisorder)

Inanysocialsituation,

Ifeltfear.Iwouldbeanxious

beforeIevenleftthehouse,

anditwouldescalateas

Igotclosertoacollege

class,aparty,orwhatever.

Iwouldfeelsickinmy

stomachitalmostfeltlike

I

had

the

flu.

My

heart

would

pound,mypalmswouldget

sweaty,andIwouldgetthis

feelingofbeingremoved

frommyselfandfrom

everybodyelse.

WhenIwouldwalkintoaroomfull

ofpeople,Idturnredanditwould

feellikeeverybodyseyeswereon

me.Iwasembarrassedtostandoff

inacornerbymyself,butIcouldnt

thinkofanythingtosaytoanybody.

Itwashumiliating.Ifeltsoclumsy,

Icouldntwaittogetout.

Socialphobia,alsocalledsocialanxietydisorder, isdiagnosed

whenpeoplebecomeoverwhelminglyanxiousandexcessivelyself-

consciousineverydaysocialsituations.Peoplewithsocialphobia

haveanintense,persistent,andchronicfearofbeingwatchedand

judgedbyothersandofdoingthingsthatwillembarrassthem.

Theycanworryfordaysorweeksbeforeadreadedsituation.This

fear

may

become

so

severe

that

it

interferes

with

work,

school,

and

otherordinaryactivities,andcanmakeithardtomakeandkeep

friends.

Whilemanypeoplewithsocialphobiarealizethattheirfearsabout

beingwithpeopleareexcessiveorunreasonable,theyareunableto

overcomethem.Eveniftheymanagetoconfronttheirfearsand

bearoundothers,theyareusuallyveryanxiousbeforehand,are

intensely

uncomfortable

throughout

the

encounter,

and

worry

abouthowtheywerejudgedforhoursafterward.


11/26


Socialphobiacanbelimitedtoonesituation(suchastalkingto

people,eatingordrinking,orwritingonablackboardinfrontof

others)ormaybesobroad(suchasingeneralizedsocialphobia)

that

the

person

experiences

anxiety

around

almost

anyone

other

thanthefamily.

Physicalsymptomsthatoftenaccompanysocialphobiainclude

blushing,profusesweating,trembling,nausea,anddifficultytalking.

Whenthesesymptomsoccur,peoplewithsocialphobiafeelas

thoughalleyesarefocusedonthem.

Social

phobia

affects

about

15

million

American

adults.1Women

andmenareequallylikelytodevelopthedisorder,10whichusually

beginsinchildhoodorearlyadolescence.2Thereissomeevidence

thatgeneticfactorsareinvolved.11 Socialphobiaisoftenaccompa-

niedbyotheranxietydisordersordepression,2,4 andsubstanceabuse

maydevelopifpeopletrytoself-medicatetheiranxiety.4,5

Socialphobiacanbesuccessfullytreatedwithcertainkindsof

psychotherapy

or

medications.


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s p ec i f i c phob i a s 11

Specific

Phobias

I'mscaredtodeathofflying,andIneverdoitanymore. Iusedtostart

dreadingaplanetripamonthbeforeIwasduetoleave.Itwasan

awfulfeelingwhenthatairplanedoorclosedandIfelttrapped.My

heartwouldpound,andIwouldsweatbullets.Whentheairplanewould

starttoascend,itjustreinforcedthefeelingthatIcouldn'tgetout.

WhenIthinkaboutflying,Ipicturemyselflosingcontrol,freakingout,

andclimbingthewalls,butofcourseIneverdidthat.I'mnotafraidof

crashingorhittingturbulence.It'sjustthatfeelingofbeingtrapped.

WheneverIvethoughtaboutchangingjobs,I'vehadtothink,Would

I

be

under

pressure

to

fly?These

days

I

only

go

places

where

I

can

driveortakeatrain.MyfriendsalwayspointoutthatIcouldntgetoff

atraintravelingathighspeedseither,sowhydonttrainsbotherme?

Ijusttellthemitisntarationalfear.

Aspecificphobiaisanintense,irrationalfearofsomething

thatactuallyposeslittleornothreat.Someofthemorecommon

specificphobiasareheights,escalators,tunnels,highwaydriving,

closed-in

places,

water,

flying,

dogs,

spiders,

and

injuries

involving

blood.Peoplewithspecificphobiasmaybeabletoskithe

worldstallestmountainswitheasebutbeunabletogoabove

thefifthfloorofanofficebuilding.Whileadultswithphobias

realizethatthesefearsareirrational,theyoftenfindthatfacing,

oreventhinkingaboutfacing,thefearedobjectorsituation

bringsonapanicattackorsevereanxiety.

Specific

phobias

affect

around

19.2

million

American

adults 1

andaretwiceascommoninwomenasmen.10Theyusuallyappear

inchildhoodoradolescenceandtendtopersistintoadulthood.12

Thecausesofspecificphobiasarenotwellunderstood,butthereis

someevidencethatthetendencytodevelopthemmayruninfamilies.11

Ifthefearedsituationorfearedobjectiseasytoavoid,peoplewith

specificphobiasmaynotseekhelp;butifavoidanceinterfereswith

their

careers

or

their

personal

lives,

it

can

become

disabling

andtreatmentisusuallypursued.

Specificphobiasrespondverywelltocarefullytargeted

psychotherapy.


13/26


GeneralizedAnxietyDisorder(GAD)

IalwaysthoughtIwasjustaworrier.

Idfeelkeyedupandunabletorelax.

At

times

it

would

come

and

go,

and

at

timesitwouldbeconstant.Itcould

goonfordays. Idworryaboutwhat

Iwasgoingtofixforadinnerparty

orwhatwouldbeagreatpresentfor

somebody.Ijustcouldntlet

somethinggo.

Whenmyproblemswereattheirworst,

Idmissworkandfeeljustterribleaboutit.

ThenIworriedthatI'dlosemyjob.Mylife

wasmiserableuntilIgottreatment.

I'dhaveterriblesleeping

problems.There

were

times

I'd

wake

up

wired

in

the

middleofthenight.Ihad

troubleconcentrating,even

reading

the

newspaper

or

a

novel.

Sometimes

I'd

feel

alittlelightheaded.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

stom-

achache,Idthinkit

wasanulcer.

People

with

generalized

anxiety

disorder

(GAD)

go

throughthedayfilledwithexaggeratedworryandtension,even

thoughthereislittleornothingtoprovokeit.Theyanticipatedisaster

andareoverlyconcernedabouthealthissues,money,familyprob-

lems,ordifficultiesatwork.Sometimesjustthethoughtofgetting

throughthedayproducesanxiety.

GADisdiagnosedwhenapersonworriesexcessivelyabouta

variety

of

everyday

problems

for

at

least

6

months.13

People

withGADcantseemtogetridoftheirconcerns,eventhoughthey

usuallyrealizethattheiranxietyismoreintensethanthesituation

warrants.Theycantrelax,startleeasily,andhavedifficulty

concentrating.Oftentheyhavetroublefallingasleeporstaying

asleep.Physicalsymptomsthatoftenaccompanytheanxiety

includefatigue,headaches,muscletension,muscleaches,difficulty

swallowing,trembling,twitching,irritability,sweating,nausea,

lightheadedness,

having

to

go

to

the

bathroom

frequently,

feeling

outofbreath,andhotflashes.


14/26

gene r a l i z e d a n x i e t y d i sord e r 13

Whentheiranxietylevelismild,peoplewithGADcanfunction

sociallyandholddownajob.Althoughtheydontavoidcertain

situationsasaresultoftheirdisorder,peoplewithGADcanhave

difficulty

carrying

out

the

simplest

daily

activities

if

their

anxiety

issevere.

GADaffectsabout6.8millionAmericanadults,1 includingtwice

asmanywomenasmen.Thedisorderdevelopsgraduallyandcan

beginatanypointinthelifecycle,althoughtheyearsofhighest

riskarebetweenchildhoodandmiddleage.2Thereisevidence

thatgenesplayamodestroleinthedisorder.13

Otheranxietydisorders,depression,orsubstanceabuse2,4 often

accompanyGAD,whichrarelyoccursalone.GADiscommonly

treatedwithmedicationorcognitive-behavioraltherapy,butco-

occurringconditionsmustalsobetreatedusingtheappropriate

therapies.


15/26


Treatment

ofAnxiety

Disorders

Ingeneral,anxietydisordersaretreatedwithmedication,specific

typesofpsychotherapy,orboth.14Treatmentchoicesdependon

theproblemandthepersonspreference.Beforetreatmentbegins,

a

doctor

must

conduct

a

careful

diagnostic

evaluation

to

deter-minewhetherapersonssymptomsarecausedbyananxietydisor-

deroraphysicalproblem.Ifananxietydisorderisdiagnosed,the

typeofdisorderorthecombinationofdisordersthatarepresent

mustbeidentified,aswellasanycoexistingconditions,suchas

depressionorsubstanceabuse.Sometimesalcoholism,depression,

orothercoexistingconditionshavesuchastrongeffectonthe

individualthattreatingtheanxietydisordermustwaituntilthe

coexisting

conditions

are

brought

under

control.

Peoplewithanxietydisorderswhohavealreadyreceivedtreatment

shouldtelltheircurrentdoctoraboutthattreatmentindetail.If

theyreceivedmedication,theyshouldtelltheirdoctorwhatmed-

icationwasused,whatthedosagewasatthebeginningoftreat-

ment,whetherthedosagewasincreasedordecreasedwhilethey

wereundertreatment,whatsideeffectsoccurred,andwhetherthe

treatment

helped

them

become

less

anxious.

If

they

received

psy-chotherapy,theyshoulddescribethetypeoftherapy,howoften

theyattendedsessions,andwhetherthetherapywasuseful.

Oftenpeoplebelievethattheyhavefailedattreatmentorthat

thetreatmentdidntworkforthemwhen,infact,itwasnotgiven

foranadequatelengthoftimeorwasadministeredincorrectly.

Sometimespeoplemusttryseveraldifferenttreatmentsorcombi-

nationsoftreatmentbeforetheyfindtheonethatworksforthem.

Medication

Medicationwillnotcureanxietydisorders,butitcankeepthem

undercontrolwhilethepersonreceivespsychotherapy.Medication

mustbeprescribedbyphysicians,usuallypsychiatrists,whocan

eitherofferpsychotherapythemselvesorworkasateamwithpsy-

chologists,socialworkers,orcounselorswhoprovidepsychothera-

py.Theprincipalmedicationsusedforanxietydisordersareantide-

pressants,

anti-anxiety

drugs,

and

beta-blockers

to

control

some

of

thephysicalsymptoms.Withpropertreatment,manypeoplewith

anxietydisorderscanleadnormal,fulfillinglives.


16/26

a n x i e t y d i sord e r s 15

Antidepressants

Antidepressantsweredevelopedtotreatdepressionbutarealso

effectiveforanxietydisorders.Althoughthesemedicationsbegin

to

alter

brain

chemistry

after

the

very

first

dose,

their

full

effect

requiresaseriesofchangestooccur;itisusuallyabout4to6

weeksbeforesymptomsstarttofade.Itisimportanttocontinue

takingthesemedicationslongenoughtoletthemwork.

SSRIs

Someofthenewestantidepressantsarecalledselectiveserotonin

reuptakeinhibitors,orSSRIs.SSRIsalterthelevelsoftheneuro-

transmitter

serotonin

in

the

brain,

which,

like

other

neurotransmit-ters,helpsbraincellscommunicatewithoneanother.

Fluoxetine(Prozac),sertraline(Zoloft),escitalopram(Lexapro),

paroxetine(Paxil),andcitalopram(Celexa)aresomeofthe

SSRIscommonlyprescribedforpanicdisorder,OCD,PTSD,and

socialphobia.SSRIsarealsousedtotreatpanicdisorderwhenit

occursincombinationwithOCD,socialphobia,ordepression.

Venlafaxine

(Effexor

),

a

drug

closely

related

to

the

SSRIs,

is

used

totreatGAD.Thesemedicationsarestartedatlowdosesandgrad-

uallyincreaseduntiltheyhaveabeneficialeffect.

SSRIshavefewersideeffectsthanolderantidepressants,butthey

sometimesproduceslightnauseaorjitterswhenpeoplefirststart

totakethem.Thesesymptomsfadewithtime.Somepeoplealso

experiencesexualdysfunctionwithSSRIs,whichmaybehelped

byadjustingthedosageorswitchingtoanotherSSRI.

Tricyclics

TricyclicsareolderthanSSRIsandworkaswellasSSRIsforanx-

ietydisordersotherthanOCD.Theyarealsostartedatlowdoses

thataregraduallyincreased.Theysometimescausedizziness,

drowsiness,drymouth,andweightgain,whichcanusuallybecor-

rectedbychangingthedosageorswitchingtoanothertricyclic

medication.

Tricyclicsincludeimipramine(Tofranil),whichisprescribedfor

panicdisorderandGAD,andclomipramine(Anafranil),whichis

theonlytricyclicantidepressantusefulfortreatingOCD.


17/26


MAOIs

Monoamineoxidaseinhibitors(MAOIs)aretheoldestclassofanti-

depressantmedications.TheMAOIsmostcommonlyprescribedfor

anxiety

disorders

are

phenelzine

(Nardil),

followed

by

tranylcypromine

(Parnate),andisocarboxazid(Marplan),whichareusefulintreat-

ingpanicdisorderandsocialphobia.PeoplewhotakeMAOIs

cannoteatavarietyoffoodsandbeverages(includingcheeseand

redwine)thatcontaintyramineortakecertainmedications,includ-

ingsometypesofbirthcontrolpills,painrelievers(suchasAdvil,

Motrin,orTylenol),coldandallergymedications,andherbal

supplements;thesesubstancescaninteractwithMAOIstocause

dangerous

increases

in

blood

pressure.The

development

of

a

newMAOIskinpatchmayhelplessentheserisks.MAOIscanalso

reactwithSSRIstoproduceaseriousconditioncalledserotonin

syndrome,whichcancauseconfusion,hallucinations,increased

sweating,musclestiffness,seizures,changesinbloodpressureor

heartrhythm,andotherpotentiallylife-threateningconditions.

Anti-AnxietyDrugs

High-potencybenzodiazepinescombatanxietyandhavefewside

effects

other

than

drowsiness.

Because

people

can

get

used

to

them

andmayneedhigherandhigherdosestogetthesameeffect,

benzodiazepinesaregenerallyprescribedforshortperiodsoftime,

especiallyforpeoplewhohaveabuseddrugsoralcoholandwho

becomedependentonmedicationeasily.Oneexceptiontothis

ruleispeoplewithpanicdisorder,whocantakebenzodiazepines

foruptoayearwithoutharm.

Clonazepam

(Klonopin)

is

used

for

social

phobia

and

GAD,

lorazepam(Ativan)ishelpfulforpanicdisorder,andalprazolam

(Xanax)isusefulforbothpanicdisorderandGAD.

Somepeopleexperiencewithdrawalsymptomsiftheystoptaking

benzodiazepinesabruptlyinsteadoftaperingoff,andanxietycan

returnoncethemedicationisstopped.Thesepotentialproblems

haveledsomephysicianstoshyawayfromusingthesedrugsorto

use

them

in

inadequate

doses.

Buspirone(Buspar),anazapirone,isaneweranti-anxietymedication

usedtotreatGAD.Possiblesideeffectsincludedizziness,headaches,

andnausea.Unlikebenzodiazepines,buspironemustbetaken

consistentlyforatleast2weekstoachieveananti-anxietyeffect.


18/26


TAKING MEDICATIONS

Before

taking

medication

for

an

anxiety

disorder:

Ask

your

doctor

to

tell

you

about

the

effects

and

side

effects

of

the

drug.

Tellyourdoctoraboutanyalternativetherapiesorover-the-countermedicationsyouareusing.Askyourdoctorwhenandhowthemedicationshouldbestopped.Somedrugscantbestoppedabruptlybutmustbetaperedoffslowlyunderadoctorssuper-vision.Workwithyourdoctor todeterminewhichmedication is right foryouandwhatdosageisbest.Beawarethatsomemedicationsareeffectiveonlyiftheyaretakenregularlyand

that

symptoms

may

recur

if

the

medication

is

stopped.

Beta-Blockers

Beta-blockers,suchaspropranolol(Inderal),whichisusedtotreat

heartconditions,canpreventthephysicalsymptomsthataccompa-

nycertainanxietydisorders,particularlysocialphobia.Whena

fearedsituationcanbepredicted(suchasgivingaspeech),adoctor

mayprescribeabeta-blockertokeepphysicalsymptomsofanxiety

under

control.

Psychotherapy

Psychotherapyinvolvestalkingwithatrainedmentalhealth

professional,suchasapsychiatrist,psychologist,socialworker,or

counselor,todiscoverwhatcausedananxietydisorderandhow

todealwithitssymptoms.

Cognitive-BehavioralTherapy

Cognitive-behavioraltherapy(CBT)isveryusefulintreatinganxi-

etydisorders.Thecognitiveparthelpspeoplechangethethinking

patternsthatsupporttheirfears,andthebehavioralparthelps

peoplechangethewaytheyreacttoanxiety-provokingsituations.

Forexample,CBTcanhelppeoplewithpanicdisorderlearnthat

theirpanicattacksarenotreallyheartattacksandhelppeoplewith

social

phobia

learn

how

to

overcome

the

belief

that

others

are

always

watchingandjudgingthem.Whenpeoplearereadytoconfront

theirfears,theyareshownhowtouseexposuretechniquesto

desensitizethemselvestosituationsthattriggertheiranxieties.


19/26


PeoplewithOCDwhofeardirtandgermsareencouragedtoget

theirhandsdirtyandwaitincreasingamountsoftimebeforewash-

ingthem.Thetherapisthelpsthepersoncopewiththeanxietythat

waiting

produces;

after

the

exercise

has

been

repeated

a

number

of

times,theanxietydiminishes.Peoplewithsocialphobiamaybe

encouragedtospendtimeinfearedsocialsituationswithoutgiving

intothetemptationtofleeandtomakesmallsocialblundersand

observehowpeoplerespondtothem.Sincetheresponseisusually

farlessharshthanthepersonfears,theseanxietiesarelessened.

PeoplewithPTSDmaybesupportedthroughrecallingtheirtraumat-

iceventinasafesituation,whichhelpsreducethefearitproduces.

CBT

therapists

also

teach

deep

breathing

and

other

types

of

exercises

torelieveanxietyandencouragerelaxation.

Exposure-basedbehavioraltherapyhasbeenusedformanyyearsto

treatspecificphobias.Thepersongraduallyencounterstheobject

orsituationthatisfeared,perhapsatfirstonlythroughpicturesor

tapes,thenlaterface-to-face.Oftenthetherapistwillaccompany

thepersontoafearedsituationtoprovidesupportandguidance.

CBTisundertakenwhenpeopledecidetheyarereadyforitand

withtheirpermissionandcooperation.Tobeeffective,thetherapy

mustbedirectedatthepersonsspecificanxietiesandmustbe

tailoredtohisorherneeds.Therearenosideeffectsotherthan

thediscomfortoftemporarilyincreasedanxiety.

CBTorbehavioraltherapyoftenlastsabout12weeks.Itmaybe

conductedindividuallyorwithagroupofpeoplewhohavesimilar

problems.

Group

therapy

is

particularly

effective

for

social

phobia.

Oftenhomeworkisassignedforparticipantstocompletebetween

sessions.ThereissomeevidencethatthebenefitsofCBTlast

longerthanthoseofmedicationforpeoplewithpanicdisorder,

andthesamemaybetrueforOCD,PTSD,andsocialphobia.

Ifadisorderrecursatalaterdate,thesametherapycanbeusedto

treatitsuccessfullyasecondtime.

Medication

can

be

combined

with

psychotherapy

for

specific

anxietydisorders,andthisisthebesttreatmentapproachfor

manypeople.


20/26


How

to

Get

Help

forAnxiety

Disorders

Ifyouthinkyouhaveananxietydisorder,thefirstperson

youshouldseeisyourfamilydoctor.Aphysiciancandetermine

whetherthesymptomsthatalarmyouareduetoananxietydisor-

der,

another

medical

condition,

or

both.

Ifananxietydisorderisdiagnosed,thenextstepisusuallyseeinga

mentalhealthprofessional.Thepractitionerswhoaremosthelpful

withanxietydisordersarethosewhohavetrainingincognitive-

behavioraltherapyand/orbehavioraltherapy,andwhoareopento

usingmedicationifitisneeded.

You

should

feel

comfortable

talking

with

the

mental

health

profes-sionalyouchoose.Ifyoudonot,youshouldseekhelpelsewhere.

Onceyoufindamentalhealthprofessionalwithwhomyouare

comfortable,thetwoofyoushouldworkasateamandmakea

plantotreatyouranxietydisordertogether.

Rememberthatonceyoustartonmedication,itisimportantnot

tostoptakingitabruptly.Certaindrugsmustbetaperedoffunder

the

supervision

of

a

doctor

or

bad

reactions

can

occur.

Make

sureyoutalktothedoctorwhoprescribedyourmedicationbeforeyou

stoptakingit.Ifyouarehavingtroublewithsideeffects,itspossi-

blethattheycanbeeliminatedbyadjustinghowmuchmedication

youtakeandwhenyoutakeit.

Mostinsuranceplans,includinghealthmaintenanceorganizations

(HMOs),willcovertreatmentforanxietydisorders.Checkwith

yourinsurancecompanyandfindout.Ifyoudonthaveinsurance,

the

Health

and

Human

Services

division

of

your

county

govern-

mentmayoffermentalhealthcareatapublicmentalhealthcenter

thatchargespeopleaccordingtohowmuchtheyareabletopay.If

youareonpublicassistance,youmaybeabletogetcarethrough

yourstateMedicaidplan.


21/26

Ways

to

Make

Treatment

More

Effective

Manypeoplewithanxietydisordersbenefitfromjoininga

self-helporsupportgroupandsharingtheirproblemsandachieve-

mentswithothers.Internetchatroomscanalsobeusefulinthis

regard,

but

any

advice

received

over

the

Internet

should

be

used

withcaution,asInternetacquaintanceshaveusuallyneverseen

eachotherandfalseidentitiesarecommon.Talkingwithatrusted

friendormemberoftheclergycanalsoprovidesupport,butitis

notasubstituteforcarefromamentalhealthprofessional.

Stressmanagementtechniquesandmeditationcanhelppeople

withanxietydisorderscalmthemselvesandmayenhancetheeffects

of

therapy.There

is

preliminary

evidence

that

aerobic

exercise

may

haveacalmingeffect.Sincecaffeine,certainillicitdrugs,andeven

someover-the-countercoldmedicationscanaggravatethesymp-

tomsofanxietydisorders,theyshouldbeavoided.Checkwithyour

physicianorpharmacistbeforetakinganyadditionalmedications.

Thefamilyisveryimportantintherecoveryofapersonwithan

anxietydisorder.Ideally,thefamilyshouldbesupportivebutnot

help

perpetuate

their

loved

ones

symptoms.

Family

members

shouldnottrivializethedisorderordemandimprovementwithout

treatment.Ifyourfamilyisdoingeitherofthesethings,youmay

wanttoshowthemthisbookletsotheycanbecomeeducatedallies

andhelpyousucceedintherapy.



22/26


TheRoleofResearchinImprovingtheUnderstanding

andTreatmentofAnxietyDisorders

NIMHsupportsresearch intothecauses,diagnosis,preven-

tion,andtreatmentofanxietydisordersandothermentalillnesses.

Scientistsarelookingatwhatrolegenesplayinthedevelopment

of

these

disorders

and

are

also

investigating

the

effects

of

environ-

mentalfactorssuchaspollution,physicalandpsychologicalstress,

anddiet.Inaddition,studiesarebeingconductedonthenatural

history(whatcoursetheillnesstakeswithouttreatment)ofa

varietyofindividualanxietydisorders,combinationsofanxiety

disorders,andanxietydisordersthatareaccompaniedbyother

mentalillnessessuchasdepression.

Scientists

currently

think

that,

like

heart

disease

and

type

1

diabetes,mentalillnessesarecomplexandprobablyresultfroma

combinationofgenetic,environmental,psychological,anddevel-

opmentalfactors.Forinstance,althoughNIMH-sponsoredstudies

oftwinsandfamiliessuggestthatgeneticsplayaroleinthedevel-

opmentofsomeanxietydisorders,problemssuchasPTSDare

triggeredbytrauma.Geneticstudiesmayhelpexplainwhysome

peopleexposedtotraumadevelopPTSDandothersdonot.

Severalpartsofthebrainarekeyactorsintheproductionoffear

andanxiety.15Usingbrainimagingtechnologyandneurochemical

techniques,scientistshavediscoveredthattheamygdalaandthe

hippocampusplaysignificantrolesinmostanxietydisorders.

Theamygdalaisanalmond-shapedstructuredeepinthebrain

thatisbelievedtobeacommunicationshubbetweenthepartsof

thebrainthatprocessincomingsensorysignalsandthepartsthat

interpret

these

signals.

It

can

alert

the

rest

of

the

brain

that

a

threat

ispresentandtriggerafearoranxietyresponse.Itappearsthat

emotionalmemoriesarestoredinthecentralpartoftheamygdala

andmayplayaroleinanxietydisordersinvolvingverydistinct

fears,suchasfearsofdogs,spiders,orflying.


23/26


Thehippocampusisthepartofthebrainthatencodesthreatening

events intomemories.Studieshave shown that thehip-

pocampusappearstobesmallerinsomepeoplewhowerevictims

of

child

abuse

or

who

served

in

military

combat.16,17Research

will

determinewhatcausesthisreductioninsizeandwhatroleitplays

intheflashbacks,deficitsinexplicitmemory,andfragmented

memoriesofthetraumaticeventthatarecommoninPTSD.

Bylearningmoreabouthowthebraincreatesfearandanxiety,sci-

entistsmaybeabletodevisebettertreatmentsforanxietydisorders.

Forexample,ifspecificneurotransmittersarefoundtoplayan

important

role

in

fear,

drugs

may

be

developed

that

will

blockthemanddecreasefearresponses;ifenoughislearnedabouthow

thebraingeneratesnewcellsthroughoutthelifecycle,itmaybe

possibletostimulatethegrowthofnewneuronsinthehippocam-

pusinpeoplewithPTSD.18

CurrentresearchatNIMHonanxietydisordersincludesstudies

thataddresshowwellmedicationandbehavioraltherapiesworkin

the

treatment

of

OCD,

and

the

safety

and

effectiveness

of

med-icationsforchildrenandadolescentswhohaveacombinationof

anxietydisordersandattentiondeficithyperactivitydisorder.


24/26


Citations

1. KesslerRC,ChiuWT,DemlerO,WaltersEE.

Prevalence,severity,andcomorbidityoftwelve-

monthDSM-IVdisordersintheNational

ComorbiditySurveyReplication(NCS-R).Archives

of

General

Psychiatry.

2005;

62(6):617627.

2. RobinsLN,RegierDA,eds.PsychiatricDisordersin

America:theEpidemiologicCatchmentAreaStudy.New

York:TheFreePress,1991.

3. TheNIMHGeneticsWorkgroup.Geneticsandmental

disorders,NIHPublicationNo.98-4268.Rockville,

MD:NationalInstituteofMentalHealth,1998.

4. RegierDA,RaeDS,NarrowWE,etal.Prevalence

of

anxiety

disorders

and

their

comorbidity

withmoodandaddictivedisorders.BritishJournalof

PsychiatrySupplement.1998;34:2428.

5. KushnerMG,SherKJ,BeitmanBD.Therelation

betweenalcoholproblemsandtheanxietydisorders.

AmericanJournalofPsychiatry.1990;147(6):685695.

6. WonderlichSA,MitchellJE.Eatingdisordersand

comorbidity:Empirical,conceptual,andclinical

implications.PsychopharmacologyBulletin.

1997;33(3):381390.

7. MargolinG,GordisEB.Theeffectsoffamilyand

communityviolenceonchildren.AnnualReviewof

Psychology.2000;51:445479.

8. DavidsonJR.Trauma:Theimpactofpost-traumatic

stressdisorder.JournalofPsychopharmacology.

2000;14(2Suppl1):S5S12.

9. YehudaR.Biologicalfactorsassociatedwithsuscep-

tibilitytoposttraumaticstressdisorder.Canadian

Journal

of

Psychiatry.

1999;44(1):3439.

10. BourdonKH,BoydJH,RaeDS,etal.Genderdif-

ferencesinphobias:ResultsoftheECAcommunity

survey.JournalofAnxietyDisorders.1998;2:227241.

11. KendlerKS,WaltersEE,TruettKR, etal.Atwin-

familystudyofself-reportsymptomsofpanic-pho-

biaandsomatization.BehaviorGenetics.

1995;25(6):499515.

12. BoydJH,RaeDS,ThompsonJW,etal.Phobia:

Prevalenceandriskfactors.SocialPsychiatryand

PsychiatricEpidemiology.1990;25(6):314323.

13. KendlerKS,NealeMC,KesslerRC,etal.

Generalizedanxietydisorderinwomen.Apopula-

tion-basedtwinstudy.ArchivesofGeneralPsychiatry.

1992;49(4):267272.

14.HymanSE,RudorferMV.Anxietydisorders.In:

Dale

DC,

Federman

DD,

eds.

Scientific

AmericanMedicine.Volume3.NewYork:Healtheon/WebMD

Corp., 2000, Section13, SubsectionVII.

15. LeDouxJ.Fearandthebrain:Wherehavewebeen,

andwherearewegoing?BiologicalPsychiatry.

1998;44(12):12291238.

16. BremnerJD,RandallP,ScottTM,etal.MRI-based

measurementofhippocampalvolumeincombat-

relatedposttraumaticstressdisorder.AmericanJournal

ofPsychiatry.1995;152:973981.

17. SteinMB,HannaC,KoverolaC,etal.Structural

brainchangesinPTSD:Doestraumaalterneu-

roanatomy?In:YehudaR,McFarlandAC,eds.

Psychobiologyofposttraumaticstressdisorder.Annalsofthe

NewYorkAcademyofSciences,821.NewYork:New

YorkAcademyofSciences,1997.

18.GouldE,ReevesAJ,FallahM,etal.Hippocampal

neurogenesisinadultOldWorldprimates.Proceedings

oftheNationalAcademyofSciencesUSA.

1999;96(9):52635267.


25/26


ForMoreInformationonAnxietyDisorders

VisittheNationalLibraryofMedicines

MedlinePlus

http://www.nlm.nih.gov/medlineplus

EnEspaol,http://medlineplus.gov/spanish

ForInformationon

ClinicalTrialsforAnxietyDisorders

NIMHClinicalTrialsWebpagehttp://www.nimh.nih.gov/health/trials/index.shtml

NationalLibraryofMedicineClinicalTrialsDatabasehttp://www.clinicaltrials.gov

InformationfromNIMHisavailableinmultipleformats.Youcanbrowseonline,downloaddocumentsinPDF,andorderpaperbrochuresthroughthemail. IfyouwouldliketohaveNIMHpublications,youcanorderthemonlineathttp://www.nimh.nih.gov. IfyoudonothaveInternet

access

and

wish

to

have

information

that

supplements

thispublication,pleasecontacttheNIMHInformation

ResourceCenteratthenumberslistedbelow.

NationalInstituteofMentalHealthScienceWriting,Press&DisseminationBranch

6001ExecutiveBoulevardRoom8184,MSC9663Bethesda,MD20892-9663Phone:

301-443-4513

or

1-866-615-NIMH(6464)toll-freeTTY:301-443-8431or1-866-415-8051toll-freeFAX:301-443-4279E-mail:[email protected]:http://www.nimh.nih.gov


26/26

U.S.DEPARTMENTOFHEALTHANDHUMANSERVICES

National Institutes of Health

Anxiety Disorder - NIMH

Documents