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
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.
This brochure will
- help you identify the symptoms of anxiety disorders,
- explain the role of research in understanding
the causes of these conditions,
- describe effective treatments,
- help you learn how to obtain treatment and
work with a doctor or therapist, and
- suggest ways to make treatment more effective.
The anxiety disorders discussed in this brochure
- panic disorder,
- obsessive-compulsive disorder,
- post-traumatic stress disorder,
- social phobia (or social anxiety disorder),
- specific phobias, and
- generalized anxiety disorder.
anxiety disorder has its own distinct features, but they are all
bound together by the common theme of excessive, irrational fear
National Institute of Mental Health (NIMH) supports scientific investigation
into the causes, diagnosis, treatment, and prevention of anxiety
disorders and other mental illnesses. The NIMH mission is to reduce
the burden of mental illness through research on mind, brain, and
behavior. NIMH is a component of the National Institutes of Health,
which is part of the U.S. Department of Health and Human Services.
"It started 10 years ago,
when I had just graduated from college and started a new job.
I was sitting in a business seminar in a hotel and this thing
came out of the blue. I felt like I was dying.
"For me, a panic attack is
almost a violent experience. I feel disconnected from reality.
I feel like I'm losing control in a very extreme way. My heart
pounds really hard, I feel like I can't get my breath, and there's
an overwhelming feeling that things are crashing in on me.
"In between attacks there
is this dread and anxiety that it's going to happen again. I'm
afraid to go back to places where I've had an attack. Unless I
get help, there soon won't be anyplace where I can go and feel
safe from panic."
with panic disorder have feelings of terror that strike suddenly
and repeatedly with no warning. They can't predict when an attack
will occur, and many develop intense anxiety between episodes, worrying
when and where the next one will strike.
you are having a panic attack, most likely your heart will pound
and you may feel sweaty, weak, faint, or dizzy. Your hands may tingle
or feel numb, and you might feel flushed or chilled. You may have
nausea, chest pain or smothering sensations, a sense of unreality,
or fear of impending doom or loss of control. You may genuinely
believe you're having a heart attack or losing your mind, or on
the verge of death.
attacks can occur at any time, even during sleep. An attack generally
peaks within 10 minutes, but some symptoms may last much longer.
disorder affects about 2.4 million adult Americans1
and is twice as common in women as in men.2
It most often begins during late adolescence or early adulthood.2
Risk of developing panic disorder appears to be inherited.3
Not everyone who experiences panic attacks will develop panic disorder—for
example, many people have one attack but never have another. For
those who do have panic disorder, though, it's important to seek
treatment. Untreated, the disorder can become very disabling.
people with panic disorder visit the hospital emergency room repeatedly
or see a number of doctors before they obtain a correct diagnosis.
Some people with panic disorder may go for years without learning
that they have a real, treatable illness.
disorder is often accompanied by other serious conditions such as
depression, drug abuse, or alcoholism4,5
and may lead to a pattern of avoidance of places or situations where
panic attacks have occurred. For example, if a panic attack strikes
while you're riding in an elevator, you may develop a fear of elevators.
If you start avoiding them, that could affect your choice of a job
or apartment and greatly restrict other parts of your life.
people's lives become so restricted that they avoid normal, everyday
activities such as grocery shopping or driving. In some cases they
become housebound. Or, they may be able to confront a feared situation
only if accompanied by a spouse or other trusted person.
these people avoid any situation in which they would feel helpless
if a panic attack were to occur. When people's lives become so restricted,
as happens in about one-third of people with panic disorder,2
the condition is called agoraphobia. Early treatment of
panic disorder can often prevent agoraphobia.
disorder is one of the most treatable of the anxiety disorders,
responding in most cases to medications or carefully targeted psychotherapy.
You may genuinely believe you're having a heart attack, losing
your mind, or are on the verge of death. Attacks can occur at any
time, even during sleep.
Depression often accompanies
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 couldn't do anything without
rituals. They invaded every aspect of my life. Counting really
bogged me down. I would wash my hair three times as opposed to
once because three was a good luck number and one wasn't. It took
me longer to read because I'd count the lines in a paragraph.
When I set my alarm at night, I had to set it to a number that
wouldn't add up to a "bad" number.
"Getting dressed in the morning
was tough because I had a routine, and if I didn't follow the
routine, I'd get anxious and would have to get dressed again.
I always worried that if I didn't do something, my parents were
going to die. I'd have these terrible thoughts of harming my parents.
That was completely irrational, but the thoughts triggered more
anxiety and more senseless behavior. Because of the time I spent
on rituals, I was unable to do a lot of things that were important
"I knew the rituals didn't
make sense, and I was deeply ashamed of them, but I couldn't seem
to overcome them until I had therapy."
disorder, or OCD, involves anxious thoughts or rituals you feel
you can't control. If you have OCD, you may be plagued by persistent,
unwelcome thoughts or images, or by the urgent need to engage in
may be obsessed with germs or dirt, so you wash your hands over
and over. You may be filled with doubt and feel the need to check
things repeatedly. You may have frequent thoughts of violence, and
fear that you will harm people close to you. You may spend long
periods touching things or counting; you may be pre-occupied by
order or symmetry; you may have persistent thoughts of performing
sexual acts that are repugnant to you; or you may be troubled by
thoughts that are against your religious beliefs.
disturbing thoughts or images are called obsessions, and the rituals
that are performed to try to prevent or get rid of them are called
compulsions. There is no pleasure in carrying out the rituals you
are drawn to, only temporary relief from the anxiety that grows
when you don't perform them.
lot of healthy people can identify with some of the symptoms of
OCD, such as checking the stove several times before leaving the
house. But for people with OCD, such activities consume at least
an hour a day, are very distressing, and interfere with daily life.
adults with this condition recognize that what they're doing is
senseless, but they can't stop it. Some people, though, particularly
children with OCD, may not realize that their behavior is out of
afflicts about 3.3 million adult Americans.1
It strikes men and women in approximately equal numbers and usually
first appears in childhood, adolescence, or early adulthood.2
One-third of adults with OCD report having experienced their first
symptoms as children. The course of the disease is variable—symptoms
may come and go, they may ease over time, or they can grow progressively
worse. Research evidence suggests that OCD might run in families.3
or other anxiety disorders may accompany OCD,2,4
and some people with OCD also have eating disorders.6
In addition, people with OCD may avoid situations in which they
might have to confront their obsessions, or they may try unsuccessfully
to use alcohol or drugs to calm themselves.4,5
If OCD grows severe enough, it can keep someone from holding down
a job or from carrying out normal responsibilities at home.
generally responds well to treatment with medications or carefully
The disturbing thoughts or images are called obsessions,
and the rituals performed to try to prevent or get rid
of them are called compulsions. There is no pleasure in
carrying out the rituals you are drawn to, only temporary
relief from the anxiety that grows when you don't perform
Post-Traumatic Stress Disorder
"I was raped when I was 25
years old. For a long time, I spoke about the rape as though it
was something that happened to someone else. I was very aware
that it had happened to me, but there was just no feeling.
"Then I started having flashbacks.
They kind of came over me like a splash of water. I would be terrified.
Suddenly I was reliving the rape. Every instant was startling.
I wasn't aware of anything around me, I was in a bubble, just
kind of floating. And it was scary. Having a flashback can wring
"The rape happened the week
before Thanksgiving, and I can't believe the anxiety and fear
I feel every year around the anniversary date. It's as though
I've seen a werewolf. I can't relax, can't sleep, don't want to
be with anyone. I wonder whether I'll ever be free of this terrible
stress disorder (PTSD) is a debilitating condition that can develop
following a terrifying event. Often, people with PTSD have persistent
frightening thoughts and memories of their ordeal and feel emotionally
numb, especially with people they were once close to. PTSD was first
brought to public attention by war veterans, but it can result from
any number of traumatic incidents. These include violent attacks
such as mugging, rape, or torture; being kidnapped or held captive;
child abuse; serious accidents such as car or train wrecks; and
natural disasters such as floods or earthquakes. The event that
triggers PTSD may be something that threatened the person's life
or the life of someone close to him or her. Or it could be something
witnessed, such as massive death and destruction after a building
is bombed or a plane crashes.
the source of the problem, some people with PTSD repeatedly relive
the trauma in the form of nightmares and disturbing recollections
during the day. They may also experience other sleep problems, feel
detached or numb, or be easily startled. They may lose interest
in things they used to enjoy and have trouble feeling affectionate.
They may feel irritable, more aggressive than before, or even violent.
Things that remind them of the trauma may be very distressing, which
could lead them to avoid certain places or situations that bring
back those memories. Anniversaries of the traumatic event are often
affects about 5.2 million adult Americans.1
Women are more likely than men to develop PTSD.7
It can occur at any age, including childhood,8
and there is some evidence that susceptibility to PTSD may run in
families.9 The disorder
is often accompanied by depression, substance abuse, or one or more
other anxiety disorders.4
In severe cases, the person may have trouble working or socializing.
In general, the symptoms seem to be worse if the event that triggered
them was deliberately initiated by a person—such as a rape or kidnapping.
events can serve as reminders of the trauma and trigger flashbacks
or intrusive images. A person having a flashback, which can come
in the form of images, sounds, smells, or feelings, may lose touch
with reality and believe that the traumatic event is happening all
every traumatized person gets full-blown PTSD, or experiences PTSD
at all. PTSD is diagnosed only if the symptoms last more than a
month. In those who do develop PTSD, symptoms usually begin within
3 months of the trauma, and the course of the illness varies. Some
people recover within 6 months, others have symptoms that last much
longer. In some cases, the condition may be chronic. Occasionally,
the illness doesn't show up until years after the traumatic event.
with PTSD can be helped by medications and carefully targeted psychotherapy.
Ordinary events can serve as reminders of the trauma and
trigger flashbacks or intrusive images. Anniversaries
of the traumatic event are often very difficult.
(Social Anxiety Disorder)
"In any social situation,
I felt fear. I would be anxious before I even left the house,
and it would escalate as I got closer to a college class, a party,
or whatever. I would feel sick at my stomach—it almost felt like
I had the flu. My heart would pound, my palms would get sweaty,
and I would get this feeling of being removed from myself and
from everybody else.
"When I would walk into a
room full of people, I'd turn red and it would feel like everybody's
eyes were on me. I was embarrassed to stand off in a corner by
myself, but I couldn't think of anything to say to anybody. It
was humiliating. I felt so clumsy, I couldn't wait to get out.
"I couldn't go on dates, and
for a while I couldn't even go to class. My sophomore year of
college I had to come home for a semester. I felt like such a
phobia, also called social anxiety disorder, involves overwhelming
anxiety and excessive self-consciousness in everyday social situations.
People with social phobia have a persistent, intense, and chronic
fear of being watched and judged by others and being embarrassed
or humiliated by their own actions. Their fear may be so severe
that it interferes with work or school, and other ordinary activities.
While many people with social phobia recognize that their fear of
being around people may be excessive or unreasonable, they are unable
to overcome it. They often worry for days or weeks in advance of
a dreaded situation.
phobia can be limited to only one type of situation—such as a fear
of speaking in formal or informal situations, or eating, drinking,
or writing in front of others—or, in its most severe form, may be
so broad that a person experiences symptoms almost anytime they
are around other people. Social phobia can be very debilitating—it
may even keep people from going to work or school on some days.
Many people with this illness have a hard time making and keeping
symptoms often accompany the intense anxiety of social phobia and
include blushing, profuse sweating, trembling, nausea, and difficulty
talking. If you suffer from social phobia, you may be painfully
embarrassed by these symptoms and feel as though all eyes are focused
on you. You may be afraid of being with people other than your family.
with social phobia are aware that their feelings are irrational.
Even if they manage to confront what they fear, they usually feel
very anxious beforehand and are intensely uncomfortable throughout.
Afterward, the unpleasant feelings may linger, as they worry about
how they may have been judged or what others may have thought or
observed about them.
phobia affects about 5.3 million adult Americans.1
Women and men are equally likely to develop social phobia.10
The disorder usually begins in childhood or early adolescence,2
and there is some evidence that genetic factors are involved.11
Social phobia often co-occurs with other anxiety disorders or depression.2,4
Substance abuse or dependence may develop in individuals who attempt
to "self-medicate" their social phobia by drinking or using drugs.4,5
Social phobia can be treated successfully with carefully targeted
psychotherapy or medications.
Social phobia can severely disrupt normal life, interfering
with school, work, or social relationships. The dread of
a feared event can begin weeks in advance and be quite debilitating.
"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."
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.
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
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
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.
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.
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.
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.
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
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.
Research in Improving the Understanding and Treatment of Anxiety
supports research into the causes, diagnosis, prevention, and treatment
of anxiety disorders and other mental illnesses. Studies examine
the genetic and environmental risks for major anxiety disorders,
their course—both alone and when they occur along with other diseases
such as depression—and their treatment. The ultimate goal is to
be able to cure, and perhaps even to prevent, anxiety disorders.
is harnessing the most sophisticated scientific tools available
to determine the causes of anxiety disorders. Like heart disease
and diabetes, these brain disorders are complex and probably result
from a combination of genetic, behavioral, developmental, and other
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.
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.
research indicates that other brain parts called the basal ganglia
and striatum are involved in obsessive-compulsive disorder.17
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.
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.
supported by NIMH are also conducting clinical trials to find the
most effective ways of treating anxiety disorders. For example,
one trial is examining how well medication and behavioral therapies
work together and separately in the treatment of OCD. Another trial
is assessing the safety and efficacy of medication treatments for
anxiety disorders in children and adolescents with co-occurring
attention deficit hyperactivity disorder (ADHD).
Treatment of Anxiety Disorders
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.
When choosing a therapist, you should find out whether medications
will be available if needed.
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.
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.
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
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.
major classes of medications used for various anxiety disorders
are described below.
number of medications that were originally approved for treatment
of depression have been found to be effective for anxiety disorders.
If your doctor prescribes an antidepressant, you will need to take
it for several weeks before symptoms start to fade. So it is important
not to get discouraged and stop taking these medications before
they've had a chance to work.
of the newest antidepressants are called selective
serotonin reuptake inhibitors, or
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.
sertraline, fluvoxamine, paroxetine, and citalopram are among the
SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social
phobia. SSRIs are often used to treat people who have panic disorder
in combination with OCD, social phobia, or depression. Venlafaxine,
a drug closely related to the SSRIs, is useful for treating GAD.
Other newer antidepressants are under study in anxiety disorders,
although one, bupropion, does not appear effective for these conditions.
These medications are started at a low dose and gradually increased
until they reach a therapeutic level.
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.
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.
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.
benzodiazepines relieve symptoms quickly and have few side
effects, although drowsiness can be a problem. Because people can
develop a tolerance to them—and would have to continue increasing
the dosage to get the same effect—benzodiazepines are generally
prescribed for short periods of time. One exception is panic disorder,
for which they may be used for 6 months to a year. People who have
had problems with drug or alcohol abuse are not usually good candidates
for these medications because they may become dependent on them.
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.
include clonazepam, which is used for social phobia and GAD; alprazolam,
which is helpful for panic disorder and GAD; and lorazepam, which
is also useful for panic disorder.
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
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
taking medication for an anxiety disorder:
your doctor to tell you about the effects and side
effects of the drug he or she is prescribing.
your doctor about any alternative therapies or over-the-counter
medications you are using.
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.
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
together with your doctor to determine the right dosage
of the right medication to treat your anxiety disorder.
involves talking with a trained mental health professional, such
as a psychiatrist, psychologist, social worker, or counselor to
learn how to deal with problems like anxiety disorders.
Cognitive-Behavioral and Behavioral Therapy
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
How to Get Help for Anxiety Disorders
you, or someone you know, has symptoms of anxiety, a visit to the
family physician is usually the best place to start. A physician
can help determine whether the symptoms are due to an anxiety disorder,
some other medical condition, or both. Frequently, the next step
in getting treatment for an anxiety disorder is referral to a mental
the professionals who can help are psychiatrists, psychologists,
social workers, and counselors. However, it's best to look for a
professional who has specialized training in cognitive-behavioral
therapy and/or behavioral therapy, as appropriate, and who is open
to the use of medications, should they be needed.
stated earlier, psychologists, social workers, and counselors sometimes
work closely with a psychiatrist or other physician, who will prescribe
medications when they are required. For some people, group therapy
is a helpful part of treatment.
important that you feel comfortable with the therapy that the mental
health professional suggests. If this is not the case, seek help
elsewhere. However, if you've been taking medication, it's important
not to discontinue it abruptly, as stated before. Certain drugs
have to be tapered off under the supervision of your physician.
though, that when you find a health care professional that you're
satisfied with, the two of you are working together as a team. Together
you will be able to develop a plan to treat your anxiety disorder
that may involve medications, cognitive-behavioral or other talk
therapy, or both, as appropriate.
may be concerned about paying for treatment for an anxiety disorder.
If you belong to a Health Maintenance Organization (HMO) or have
some other kind of health insurance, the costs of your treatment
may be fully or partially covered. There are also public mental
health centers that charge people according to how much they are
able to pay. If you are on public assistance, you may be able to
get care through your state Medicaid plan.
Strategies To Make Treatment More Effective
people with anxiety disorders benefit from joining a self-help group
and sharing their problems and achievements with others. Talking
with trusted friends or a trusted member of the clergy can also
be very helpful, although not a substitute for mental health care.
Participating in an Internet chat room may also be of value in sharing
concerns and decreasing a sense of isolation, but any advice received
should be viewed with caution.
family is of great importance in the recovery of a person with an
anxiety disorder. Ideally, the family should be supportive without
helping to perpetuate the person's symptoms. If the family tends
to trivialize the disorder or demand improvement without treatment,
the affected person will suffer. You may wish to show this booklet
to your family and enlist their help as educated allies in your
fight against your anxiety disorder.
management techniques and meditation may help you to calm yourself
and enhance the effects of therapy, although there is as yet no
scientific evidence to support the value of these "wellness" approaches
to recovery from anxiety disorders. There is preliminary evidence
that aerobic exercise may be of value, and it is known that caffeine,
illicit drugs, and even some over-the-counter cold medications can
aggravate the symptoms of an anxiety disorder. Check with your physician
or pharmacist before taking any additional medicines.
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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.