AnxietyDisorders

NationalInstituteofMentalHealth
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health
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.

Thisbookletwill:
describethesymptomsofanxietydisorders,
explaintheroleofresearchinunderstandingthecausesofthese
conditions,
describeeffectivetreatments,
helpyoulearnhowtoobtaintreatmentandworkwithadoctoror
therapist,and
suggestwaystomaketreatmentmoreeffective.
Thefollowinganxietydisordersarediscussedinthisbrochure:
panicdisorder,
obsessive-compulsivedisorder(OCD),
post-traumaticstressdisorder(PTSD),
socialphobia(orsocialanxietydisorder),
specificphobias,and
generalizedanxietydisorder(GAD).
Eachanxietydisorderhasdifferentsymptoms,butallthesymptoms
clusteraroundexcessive,irrationalfearanddread.
pa ni c di s or de r 3
PanicDisorder
Forme,apanicattack
isalmostaviolent
experience.Ifeel
disconnectedfrom
reality.IfeellikeI'm
losingcontrolina
veryextremeway.
Myheartpounds
reallyhard,Ifeel
likeIcantgetmy
breath,andtheresan
overwhelmingfeeling
thatthingsarecrash-
inginonme.
Itstarted10yearsago,whenIhad
justgraduatedfromcollegeand
startedanewjob.Iwassittingin
abusinessseminarinahoteland
thisthingcameoutoftheblue.
IfeltlikeIwasdying.
Inbetweenattacks,thereis
thisdreadandanxietythat
itsgoingtohappenagain.
Imafraidtogobacktoplaces
whereIvehadanattack.
UnlessIgethelp,theresoon
wontbeanyplacewhereIcan
goandfeelsafefrompanic.
Panicdisorderisarealillnessthatcanbesuccessfullytreated.Itis
characterizedbysuddenattacksofterror,usuallyaccompaniedbya
poundingheart,sweatiness,weakness,faintness,ordizziness.During
theseattacks,peoplewithpanicdisordermayflushorfeelchilled;
theirhandsmaytingleorfeelnumb;andtheymayexperience
nausea,chestpain,orsmotheringsensations.Panicattacksusually
produceasenseofunreality,afearofimpendingdoom,orafear
oflosingcontrol.
Afearofonesownunexplainedphysicalsymptomsisalsoasymptom
ofpanicdisorder.Peoplehavingpanicattackssometimesbelieve
theyarehavingheartattacks,losingtheirminds,oronthevergeof
death.Theycantpredictwhenorwhereanattackwilloccur,and
betweenepisodesmanyworryintenselyanddreadthenextattack.
Panic attacks can occur at any time,even during sleep.
Anattackusuallypeakswithin10minutes,butsomesymptoms
maylastmuchlonger.
4 nat i ona l i ns t i t u t e of me nta l he a lt h
Panicdisorderaffectsabout6millionAmericanadults
1
andistwice
ascommoninwomenasmen.
2
Panicattacksoftenbegininlate
adolescenceorearlyadulthood,
2
butnoteveryonewhoexperiences
panicattackswilldeveloppanicdisorder.Manypeople have just
one attackandneverhaveanother.The tendencytodevelop
panicattacksappearstobeinherited.
3
Peoplewhohavefull-blown,repeatedpanicattackscanbecome
verydisabledbytheirconditionandshouldseektreatmentbefore
theystarttoavoidplacesorsituationswherepanicattackshave
occurred.Forexample,ifapanicattackhappenedinanelevator,
someonewithpanicdisordermaydevelopafearofelevatorsthat
couldaffectthechoiceofajoboranapartment,andrestrictwhere
thatpersoncanseekmedicalattentionorenjoyentertainment.
Somepeopleslivesbecomesorestrictedthattheyavoidnormal
activities, suchasgroceryshoppingordriving. Aboutone-third
becomehouseboundorareabletoconfrontafearedsituationonly
whenaccompaniedbyaspouseorothertrustedperson.
2
When
theconditionprogressesthisfar,itiscalledagoraphobia,orfearof
openspaces.
Earlytreatmentcanoftenpreventagoraphobia,butpeoplewith
panicdisordermaysometimesgofromdoctortodoctorforyears
andvisittheemergencyroomrepeatedlybeforesomeonecorrectly
diagnosestheircondition.Thisisunfortunate,becausepanicdisor-
derisoneofthemosttreatableofalltheanxietydisorders,
respondinginmostcasestocertainkindsofmedicationorcertain
kindsofcognitivepsychotherapy, whichhelpchangethinkingpat-
ternsthatleadtofearandanxiety.
Panicdisorderisoftenaccompaniedbyotherseriousproblems,such
asdepression,drugabuse,oralcoholism.
4,5
Theseconditionsneedto
betreatedseparately.Symptomsofdepressionincludefeelingsofsad-
nessorhopelessness,changesinappetiteorsleeppatterns,low
energy,anddifficultyconcentrating.Mostpeoplewithdepression
canbeeffectivelytreatedwithantidepressantmedications,certain
typesofpsychotherapy,oracombinationofthetwo.
ob s e s s i v e- comp u l s i v e di s or de r 5
Obsessive-CompulsiveDisorder(OCD)
Icouldntdoanythingwithoutrituals.
Theyinvadedeveryaspectofmylife.
Countingreallyboggedmedown.Iwould
washmyhairthreetimesasopposedtoonce
becausethreewasagoodlucknumberand
onewasnt.Ittookmelongertoreadbecause
Idcountthelinesinaparagraph. WhenIset
myalarmatnight,Ihadtosetittoanumber
thatwouldn'tadduptoabadnumber.
Iknewtherituals
didntmakesense,
andIwasdeeply
ashamedofthem,
butIcouldntseem
toovercomethem
untilIhadtherapy.
Gettingdressedinthemorn-
ingwastough,becauseI
hadaroutine,andifIdidnt
followtheroutine,Idget
anxiousandwouldhaveto
getdressedagain.Ialways
worriedthatifIdidn'tdo
something, myparentswere
goingtodie.Idhavethese
terriblethoughtsofharming
myparents.Thatwascom-
pletelyirrational,butthe
thoughtstriggeredmore
anxietyandmoresenseless
behavior.Becauseofthe
timeIspentonrituals,
Iwasunabletodoalotof
thingsthatwereimportant
tome.
Peoplewithobsessive-compulsivedisorder(OCD)havepersist-
ent,upsettingthoughts(obsessions)anduserituals(compulsions)to
controltheanxietythesethoughtsproduce.Mostofthetime,the
ritualsendupcontrollingthem.
Forexample,ifpeopleareobsessedwithgermsordirt,theymay
developacompulsiontowashtheirhandsoverandoveragain.If
theydevelopanobsessionwithintruders,theymaylockandrelock
theirdoorsmanytimesbeforegoingtobed.Beingafraidofsocial
embarrassmentmaypromptpeoplewithOCDtocombtheirhair
compulsivelyinfrontofamirrorsometimestheygetcaughtin
themirrorandcantmoveawayfromit.Performingsuchritualsis
notpleasurable. Atbest,itproducestemporaryrelieffromthe
anxietycreatedbyobsessivethoughts.
Othercommonritualsareaneedtorepeatedlycheckthings,touch
things(especiallyinaparticularsequence),orcountthings.Some
commonobsessionsincludehavingfrequentthoughtsofviolence
andharminglovedones,persistentlythinkingaboutperforming
sexualacts thepersondislikes,or havingthoughtsthat are
6 nat i ona l i ns t i t u t e of me nta l he a lt h
prohibitedbyreligiousbeliefs.PeoplewithOCDmayalsobe
preoccupiedwithorderandsymmetry,havedifficultythrowing
thingsout(sotheyaccumulate),orhoardunneededitems.
Healthypeoplealsohaverituals,suchascheckingtoseeifthestove
isoffseveraltimesbeforeleavingthehouse.Thedifferenceisthat
peoplewithOCDperformtheirritualseventhoughdoingso
interfereswithdailylifeandtheyfindtherepetitiondistressing.
AlthoughmostadultswithOCDrecognizethatwhattheyare
doingissenseless,someadultsandmostchildrenmaynotrealize
thattheirbehaviorisoutoftheordinary.
OCDaffectsabout2.2millionAmericanadults,
1
andtheproblem
canbeaccompaniedbyeatingdisorders,
6
otheranxietydisorders,or
depression.
2,4
Itstrikesmenandwomeninroughlyequalnumbers
andusuallyappearsinchildhood,adolescence,orearlyadulthood.
2
One-thirdofadultswithOCDdevelopsymptomsaschildren,
andresearchindicatesthatOCDmightruninfamilies.
3
Thecourseofthediseaseisquitevaried.Symptomsmaycomeand
go,easeovertime,orgetworse.IfOCDbecomessevere,itcankeep
apersonfromworkingorcarryingoutnormalresponsibilitiesat
home.PeoplewithOCDmaytrytohelpthemselvesbyavoiding
situationsthattriggertheirobsessions,ortheymayusealcoholor
drugstocalmthemselves.
4,5
OCDusuallyrespondswelltotreatmentwithcertainmedications
and/orexposure-basedpsychotherapy,inwhichpeopleface
situationsthatcausefearoranxietyandbecomelesssensitive
(desensitized)tothem.NIMHissupportingresearchintonew
treatmentapproachesforpeoplewhoseOCDdoesnotrespond
welltotheusualtherapies.Theseapproachesincludecombination
andaugmentation(add-on)treatments,aswellasmodern
techniquessuchasdeepbrainstimulation.
p os t-t r au mat i c s t r e s s di s or de r 7
Post-TraumaticStressDisorder(PTSD)
IwasrapedwhenIwas25yearsold.Foralongtime,I
spokeabouttherapeasthoughitwassomethingthat
happenedtosomeoneelse.Iwasveryawarethatithad
happenedtome,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) developsaftera
terrifyingordealthatinvolvedphysicalharmorthethreatofphysi-
calharm.ThepersonwhodevelopsPTSDmayhavebeentheone
whowasharmed,theharmmayhavehappenedtoalovedone,or
thepersonmayhavewitnessedaharmfuleventthathappenedto
lovedonesorstrangers.
PTSDwasfirstbroughttopublicattentioninrelationtowarvet-
erans,butitcanresultfromavarietyoftraumaticincidents,such
asmugging,rape,torture,beingkidnappedorheldcaptive,child
abuse,caraccidents,trainwrecks,planecrashes,bombings,ornatural
disasterssuchasfloodsorearthquakes.
PeoplewithPTSDmaystartleeasily,becomeemotionallynumb
(especiallyinrelationtopeoplewithwhomtheyusedtobeclose),
loseinterestinthingstheyusedtoenjoy,havetroublefeeling
affectionate,beirritable,becomemoreaggressive,orevenbecome
violent.Theyavoidsituationsthatremindthemoftheoriginal
incident,andanniversariesoftheincidentareoftenverydifficult.
PTSDsymptomsseemtobeworseiftheeventthattriggered
themwasdeliberatelyinitiatedbyanotherperson,asinamugging
orakidnapping.
8 nat i ona l i ns t i t u t e of me nta l he a lt h
MostpeoplewithPTSDrepeatedlyrelivethetraumaintheir
thoughtsduringthedayandinnightmareswhentheysleep.
Thesearecalledflashbacks.Flashbacksmayconsistofimages,
sounds,smells,orfeelings,andareoftentriggeredbyordinary
occurrences,suchasadoorslammingoracarbackfiringonthe
street. Apersonhavingaflashbackmaylosetouchwithrealityand
believethatthetraumaticincidentishappeningalloveragain.
Noteverytraumatizedpersondevelopsfull-blownorevenminor
PTSD.Symptomsusuallybeginwithin3monthsoftheincident
butoccasionallyemergeyearsafterward.Theymustlastmorethan
amonthtobeconsideredPTSD.Thecourseoftheillnessvaries.
Somepeoplerecoverwithin6months,whileothershavesymptoms
thatlastmuchlonger.Insomepeople,theconditionbecomes
chronic.
PTSDaffectsabout7.7millionAmericanadults,
1
butitcanoccur
atanyage,includingchildhood.
7
Womenaremorelikelytodevelop
PTSDthanmen,
8
andthereissomeevidencethatsusceptibilityto
thedisordermayruninfamilies.
9
PTSDisoftenaccompaniedby
depression,substanceabuse,oroneormoreoftheotheranxiety
disorders.
4
Certainkindsofmedicationandcertainkindsofpsychotherapy
usuallytreatthesymptomsofPTSDveryeffectively.
s oci a l p hob i a 9
SocialPhobia(SocialAnxietyDisorder)
Inanysocialsituation,
Ifeltfear.Iwouldbeanxious
beforeIevenleftthehouse,
anditwouldescalateas
Igotclosertoacollege
class,aparty,orwhatever.
Iwouldfeelsickinmy
stomachitalmostfeltlike
Ihadtheflu.Myheartwould
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
fearmaybecomesoseverethatitinterfereswithwork,school,and
otherordinaryactivities,andcanmakeithardtomakeandkeep
friends.
Whilemanypeoplewithsocialphobiarealizethattheirfearsabout
beingwithpeopleareexcessiveorunreasonable,theyareunableto
overcomethem.Eveniftheymanagetoconfronttheirfearsand
bearoundothers,theyareusuallyveryanxiousbeforehand,are
intenselyuncomfortablethroughouttheencounter,andworry
abouthowtheywerejudgedforhoursafterward.
10 nat i ona l i ns t i t u t e of me nta l he a lt h
Socialphobiacanbelimitedtoonesituation(suchastalkingto
people,eatingordrinking,orwritingonablackboardinfrontof
others)ormaybesobroad(suchasingeneralizedsocialphobia)
thatthepersonexperiencesanxietyaroundalmostanyoneother
thanthefamily.
Physicalsymptomsthatoftenaccompanysocialphobiainclude
blushing,profusesweating,trembling,nausea,anddifficultytalking.
Whenthesesymptomsoccur,peoplewithsocialphobiafeelas
thoughalleyesarefocusedonthem.
Socialphobiaaffectsabout15millionAmericanadults.
1
Women
andmenareequallylikelytodevelopthedisorder,
10
whichusually
beginsinchildhoodorearlyadolescence.
2
Thereissomeevidence
thatgeneticfactorsareinvolved.
11
Socialphobiaisoftenaccompa-
niedbyotheranxietydisordersordepression,
2,4
andsubstanceabuse
maydevelopifpeopletrytoself-medicatetheiranxiety.
4,5
Socialphobiacanbesuccessfullytreatedwithcertainkindsof
psychotherapyormedications.
s p e ci f i c p hob i a s 11
SpecificPhobias
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
Ibeunderpressuretofly?ThesedaysIonlygoplaceswhereIcan
driveortakeatrain.MyfriendsalwayspointoutthatIcouldntgetoff
atraintravelingathighspeedseither,sowhydonttrainsbotherme?
Ijusttellthemitisntarationalfear.
Aspecificphobiaisanintense,irrationalfearofsomething
thatactuallyposeslittleornothreat.Someofthemorecommon
specificphobiasareheights,escalators,tunnels,highwaydriving,
closed-inplaces,water,flying,dogs,spiders,andinjuriesinvolving
blood.Peoplewithspecificphobiasmaybeabletoskithe
worldstallestmountainswitheasebutbeunabletogoabove
thefifthfloorofanofficebuilding. Whileadultswithphobias
realizethatthesefearsareirrational,theyoftenfindthatfacing,
oreventhinkingaboutfacing,thefearedobjectorsituation
bringsonapanicattackorsevereanxiety.
Specific phobias affect around 19.2 millionAmerican adults
1
andaretwiceascommoninwomenasmen.
10
Theyusuallyappear
inchildhoodoradolescenceandtendtopersistintoadulthood.
12
Thecausesofspecificphobiasarenotwellunderstood,butthereis
someevidencethatthetendencytodevelopthemmayruninfamilies.
11
Ifthefearedsituationorfearedobjectiseasytoavoid,peoplewith
specificphobiasmaynotseekhelp;butifavoidanceinterfereswith
theircareersortheirpersonallives,itcanbecomedisablingand
treatmentisusuallypursued.
Specificphobiasrespondverywelltocarefullytargeted
psychotherapy.
12 nat i ona l i ns t i t u t e of me nta l he a lt h
GeneralizedAnxietyDisorder(GAD)
IalwaysthoughtIwasjustaworrier.
Idfeelkeyedupandunabletorelax.
Attimesitwouldcomeandgo,andat
timesitwouldbeconstant.Itcould
goonfordays. Idworryaboutwhat
Iwasgoingtofixforadinnerparty
orwhatwouldbeagreatpresentfor
somebody.Ijustcouldntlet
somethinggo.
Whenmyproblemswereattheirworst,
Idmissworkandfeeljustterribleaboutit.
ThenIworriedthatI'dlosemyjob.Mylife
wasmiserableuntilIgottreatment.
I'dhaveterriblesleeping
problems.Thereweretimes
I'dwakeupwiredinthe
middleofthenight.Ihad
troubleconcentrating,even
readingthenewspaperor
anovel.SometimesI'dfeel
alittlelightheaded.My
heartwouldraceorpound.
Andthatwouldmakeme
worrymore.Iwasalways
imaginingthingswere
worsethantheyreally
were. WhenIgotastom-
achache,Idthinkit
wasanulcer.
Peoplewithgeneralizedanxietydisorder(GAD) go
throughthedayfilledwithexaggeratedworryandtension,even
thoughthereislittleornothingtoprovokeit.Theyanticipatedisaster
andareoverlyconcernedabouthealthissues,money,familyprob-
lems,ordifficultiesatwork.Sometimesjustthethoughtofgetting
throughthedayproducesanxiety.
GADisdiagnosedwhenapersonworriesexcessivelyabouta
varietyofeverydayproblemsforatleast6months.
13
Peoplewith
GADcantseemtogetridoftheirconcerns,eventhoughthey
usuallyrealizethattheiranxietyismoreintensethanthesituation
warrants.Theycantrelax,startleeasily,andhavedifficulty
concentrating.Oftentheyhavetroublefallingasleeporstaying
asleep.Physicalsymptomsthatoftenaccompanytheanxiety
includefatigue,headaches,muscletension,muscleaches,difficulty
swallowing,trembling,twitching,irritability,sweating,nausea,
lightheadedness,havingtogotothebathroomfrequently,feeling
outofbreath,andhotflashes.
ge ne r a l i z e d a nx i e t y di s or de r 13
Whentheiranxietylevelismild,peoplewithGADcanfunction
sociallyandholddownajob. Althoughtheydontavoidcertain
situationsasaresultoftheirdisorder,peoplewithGADcanhave
difficultycarryingoutthesimplestdailyactivitiesiftheiranxiety
issevere.
GADaffectsabout6.8millionAmericanadults,
1
includingtwice
asmanywomenasmen.Thedisorderdevelopsgraduallyandcan
beginatanypointinthelifecycle,althoughtheyearsofhighest
riskarebetweenchildhoodandmiddleage.
2
Thereisevidence
thatgenesplayamodestroleinthedisorder.
13
Otheranxietydisorders,depression,orsubstanceabuse
2,4
often
accompanyGAD,whichrarelyoccursalone.GADiscommonly
treatedwithmedicationorcognitive-behavioraltherapy,butco-
occurringconditionsmustalsobetreatedusingtheappropriate
therapies.
14 nat i ona l i ns t i t u t e of me nta l he a lt h
TreatmentofAnxietyDisorders
Ingeneral,anxietydisordersaretreatedwithmedication,specific
typesofpsychotherapy,orboth.
14
Treatmentchoicesdependon
theproblemandthepersonspreference.Beforetreatmentbegins,
adoctormustconductacarefuldiagnosticevaluationtodeter-
minewhetherapersonssymptomsarecausedbyananxietydisor-
deroraphysicalproblem.Ifananxietydisorderisdiagnosed,the
typeofdisorderorthecombinationofdisordersthatarepresent
mustbeidentified,aswellasanycoexistingconditions,suchas
depressionorsubstanceabuse.Sometimesalcoholism,depression,
orothercoexistingconditionshavesuchastrongeffectonthe
individualthattreatingtheanxietydisordermustwaituntilthe
coexistingconditionsarebroughtundercontrol.
Peoplewithanxietydisorderswhohavealreadyreceivedtreatment
shouldtelltheircurrentdoctoraboutthattreatmentindetail.If
theyreceivedmedication,theyshouldtelltheirdoctorwhatmed-
icationwasused,whatthedosagewasatthebeginningoftreat-
ment,whetherthedosagewasincreasedordecreasedwhilethey
wereundertreatment,whatsideeffectsoccurred,andwhetherthe
treatmenthelpedthembecomelessanxious.Iftheyreceivedpsy-
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-anxietydrugs,andbeta-blockerstocontrolsomeof
thephysicalsymptoms.Withpropertreatment,manypeoplewith
anxietydisorderscanleadnormal,fulfillinglives.
a nx i e t y di s or de r s 15
Antidepressants
Antidepressantsweredevelopedtotreatdepressionbutarealso
effectiveforanxietydisorders. Althoughthesemedicationsbegin
toalterbrainchemistryaftertheveryfirstdose,theirfulleffect
requiresaseriesofchangestooccur;itisusuallyabout4to6
weeksbeforesymptomsstarttofade.Itisimportanttocontinue
takingthesemedicationslongenoughtoletthemwork.
SSRIs
Someofthenewestantidepressantsarecalledselectiveserotonin
reuptakeinhibitors,orSSRIs.SSRIsalterthelevelsoftheneuro-
transmitterserotonininthebrain,which,likeotherneurotransmit-
ters,helpsbraincellscommunicatewithoneanother.
Fluoxetine(Prozac

),sertraline(Zoloft

),escitalopram(Lexapro

),
paroxetine(Paxil

),andcitalopram(Celexa

)aresomeofthe
SSRIscommonlyprescribedforpanicdisorder,OCD,PTSD,and
socialphobia.SSRIsarealsousedtotreatpanicdisorderwhenit
occursincombinationwithOCD,socialphobia,ordepression.
Venlafaxine(Effexor

),adrugcloselyrelatedtotheSSRIs,isused
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.
16 nat i ona l i ns t i t u t e of me nta l he a lt h
MAOIs
Monoamineoxidaseinhibitors(MAOIs)aretheoldestclassofanti-
depressantmedications.TheMAOIsmostcommonlyprescribedfor
anxietydisordersarephenelzine(Nardil

),followedbytranylcypromine
(Parnate

),andisocarboxazid(Marplan

),whichareusefulintreat-
ingpanicdisorderandsocialphobia.PeoplewhotakeMAOIs
cannoteatavarietyoffoodsandbeverages(includingcheeseand
redwine)thatcontaintyramineortakecertainmedications,includ-
ingsometypesofbirthcontrolpills,painrelievers(suchasAdvil

,
Motrin

,orTylenol

),coldandallergymedications,andherbal
supplements;thesesubstancescaninteractwithMAOIstocause
dangerousincreasesinbloodpressure.Thedevelopmentofanew
MAOIskinpatchmayhelplessentheserisks.MAOIscanalso
reactwithSSRIstoproduceaseriousconditioncalledserotonin
syndrome,whichcancauseconfusion,hallucinations,increased
sweating,musclestiffness,seizures,changesinbloodpressureor
heartrhythm,andotherpotentiallylife-threateningconditions.
Anti-AnxietyDrugs
High-potencybenzodiazepinescombatanxietyandhavefewside
effectsotherthandrowsiness.Becausepeoplecangetusedtothem
andmayneedhigherandhigherdosestogetthesameeffect,
benzodiazepinesaregenerallyprescribedforshortperiodsoftime,
especiallyforpeoplewhohaveabuseddrugsoralcoholandwho
becomedependentonmedicationeasily.Oneexceptiontothis
ruleispeoplewithpanicdisorder,whocantakebenzodiazepines
foruptoayearwithoutharm.
Clonazepam(Klonopin

)isusedforsocialphobiaandGAD,
lorazepam(Ativan

)ishelpfulforpanicdisorder,andalprazolam
(Xanax

)isusefulforbothpanicdisorderandGAD.
Somepeopleexperiencewithdrawalsymptomsiftheystoptaking
benzodiazepinesabruptlyinsteadoftaperingoff,andanxietycan
returnoncethemedicationisstopped.Thesepotentialproblems
haveledsomephysicianstoshyawayfromusingthesedrugsorto
usethemininadequatedoses.
Buspirone(Buspar

),anazapirone,isaneweranti-anxietymedication
usedtotreatGAD.Possiblesideeffectsincludedizziness,headaches,
andnausea.Unlikebenzodiazepines,buspironemustbetaken
consistentlyforatleast2weekstoachieveananti-anxietyeffect.

a nx i e t y di s or de r s 17
TAKI NG MEDI CATI ONS
Before taking medication for an anxiety disorder:
Askyourdoctortotellyouabouttheeffectsandsideeffectsofthedrug.
Tellyourdoctoraboutanyalternativetherapiesorover-the-countermedications
youareusing.
Askyourdoctorwhenandhowthemedicationshouldbestopped.Somedrugs
cantbestoppedabruptlybutmustbetaperedoffslowlyunderadoctorssuper-
vision.
Work with your doctor to determine which medication is right for you and
whatdosageisbest.
Beawarethatsomemedicationsareeffectiveonlyiftheyaretakenregularlyand
thatsymptomsmayrecurifthemedicationisstopped.
Beta-Blockers
Beta-blockers,suchaspropranolol(Inderal

),whichisusedtotreat
heartconditions,canpreventthephysicalsymptomsthataccompa-
nycertainanxietydisorders,particularlysocialphobia.Whena
fearedsituationcanbepredicted(suchasgivingaspeech),adoctor
mayprescribeabeta-blockertokeepphysicalsymptomsofanxiety
undercontrol.
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
socialphobialearnhowtoovercomethebeliefthatothersarealways
watchingandjudgingthem.Whenpeoplearereadytoconfront
theirfears,theyareshownhowtouseexposuretechniquesto
desensitizethemselvestosituationsthattriggertheiranxieties.
18 nat i ona l i ns t i t u t e of me nta l he a lt h
PeoplewithOCDwhofeardirtandgermsareencouragedtoget
theirhandsdirtyandwaitincreasingamountsoftimebeforewash-
ingthem.Thetherapisthelpsthepersoncopewiththeanxietythat
waitingproduces;aftertheexercisehasbeenrepeatedanumberof
times,theanxietydiminishes.Peoplewithsocialphobiamaybe
encouragedtospendtimeinfearedsocialsituationswithoutgiving
intothetemptationtofleeandtomakesmallsocialblundersand
observehowpeoplerespondtothem.Sincetheresponseisusually
farlessharshthanthepersonfears,theseanxietiesarelessened.
PeoplewithPTSDmaybesupportedthroughrecallingtheirtraumat-
iceventinasafesituation,whichhelpsreducethefearitproduces.
CBTtherapistsalsoteachdeepbreathingandothertypesofexercises
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.Grouptherapyisparticularlyeffectiveforsocialphobia.
Oftenhomeworkisassignedforparticipantstocompletebetween
sessions.ThereissomeevidencethatthebenefitsofCBTlast
longerthanthoseofmedicationforpeoplewithpanicdisorder,
andthesamemaybetrueforOCD,PTSD,andsocialphobia.
Ifadisorderrecursatalaterdate,thesametherapycanbeusedto
treatitsuccessfullyasecondtime.
Medicationcanbecombinedwithpsychotherapyforspecific
anxietydisorders,andthisisthebesttreatmentapproachfor
manypeople.
a nx i e t y di s or de r s 19
HowtoGetHelpforAnxietyDisorders
Ifyouthinkyouhaveananxietydisorder,thefirstperson
youshouldseeisyourfamilydoctor. Aphysiciancandetermine
whetherthesymptomsthatalarmyouareduetoananxietydisor-
der,anothermedicalcondition,orboth.
Ifananxietydisorderisdiagnosed,thenextstepisusuallyseeinga
mentalhealthprofessional.Thepractitionerswhoaremosthelpful
withanxietydisordersarethosewhohavetrainingincognitive-
behavioraltherapyand/orbehavioraltherapy,andwhoareopento
usingmedicationifitisneeded.
Youshouldfeelcomfortabletalkingwiththementalhealthprofes-
sionalyouchoose.Ifyoudonot,youshouldseekhelpelsewhere.
Onceyoufindamentalhealthprofessionalwithwhomyouare
comfortable,thetwoofyoushouldworkasateamandmakea
plantotreatyouranxietydisordertogether.
Rememberthatonceyoustartonmedication,itisimportantnot
tostoptakingitabruptly.Certaindrugsmustbetaperedoffunder
thesupervisionofadoctororbadreactionscanoccur.Makesure
youtalktothedoctorwhoprescribedyourmedicationbeforeyou
stoptakingit.Ifyouarehavingtroublewithsideeffects,itspossi-
blethattheycanbeeliminatedbyadjustinghowmuchmedication
youtakeandwhenyoutakeit.
Mostinsuranceplans,includinghealthmaintenanceorganizations
(HMOs),willcovertreatmentforanxietydisorders.Checkwith
yourinsurancecompanyandfindout.Ifyoudonthaveinsurance,
theHealthandHumanServicesdivisionofyourcountygovern-
mentmayoffermentalhealthcareatapublicmentalhealthcenter
thatchargespeopleaccordingtohowmuchtheyareabletopay.If
youareonpublicassistance,youmaybeabletogetcarethrough
yourstateMedicaidplan.
WaystoMakeTreatmentMoreEffective
Manypeoplewithanxietydisordersbenefitfromjoininga
self-helporsupportgroupandsharingtheirproblemsandachieve-
mentswithothers.Internetchatroomscanalsobeusefulinthis
regard,butanyadvicereceivedovertheInternetshouldbeused
withcaution,asInternetacquaintanceshaveusuallyneverseen
eachotherandfalseidentitiesarecommon.Talkingwithatrusted
friendormemberoftheclergycanalsoprovidesupport,butitis
notasubstituteforcarefromamentalhealthprofessional.
Stressmanagementtechniquesandmeditationcanhelppeople
withanxietydisorderscalmthemselvesandmayenhancetheeffects
oftherapy.Thereispreliminaryevidencethataerobicexercisemay
haveacalmingeffect.Sincecaffeine,certainillicitdrugs,andeven
someover-the-countercoldmedicationscanaggravatethesymp-
tomsofanxietydisorders,theyshouldbeavoided.Checkwithyour
physicianorpharmacistbeforetakinganyadditionalmedications.
Thefamilyisveryimportantintherecoveryofapersonwithan
anxietydisorder.Ideally,thefamilyshouldbesupportivebutnot
helpperpetuatetheirlovedonessymptoms.Familymembers
shouldnottrivializethedisorderordemandimprovementwithout
treatment.Ifyourfamilyisdoingeitherofthesethings,youmay
wanttoshowthemthisbookletsotheycanbecomeeducatedallies
andhelpyousucceedintherapy.
20 nat i ona l i ns t i t u t e of me nta l he a lt h
a nx i e t y di s or de r s 21
TheRoleofResearchinImprovingtheUnderstanding
andTreatmentofAnxietyDisorders
NIMHsupportsresearch intothecauses,diagnosis,preven-
tion,andtreatmentofanxietydisordersandothermentalillnesses.
Scientistsarelookingatwhatrolegenesplayinthedevelopment
ofthesedisordersandarealsoinvestigatingtheeffectsofenviron-
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.
15
Usingbrainimagingtechnologyandneurochemical
techniques,scientistshavediscoveredthattheamygdalaandthe
hippocampusplaysignificantrolesinmostanxietydisorders.
Theamygdalaisanalmond-shapedstructuredeepinthebrain
thatisbelievedtobeacommunicationshubbetweenthepartsof
thebrainthatprocessincomingsensorysignalsandthepartsthat
interpretthesesignals.Itcanalerttherestofthebrainthatathreat
ispresentandtriggerafearoranxietyresponse.Itappearsthat
emotionalmemoriesarestoredinthecentralpartoftheamygdala
andmayplayaroleinanxietydisordersinvolvingverydistinct
fears,suchasfearsofdogs,spiders,orflying.
22 nat i ona l i ns t i t u t e of me nta l he a lt h
Thehippocampusisthepartofthebrainthatencodesthreatening
events into memories.Studies have shown that the hip-
pocampusappearstobesmallerinsomepeoplewhowerevictims
ofchildabuseorwhoservedinmilitarycombat.
16,17
Researchwill
determinewhatcausesthisreductioninsizeandwhatroleitplays
intheflashbacks,deficitsinexplicitmemory,andfragmented
memoriesofthetraumaticeventthatarecommoninPTSD.
Bylearningmoreabouthowthebraincreatesfearandanxiety,sci-
entistsmaybeabletodevisebettertreatmentsforanxietydisorders.
Forexample,ifspecificneurotransmittersarefoundtoplayan
importantroleinfear,drugsmaybedevelopedthatwillblock
themanddecreasefearresponses;ifenoughislearnedabouthow
thebraingeneratesnewcellsthroughoutthelifecycle,itmaybe
possibletostimulatethegrowthofnewneuronsinthehippocam-
pusinpeoplewithPTSD.
18
CurrentresearchatNIMHonanxietydisordersincludesstudies
thataddresshowwellmedicationandbehavioraltherapiesworkin
thetreatmentofOCD,andthesafetyandeffectivenessofmed-
icationsforchildrenandadolescentswhohaveacombinationof
anxietydisordersandattentiondeficithyperactivitydisorder.
a nx i e t y di s or de r s 23
Citations
1. KesslerRC,ChiuWT,DemlerO,WaltersEE.
Prevalence,severity,andcomorbidityoftwelve-
monthDSM-IVdisordersintheNational
ComorbiditySurveyReplication(NCS-R).Archives
ofGeneralPsychiatry.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
ofanxietydisordersandtheircomorbiditywith
moodandaddictivedisorders.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.
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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
JournalofPsychiatry.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:
DaleDC,FedermanDD,eds.ScientificAmerican
Medicine.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
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24 nat i ona l i ns t i t u t e of me nta l he a lt h
ForMoreInformationonAnxietyDisorders
VisittheNationalLibraryofMedicines
MedlinePlushttp://www.nlm.nih.gov/medlineplus
EnEspaol,http://medlineplus.gov/spanish
ForInformationon
ClinicalTrialsforAnxietyDisorders
NIMHClinicalTrialsWebpage
http://www.nimh.nih.gov/health/trials/index.shtml
NationalLibraryofMedicineClinicalTrialsDatabase
http://www.clinicaltrials.gov
InformationfromNIMHisavailableinmultipleformats.
Youcanbrowseonline,downloaddocumentsinPDF,and
orderpaperbrochuresthroughthemail. Ifyouwouldlike
tohaveNIMHpublications,youcanorderthemonlineat
http://www.nimh.nih.gov. IfyoudonothaveInternet
accessandwishtohaveinformationthatsupplementsthis
publication,pleasecontacttheNIMHInformation
ResourceCenteratthenumberslistedbelow.
National Institute of Mental Health
ScienceWriting,Press&DisseminationBranch
6001ExecutiveBoulevard
Room8184,MSC9663
Bethesda,MD20892-9663
Phone:301-443-4513or
1-866-615-NIMH(6464)toll-free
TTY:301-443-8431or
1-866-415-8051toll-free
FAX:301-443-4279
E-mail:nimhinfo@nih.gov
Website:http://www.nimh.nih.gov
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 09 3879
2009