Anxiety Disorders:
A Psychiatrist Answers Your Questions

by Philip Fox, M.D., as told to Valerie Nanninga Engeltjes, M.A.

Q. What is anxiety?

Anxiety is a healthy feeling that warns us there is danger. It prompts us to ask, "What's the problem? How can I prepare?"

Anxiety is often accompanied by physical sensations such as sweating, accelerated heart rate, hyperalertness, and tremors. These are signs that our body is ready to protect itself.

Q. Since we all experience anxiety, how do we know when we should get help dealing with it?

Healthy anxiety becomes unhealthy when it is so time-consuming that it interferes with our functioning, makes us unrealistically fearful, or when the methods we use to avoid anxiety become worse than the problem.

To understand this better, let's compare anxiety to pain. Anxiety is to our emotional health what pain is to our physical health. Both tell us something's wrong. If I have a pain in my foot, I think, "Is my shoe too tight? Have I strained my foot? Do I have some kind of disease?" Pain directs me to fix my foot.

The pain becomes a problem when it keeps telling me there's something wrong when there isn't. Similarly, anxiety becomes a disorder when it starts giving inaccurate messages.

Q. What are the most common anxiety disorders?

There are many anxiety disorders, but the most common and disabling are panic disorder, generalized anxiety disorder, obsessive compulsive disorder (OCD), and post traumatic stress disorder (PTSD).

In panic disorder, people have brief episodes of overwhelming anxiety with many physical symptoms. Often they think they are going crazy or are about to die. Sometimes they start to avoid the situations or places where they've had panic attacks. This may prevent them from shopping, traveling long distances, and attending church or movies.

In generalized anxiety, the person constantly and futilely ruminates about real life problems. The person doesn't have the acute physical distress that people with panic disorder experience.

Obsessive compulsive disorder is when a person's attempts to control the anxiety have become the problem. The person tries to ward off anxiety by using ruminative thoughts or rituals like excessive washing, checking locks, or counting behaviors. These may consume hours each day. Some rituals often have deeper meaning. Excessive washing, for example, may reflect a person's sense of being dirty, sinful, or unworthy. The classic example is Pontius Pilate, who washed his hands after unjustly condemning Jesus.

People who suffer from post traumatic stress disorder constantly relive the anxiety of a traumatic event. Typical examples are soldiers returning from battle or coworkers who witness a tragic workplace death such as electrocution. These events are beyond the normal person's experience and may cause nightmares, flashbacks, irritability, hypervigilance, and emotional numbness.

Q. How can you be sure the person doesn't have a health problem?

That is very important to evaluate. Many health problems can cause anxiety. Thyroid problems, headaches, respiratory problems, and cardiac disease can all have anxiety as an early symptom. Paradoxically, most people with only anxiety think they have cancer or heart disease or an aneurism. Often, the timing of the anxiety after an emotional trigger helps us make the diagnosis. However, it's still important to get a complete physical examination to rule out other diseases.

Q. If we've ruled out physical problems, how do we determine that the problem is an anxiety disorder and not some other mental problem?

It can be hard to separate anxiety disorders from other emotional problems. Anxiety is one of the symptoms of many psychiatric problems. People with a psychotic disorder often have anxiety about their disturbed thoughts. Those with a bipolar disorder may have anxiety with their highs, making it hard to separate the anxiety from the mania. A person with attention deficit hyperactivity disorder can move around in a way that appears anxious.

These complicating factors make an intensive assessment essential. Often, the diagnosis can be made from a careful description of the symptoms, how they developed, response to treatment, and the family psychiatric history. Sometimes, psychological testing is needed.

Q. Once the problem is diagnosed, how does treatment begin?

We must get the anxiety down to a low enough level that people start to feel some hope. This allows them to work on the anxiety as a problem rather than on just trying to survive. Sometimes, simply learning that the problem is anxiety provides relief. Understanding what brings it on is helpful. Often, medications are necessary to bring it under control.

Q. What are some of the medication options?

The first group is the benzodiazepine anxiolytics (Xanax, Klonopin, Librium, and Ativan), which give relief quickly, often within a half hour. However, the medications' effectiveness eventually goes down. Over time, people build up a tolerance, so these are potentially addictive both psychologically and physically.

These medications are most effective in panic disorders. They bring relief in general anxiety disorder, but we use them only at times of stress. They have some benefit in OCD and PTSD as well.

Q. Are there other medications?

The second main group is the "new" antidepressants like Prozac, Zoloft, and Paxil. Since most severe anxiety disorders are complicated by depression, these medications treat the depression. In high doses, they're also useful in treating OCD. They may have some benefit in panic disorders, but usually don't help generalized anxiety disorders.

The third main group is the "old" antidepressants like Elavil, Tofranil, Disipramine, Pamelor. These treat depression and prevent panic attacks. Another one, Anafranil, is effective in treating OCD. If someone needs long-term treatment for panic disorder, we prefer to use one of these because there's no risk of addiction.

Q. Since there's no risk of addiction, why don't you always use these?

The initial side effects (dry mouth, dizziness, sweating) make it hard for a person with an anxiety disorder to use them. For several weeks, all they get are side effects and no benefits. However, as the side effects diminish, the benefits increase. If people can stick it out, it's worth it. They need a lot of support during that time.

It's common for people to begin several medications simultaneously. They may get quick relief from an anxiolytic and then get a more solid response from an antidepressant. They taper off the anxiolytic quickly and then taper off the antidepressant over months or a year or two.

Q. Are there any other medications people use for panic disorders?

Another option is the beta blockers. A panic attack is similar to the fight/flight response in the body when a person is frightened. Beta blockers prevent the effects of adrenaline in the body like sweating, rapid heart rate, and shakiness. They don't reduce anxiety in the mind, but block some of the feelings of anxiety in the body. People can then more easily control their feelings since their body's reaction is part of what's so frightening.

Q. Other than the side effects and potential addiction, are there any other problems with anxiety medications?

People can become so focused on medications that it actually interferes with their getting better. When they start to feel anxious, immediately their mind says, "This is going to be bad, get relief." The surest way they know to get relief is to take medication.

But it doesn't bring complete relief. They may take more and more and start thinking, "What if I run out of my medicine? What if I get addicted?" They can start obsessing about the medication and none of their energy goes to dealing with what's making them anxious. Sometimes we deal with this by giving medications on a regular schedule rather than when people feel the acute need. Other people may need to stop anxiolytics completely to avoid focusing on them too much.

Medications aren't an easy answer. If they are the only treatment, most people will not be able to get off them. The benefit of medications is to reduce anxiety enough so people can use all their thinking and functional capacity to attack the problem.

Talking therapy is essential and is the most important part of treatment for all anxiety disorders.

Q. Is psychotherapy the next step in treatment?

Yes. The most common approaches are cognitive and behavioral therapy. In these approaches, people learn to change the specific thoughts that go through their minds (cognitions) and the actual actions (behaviors) that reinforce their symptoms.

This is when they learn how to help themselves. People connect what happens in their lives with the symptoms. They learn to control how they think and correct some of the distortions they have about themselves and their feelings. They learn how to stop getting into ruminative thought patterns and to confront the anxiety. They stop teaching themselves to be anxious.

Another goal is to more specifically identify the feelings underlying the anxiety. For example, a woman may get extremely anxious when she visits her aging parents. Through treatment, she realizes she's worried about her parents' dying. She becomes more sad and lonely. These feelings are closer to her real fear and dealing with them will reduce her anxiety.

Q. How do we teach ourselves anxiety?

An example is the old adage that says after getting thrown from a horse, we must climb right back on. Something bad has happened. We feel anxious. Part of that anxiety is what we imagine: "This is incredibly dangerous. I'm going to get killed."

If we respond to the anxiety by avoiding it (not getting back on the horse), we've confirmed to our body that "Yes, that anxiety is correct. If I'm ever in that situation again, I need to get out, because it's dangerous."

Each time we avoid the situation, we reinforce that message to ourself. However, we can confront the anxiety. This may mean getting back on the horse, crossing the Mackinac Bridge, or asking our supervisor for a raise. When we confront the anxiety, we've said, "I can survive this."

That's the most important initial message. We must allow the anxiety to rise enough to experience its full force and know we can survive it.

Q. Isn't that threatening for a person with an anxiety disorder?

That's why many people fear treatment. They think behavioral treatment means being forced to do what they fear most and not being able to handle it. Behavioral treatment is working with people so they understand what's going on and what will help them. They take small, incremental steps-always under their control-as they feel the strength and confidence to take them. The first step might simply be to think about doing it and complete that thought.

Then they may think about possible consequences. Are those manageable? They think about doing something different in the situation. Then they start getting close to it in real life.

Since anxiety disorders are so ingrained, treatment often takes a long time-several months at least.

Q. Do people have to be hospitalized to treat anxiety disorders?

No. Nearly everyone receives treatment in outpatient services. Hospitalization may worsen the situation by implying that they can't handle the anxiety-when they can.

Q. What is usual outpatient treatment?

Most people meet with a therapist one or two times a week for an hour each time. They work on slowly handling their disorder. As they gain more confidence, those sessions spread to every other week and gradually even less frequently.

Many people also join a group for anxiety disorders. The one Pine Rest offers runs six weeks. Most people will have been in individual treatment before the group starts and many will stay on their medications for several months or even a year or two afterward.

Q. What does group therapy offer?

First, people realize they're not alone in their disorder, which is extremely comforting. Second, they gain hope for their own progress when someone else in the group progresses. The group's momentum carries people along. Other benefits are positive peer pressure and accountability.

Q. What should we tell people with an anxiety disorder?

These disorders respond well to medication, desensitization treatment, group treatment, and individual therapy. The biggest obstacle for getting treatment is the hopelessness people feel as they suffer their disorder. Once they learn they can control their symptoms, they gain confidence and make progress toward relieving themselves of the disorder.

If someone you know suffers from an anxiety disorder, it's important to encourage him or her to get help. They're not alone, and trained professionals can help them help themselves to a normal life.