Overview

What Is It?

An anxiety disorder is an excessive or inappropriate response to stress that leaves you with feelings of apprehension, uncertainty and fear.

Anxiety is the anticipation of danger, a negative event or a negative outcome. Nearly all people experience anxiety at times. An anxiety disorder is an excessive level of anxiety that typically persists for at least six months and causes a great deal of unhappiness or creates problems in a person's life. A person who suffers from an anxiety disorder may avoid situations or endure feared situations with a great deal of distress.

According to the National Institute of Mental Health, an estimated 40 million Americans, or 18 percent of adult men and women, experience this illness within a given year. As many as 33 percent of American men and women may experience an anxiety disorder at some point in their lifetime.

Anxiety can be expressed physically through symptoms such as:

• A rise in blood pressure
• A fast heart rate
• Rapid breathing
• An increase in muscle tension
• Nausea or diarrhea

Anxious behaviors can include:

• Avoidance
• Seeking reassurance
• Ritualistic behaviors such as checking, repeating, making things "just right"
• Overpreparing
• Restlessness or fidgeting

Anxious thoughts typically focus on potential negative outcomes or scenarios or negative past events such as trauma, feared mistakes or embarrassing situations.

Without treatment, an anxiety disorder can significantly disrupt a person's life because symptoms may persist or become progressively worse. Tormented by panic attacks, irrational thoughts and fears, compulsive behaviors or rituals, flashbacks, nightmares or countless frightening physical symptoms, people with anxiety disorders may seek help in emergency departments and often rely heavily on other medical services to address their symptoms.

Their work, family and social lives are disrupted, and some even become housebound. Individuals with anxiety disorders may have other mental disorders such as depression or substance abuse.

Fortunately, treatment for anxiety disorders is, in general, very effective. Early diagnosis may aid early recovery, prevent the disorder from becoming worse and possibly prevent the disorder from developing into depression. Yet, because of a widespread lack of understanding and the stigma associated with anxiety disorders, only about one-third of those who experience them are diagnosed and receive treatment.

In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association defines several anxiety disorders. Additionally, they identify obsessive compulsive disorder and post-traumatic stress disorder as closely related to the anxiety disorders. For simplicity, this article uses the term anxiety disorders collectively to include the following:

• Generalized anxiety disorder (GAD) affects about 6.8 million Americans and affects nearly twice as many women as men. GAD is characterized by at least six months of a more-or-less constant state of tension or worry. A person with GAD may always expect a catastrophe to happen. The person may worry even when things are going relatively well. The anxious thoughts and feelings are difficult to control or turn off. The worries that accompany GAD are focused on one or more areas of a person's life, such as health, finances, work or relationships. More than half the people who suffer from GAD also have another anxiety disorder or depression.
• Panic attacks develop abruptly and generally reach a peak within 10 minutes. They may be triggered by a specific event or situation or may seem to come out of the blue. Common symptoms of panic attacks include heart palpitations; sweating; shaking; a feeling of breathlessness or smothering sensations; numbness or tingling sensations in the hands, face or feet; dizziness or feeling faint, chills or hot flushes; depersonalization or a feeling of an altered reality; fear of dying; fear of having a heart attack; or fear of losing control.
• Panic disorder, defined as repeated unexpected panic attacks or worry about such attacks, affects about 6 million Americans. It typically strikes in late adolescence or early adulthood. Women are twice as likely as men to develop panic disorder. People with panic disorder may also suffer from depression, abuse alcohol or abuse drugs such as marijuana. About one-third of people with panic disorder develop agoraphobia, in which a person fears or avoids situations where they believe they will have difficulty escaping or getting help in the event of a panic attack or other embarrassing or unpleasant physical symptoms. People with agoraphobia might avoid driving on the highway, using public transportation, going to crowded places such as shopping malls or concerts and, in severe cases, may avoid leaving their homes.
• Phobias are irrational, involuntary fears of common objects, living things or situations, such as heights, small enclosed spaces, animals, insects, air travel, blood or medical procedures. While they vary in severity, phobias can be incapacitating. Most people who suffer from phobias are aware of the irrationality of their fear, yet they avoid the feared objects or situations or endure them with intense anxiety. Specific phobias are among the most common mental health disorders. About 19.2 million Americans suffer from specific phobias, and they are twice as common in women as men.
• Social phobia, or social anxiety disorder, is caused by a fear of being embarrassed in a social situation or publicly scrutinized and humiliated. Social phobia is often accompanied by depression and may lead to alcohol or other drug abuse. About 15 million people have social phobia, which is equally common among women and men. The disorder typically begins in childhood or early adolescence and rarely develops after age 25.
• Obsessive-compulsive disorder (OCD) is characterized by recurrent, persistent and intrusive thoughts, images or impulses that cause anxiety. These mental images or ideas are called obsessions. The person tries to control or neutralize these obsessions and relieve the anxiety by performing repetitive behaviors called compulsions. The compulsions are often rigid and must be performed in a certain time-consuming order. Although adults with OCD often know these rituals are excessive, they cannot stop doing them in spite of strenuous efforts to ignore or suppress the thoughts or actions. Repeated hand washing, reordering of belongings, rechecking objects in one's house, or silently repeating words, numbers or prayers are examples of compulsions. About 2.2 million Americans have OCD. One-third of adults affected with OCD had their first symptoms in childhood. OCD affects men and women with equal frequency. OCD should not be confused with obsessive-compulsive personality disorder, which is characterized by traits such as being a perfectionist, excessively conscientious, morally rigid and preoccupied with rules and order. These traits do not necessarily occur in people with OCD.
• Post-traumatic stress disorder (PTSD) develops after exposure to an extremely stressful event that involved threatened or actual death, serious injury or sexual violence for oneself or someone else. About 7.7 million people suffer from PTSD. It may stem from trauma such as a rape, childhood sexual abuse, military combat or war-related incidents and natural disasters.

Although anxiety is a normal human response to stress, health care professionals and researchers don't know exactly why some people develop severe anxiety or panic. They believe it is most likely the result of a combination of biological and psychosocial factors such as:

• A biological tendency toward anxiety, including greater sensitivity to the effects of hormones released during anxiety, such as adrenaline; or an imbalance of certain substances called neurotransmitters (chemical messengers in the brain)
• Genetic or familial factors. People who have close relatives with anxiety disorders are more likely to suffer from anxiety disorders themselves.
• Family background, such as an early childhood conflict or trauma, or "learned" fears or phobias
• Negative or stressful life events
• Other illnesses or medications can cause symptoms of an anxiety disorder

While anxiety disorders can strike anyone of any age, gender or socioeconomic background, they most often begin in young adulthood. They often start mildly and progress, although GAD appears to be the most common form of anxiety in older ages. In addition, except for OCD and social anxiety disorder, anxiety disorders strike women at approximately twice the rate of men.

Diagnosis

The first step to properly diagnosing an anxiety disorder is to rule out another medical condition. Because anxiety accompanies so many medical conditions, some serious, it is extremely important for your health care professional to uncover any physiological medical problems or medications that might underlie or be masked by anxiety symptoms.

Thus, a physical examination and medical and personal history are essential. You should describe any history of anxiety disorders or depression in your family and mention any other contributing factors, such as excessive caffeine use, recent life changes or stressful events. It is very important to be honest with your health care professional about all conditions, including substance abuse or other psychological or mood states that might contribute to or result from the anxiety disorder.

Panic attacks may mimic or accompany diseases of the heart and lungs, but anxiety attacks do not cause heart or lung disease. Anxiety-like symptoms may occur with other medical problems, including epilepsy, hypoglycemia, adrenal-gland tumors and hyperthyroidism. Women can also experience intense anxiety attacks with hot flashes during menopause. Many drugs, including some for high blood pressure, diabetes and thyroid disorders, can produce symptoms of anxiety, as can withdrawing from certain drugs like those used to treat sleep disorders or anxiety.

Panic disorder often coexists with depression, and sometimes the symptoms overlap because anxious feelings, agitation, insomnia and problems with concentration often accompany depression.

Thus, your health care professional will use a medical evaluation to rule out alternative explanations of anxiety symptoms.

Health care professionals can use various tests from the American Psychiatric Association and other professional organizations to determine the causes, type, severity and frequency of your anxiety. Most are written, multiple-choice tests that can be administered on paper or verbally and are centered on defining the kinds of symptoms you experience as part of your anxiety.

Specific anxiety disorders are diagnosed based on the severity and duration of symptoms and on additional behavioral characteristics that accompany the symptoms of anxiety. Specifically:

• Generalized anxiety disorder (GAD) is confirmed if you meet the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. These criteria include:
  • Excessive anxiety and worry about several events and activities more days than not for at least six months
  • The anxiety is not better explained by other mental health issues, such as post-traumatic stress disorder (PTSD), substance abuse or panic disorder
  • Difficulty controlling feelings of worry
  • At least three of the following symptoms in adults and one in children: fatigue, restlessness, trouble concentrating, muscle tension, sleep problems or irritability

Symptoms should cause significant distress and impair normal functioning.

• Panic disorder is diagnosed if you meet the diagnostic criteria outlined in the DSM, including:
  • Recurrent, unexpected panic attacks
  • Worry about having another panic attack or losing control
  • Avoidance of situations you think may trigger a panic attack
  • Panic attacks that aren't caused by substance abuse or another mental health condition such as social phobia or agoraphobia
    Panic attacks include four or more of the following symptoms that develop suddenly and reach a peak within 10 minutes:
    • Palpitations, pounding heart, or accelerated heart rate
    • Sweating
    • Trembling or shaking
    • Sensations of shortness of breath or smothering
    • Feelings of choking
    • Chest pain or discomfort
    • Nausea or abdominal distress
    • Feeling dizzy, unsteady, light-headed, or faint
    • Chills or heat sensations
    • Numbness or tingling sensations
    • Feelings of unreality or depersonalization
    • Fear of losing control or going crazy
    • Fear of dying
  • Agoraphobia occurs in about one-third of people with panic disorder. It involves fear or avoidance of multiple situations such as using public transportation, being in open spaces such as marketplaces or bridges, being in closed spaces such as theaters or shops, standing in line or being in a crowd, or being outside of the home alone. In such situations, the person typically worries that there would be no escape or help would be unavailable should panic-like symptoms or other unpleasant or embarrassing symptoms occur. A person with agoraphobia might make complicated plans to avoid confronting feared situations and limit herself to places that feel safe such as home.
  • Specific phobias occurs when someone fears and may avoid specific objects, living things or situations such as small enclosed spaces, particular animals or insects, heights, air travel, blood, injury or injections. Although people with specific phobias may have panic attacks, their fear is not focused on panic symptoms. Instead, they worry that the feared object or situation itself will cause harm (e.g., the plane will crash, they will fall or jump from a high place, a dog will bite them). A person with a specific phobia may experience the following symptoms around the phobic object or situation:
    • Panicky feelings
    • Sweating
    • Rapid heartbeat
    • Avoidance behavior
    • Difficulty breathing
  • Social phobia, also known as social anxiety disorder, is a fear of being embarrassed or negatively evaluated in social situations. Symptoms vary in intensity, ranging from mild and tolerable anxiety to a full-blown panic attack. People with social phobia worry that others will perceive them as boring, stupid, weird or unlikable. They may also worry that their anxiety will be evident due to blushing, trembling, shaking or stammering. Social phobia is often accompanied by depression and may lead to substance abuse.
  • Obsessive-compulsive disorder (OCD) is diagnosed if obsessions and compulsions interfere with your normal activities or cause emotional distress or anxiety, especially if the ritualistic behavior cannot be carried out. Adults with this condition usually recognize their obsessions or compulsions as excessive and unreasonable, yet feel compelled to engage in them. The obsessive thoughts or images can range from mundane worries about whether one has locked a door to bizarre or frightening fantasies of behaving violently toward a loved one. The compulsive acts triggered by such obsessions might include repetitive checking of locked doors or unlit stove burners or calls to loved ones at frequent intervals to be sure they are safe. Some people are compelled to wash their hands every few minutes or spend inordinate amounts of time cleaning their surroundings to subdue the fear of contagion.
    
    Certain other obsessive disorders, including body dysmorphic disorder (BDD), trichotillomania and Tourette's disorder, may be part of the OCD spectrum. In BDD, people are obsessively preoccupied with an imagined defect in their appearance. People with trichotillomania continually pull out their hair, sometimes leaving bald patches. Symptoms of Tourette's disorder include both motor tics, like eye blinking, facial twitching and jerking motion of arms or head, and vocal tics, like grunting, sniffing and throat clearing. These symptoms usually start before age 18 and continue for at least one year.
  • Post-traumatic stress disorder (PTSD) symptoms can occur weeks, months or even years after the traumatic event. A person who suffers from PTSD may have the following symptoms:
    • Recurrent intrusive memories or distressing dreams about the event
    • Dissociative reactions in which the person feels the event is recurring
    • Avoidance of reminders of the event
    • Sleeplessness
    • Depression
    • Irritability or angry outbursts
    • Feelings of being "on alert" at all times
    • Emotional withdrawal
    • Hopelessness
    • Mood swings
    • Guilt over surviving the event
    • Inability to concentrate
    • Excessive startle response to noise
  • Acute stress disorder (ASD) is similar to PTSD, except it can be diagnosed immediately after a traumatic event and lasts for three days or more, but no longer than one month after the trauma. Like PTSD, it is triggered by a traumatic event such as witnessing a car accident or natural disaster or being violently assaulted. ASD symptoms overlap with those of PTSD. In some cases, anger or dissociative symptoms, such as not knowing where you are or feeling separate from your body, may be the main symptoms. Some people who suffer ASD may have previously had PTSD, and many who get ASD go on to develop PTSD.
  Finding the Right Health Care ProfessionalBecause of widespread lack of understanding and the stigma associated with anxiety disorders, many people with these disorders don't receive a diagnosis and so don't receive treatments proven effective through research. Yet anxiety disorders, like other mental disorders, are an illness and should not be faced with shame or fear. Enormous progress has been made in the scientific understanding of the underlying causes and mechanisms of anxiety disorders.To be a smart health care consumer, you need to ensure that the health care professional you see is able to recognize an anxiety disorder. While mental health treatment can be received from a wide range of professionals, including primary care physicians, psychiatrists, psychologists and social workers, you may want to consider seeking out an anxiety specialist, particularly someone who can offer the treatments found to be most successful, such as cognitive behavioral therapy and medications.You can contact the Anxiety Disorders Association of America (www.adaa.org) or the Association for Behavioral and Cognitive Therapies (www.abct.org) to find professionals specializing in anxiety. Make sure you follow the steps for seeking treatment as outlined in your health insurance plan. You may be required, for example, to see a primary care physician first. Some health insurance plans cover mental health services; some don't. Check your policy or ask your plan administrator so you can determine what your out-of-pocket expenses might be. Don't overlook the simple fact that you should like your treating professional. If you can't develop a rapport within the first two or three sessions, your therapy probably won't be successful, so keep searching for someone with whom you're comfortable.

Treatment

Anxiety disorders require professional treatment; simply trying to talk yourself out of anxiety is as futile as trying to talk yourself out of a heart or stomach problem. Fortunately, the vast majority of people with an anxiety disorder can be helped with the right professional care. Research suggests that with the right treatment, many people with anxiety disorders experience significant improvement. There are no guarantees, however, and success rates vary with circumstances.

Treatment periods vary, with some requiring only a few months of treatment and others needing a year or more. People with anxiety disorders often have more than one disorder or suffer from substance abuse or clinical depression. When more than one mental health-related condition is present, each must be accurately diagnosed and treated.

Treatments for anxiety disorders vary, with both therapy, particularly cognitive behavioral therapy (CBT), and medication, used. Often, the most effective approach for anxiety disorders is a combination of the two. With OCD, a specific type of CBT called exposure and response prevention should be used, usually in combination with medication.

Medications

Medications used to treat anxiety disorders include:

• Selective serotonin reuptake inhibitors (SSRIs) are first-line medicines used to treat anxiety disorders. Although these medications were initially approved as antidepressants, they are effective in the treatment of anxiety. Some of them have been approved by the FDA for the treatment of one or more of the anxiety syndromes. They include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), fluvoxamine (Luvox) and escitalopram oxalate (Lexapro). They work by affecting the concentration of serotonin, a chemical in the brain thought to be linked to anxiety disorders, and have traditionally been used to treat depression. SSRIs may take several weeks to have an effect. They should not be stopped suddenly as they may cause withdrawal symptoms that are unpleasant but not harmful.
  
  The most common side effects are nausea and gastrointestinal problems, drowsiness, sweating, headache, difficulty sleeping and mild tremor, all of which usually wear off as your body adjusts to the medication. Weight gain and sexual dysfunction can also be side effects of this category of medications. Occasionally they can cause agitation or worsening of anxiety. Notify your clinician immediately if this occurs.

• Tricyclic antidepressants (TCA) are older medications that were first used for treating depression. They are also effective in blocking panic attacks and for anxiety and PTSD because they regulate serotonin and/or norepinephrine in the brain. The most common TCAs used for the treatment of panic disorder are imipramine (Tofranil), desipramine (Norpramin) and nortriptyline (Pamelor). TCAs are also effective in treating agoraphobia.
  
  Clomipramine (Anafranil), which is the only TCA approved for obsessive-compulsive disorder (OCD), significantly reduces symptoms for patients who can tolerate it.
  
  Tricyclic antidepressants have more adverse side effects than SSRIs, which is why SSRIs are often tried first in the treatment of anxiety disorders. Tricyclics usually take two or three weeks to take effect. Side effects include dry mouth, blurred vision, sexual dysfunction, weight gain, difficulty urinating, constipation, disturbances in heart rhythm, drowsiness and dizziness. Blood pressure may drop slightly when sitting up or when standing from a sitting position, causing dizziness. Tricyclics also can have serious, although rare, side effects and can be potentially fatal in overdose. Elderly patients and those with a history of seizures, cardiac problems, closed-angle glaucoma and urinary retention or obstruction should be closely supervised when taking tricyclics.

• Serotonin-norepinephrine reuptake inhibitors (SNRIs) are also frequently used for treatment of anxiety disorders. These include venlafaxine (Effexor) and duloxetine (Cymbalta). Venlafaxine is approved to treat GAD, panic disorder and social anxiety disorder, while duloxetine is approved thus far only for GAD. Desvenlafaxine (Pristiq) is the newest drug in this category and so far is not approved to treat anxiety disorders but is sometimes used off-label for treatment. The side effects of SNRIs are similar to those of the SSRIs although they appear to have more pronounced withdrawal symptoms when the medication is stopped.
• Mirtazapine (Remeron) acts by increasing norepinephrine and serotonin in a different way than the SSRIs and SNRIs. It is approved by the FDA for depression, but it also can be effective for treating generalized anxiety, panic disorder and PTSD. Side effects include dry mouth, constipation, increased appetite, weight gain and sedation. This medication can also increase cholesterol and triglycerides. Because of these side effects, the use of mirtazapine is best reserved for patients experiencing weight loss and insomnia due to their anxiety.

• Monoamine oxidase inhibitors (MAOI), typically phenelzine (Nardil) or tranylcypromine (Parnate), are older antidepressants used for panic disorder, social anxiety disorder or PTSD that does not respond to other treatments. They work by blocking the effect of a brain chemical that breaks down serotonin and noradrenaline. Common side effects include a sudden drop in blood pressure upon standing, drowsiness, dizziness, sexual dysfunction and insomnia. The most serious side effect is severe hypertension, which can be brought on by eating certain foods with high tyramine content, such as aged cheeses, red wines, sauerkraut, vermouth, chicken livers, dried meats and fish, canned figs, fava beans and concentrated yeast products. They can also interact with other medications, such as over-the-counter decongestants and prescription stimulants. You shouldn't take MAOIs if you're pregnant or taking other antidepressants such as SSRIs and should have at least a two-week break between ending one antidepressant and starting on MAOIs. Because these drugs can cause a hypertensive crisis from interaction with other medications and certain foods, they are rarely used. There are many safer drugs that are effective for anxiety.
  
  (Note: In 2004, the U.S. Food and Drug Administration issued a warning that all antidepressants may lead to an increased suicide risk in adolescents and children. This was subsequently revised to include young adults through age 25. Therefore, it is important to watch anyone taking antidepressants for signs of suicidal behavior generally through the first 30 days of treatment.)
• Benzodiazepines like alprazolam (Xanax), lorazepam (Ativan), diazepam (Valium) and clonazepam (Klonopin) have been the treatment of choice for anxiety disorders for years. Benzodiazepines are mild sedatives that belong to a group of medications called central nervous system depressants. These drugs may be habit-forming, especially when taken in high doses or for an extended time.
  
  Benzodiazepines work relatively quickly. Their principal side effects are drowsiness, fatigue, dizziness, slurred speech, impaired concentration and short-term memory loss, but they have the potential for dependency after only a few weeks. Thus, if you stop taking them after taking them for a long period, you may experience rebound symptoms, sleep disturbance and anxiety within a few days. You should not stop these medications suddenly, because you may have withdrawal symptoms that can result in seizures (generally with high doses that are taken multiple times per day). Always talk to your health care provider before you stop taking benzodiazepines. You should always taper off slowly with the help of your clinician. However, benzodiazepines can be very helpful when taken under the direction of your health care provider. Benzodiazepines are often used during the initial treatment, along with other medication (such as SSRIs), because they will help immediately with the anxiety before the other drugs take effect. They can then be gradually discontinued. They may be used long-term in certain situations and can be effective as a single dose for a panic attack because they provide quick relief.
• Buspirone is the only drug available in the class called azapirones. It works via one of the serotonin receptors. Buspirone is approved for generalized anxiety disorder. It usually takes several days to weeks for the drug to become effective, and it is not useful against panic attacks. Unlike the benzodiazepines, buspirone is not addictive, even with long-term use, and it seems to have less pronounced side effects and no withdrawal effects, even when the drug is discontinued quickly. Because the drug does not produce any immediate euphoria or change in sensation, those who have taken benzodiazepines may believe it's not working. Common side effects include dizziness, drowsiness and nausea. Buspirone should not be used with MAOIs.
• Beta-blockers, including propranolol (Inderal) and atenolol (Tenormin), reduce the effects of adrenaline by blocking cellular receptors for adrenaline. They affect only the physical symptoms of anxiety, which may then lessen the psychological symptoms. They are most helpful for performance anxiety and are used prior to such situations as musical performances or public speaking. They are less helpful for other forms of anxiety. They work quickly and aren't habit forming but shouldn't be used with certain pre-existing medical conditions such as asthma, congestive heart failure, diabetes, vascular disease, hyperthyroidism and angina pectoris.

Researchers are currently working on developing drugs that target specific brain cells involved in anxiety disorders.

Therapy

• Behavioral techniques focus on changing negative thinking and behaviors that can contribute to anxiety disorders. Talking to a mental health therapist can provide relief, lead to new insights and help replace unhealthy behaviors with more effective ways of coping. Most mental health professionals tailor their approaches to the needs, problems and personalities of the people seeking help and may combine different techniques in the course of therapy. The various types of behavioral techniques used to treat anxiety disorders include:
  • Cognitive-behavioral therapy focuses on identifying and modifying the faulty thoughts and negative behaviors that keep a person stuck in the anxiety pattern. There are several parts to this therapy. Treatment begins with education about the disorder: the causes, common symptoms and treatment plan. Next, the person learns to identify the specific thoughts behind their anxiety (for example, what specifically are they thinking when they feel anxious?). They examine these thoughts using evidence to ensure that they are looking at things accurately and not exaggerating the likelihood of negative events or outcomes or the potential consequences of them. They learn to recognize and then give up their anxious behaviors (e.g., avoidance, rituals, reassurance seeking) and increase positive, healthy behaviors like good sleep, exercise, problem solving or assertiveness. The second part of the therapy consists of facing the stimulus or situation that triggers anxiety so that the anxious response will decrease over time and the person learns that the feared outcome rarely happens or is not as catastrophic as they thought it would be.
  • Systematic desensitization requires a woman to gradually confront the object of fear with a goal of breaking the link between the anxiety-provoking stimulus and the anxiety response. First, you undergo relaxation training and compose a list that prioritizes anxiety-inducing situations by the degree of fear they invoke. Next, you undergo the desensitization procedure, confronting each item on the list, starting with the least stressful. This treatment is especially effective for simple phobias, social phobias, agoraphobia and post-traumatic stress disorder.
  • Breathing retraining helps women with panic disorder practice measured, controlled breathing. Because many people with panic disorder hyperventilate, breathing rapidly and tensely and expelling too much carbon dioxide, they suffer from chest pain, dizziness, tingling of the mouth and fingers and muscle cramps. People learn to practice diaphragmatic breathing, taking slow deep breaths versus rapid, shallow ones. By correcting her breathing, a woman can relieve unpleasant (though harmless) symptoms and may avoid the onset of a panic attack. This technique is frequently used in conjunction with other treatments for anxiety disorders.
• Other forms of psychotherapy, commonly called "talk" therapies, deal more with childhood roots of anxiety and usually, although not always, require longer treatments. They include interpersonal therapy, supportive psychotherapy, attention intervention and psychoanalysis. Some experts believe that such therapies might be more useful for generalized anxiety, which may require more sustained work over a longer time.
• Hypnotherapy, which uses the technique of hypnosis, may also be an appropriate treatment option for some people. Hypnosis is a form of intense receptive concentration. Accordingly, hypnosis often is used to modify behavior and overcome phobias and bad habits—it can help you make changes that you've been unable to make otherwise. Often hypnotherapy is combined with other relaxation techniques.

Prevention

People with anxiety disorders often are known as "worriers," concerned about control and perfectionism. These can be good traits to have. But when the need for perfectionism or control interferes with your life, you may have an anxiety disorder. The first step in prevention is to look at how you can respond differently to situations that make you anxious, modify the physiological response to those situations and master negative thinking.

A healthy lifestyle that includes regular aerobic exercise, relaxation techniques such as yoga, adequate rest and good nutrition can help reduce the impact of anxiety.

To prevent your normal anxious feelings from going too far, try these suggestions:

• Identify situations that make you anxious, consider actions that will reduce the threat and try them out (for example, attend childbirth preparation classes to deal with the stress of labor and delivery; eliminate or reduce caffeine intake if nervousness alone is the problem).
• Avoid potentially dangerous ways of coping with anxiety, like smoking, alcohol, drug dependence or abnormal eating patterns.
• Express your feelings to someone you trust and can talk with comfortably. This often leads to a relief of anxious feelings.
• Try relaxation techniques or meditation such as yoga or stress reduction classes.
• Try walking, jogging, swimming or any aerobic exercise.
• Avoid unnecessary stress by eliminating as many nonessential activities as possible from your daily routine. Delegate tasks when possible and practice saying "no," rather than taking on more responsibilities than you can manage.
• If your anxiety persists or becomes chronic, seek out a competent mental health professional. You can ask for help or a referral from your primary health care professional, a community mental health center, a mental health association or your local health department.

Facts to Know

1. According to the National Institute of Mental Health, an estimated 40 million American adults experience anxiety disorders within a given year.
2. Without treatment, an anxiety disorder can significantly disrupt your life. You may be tormented by panic attacks, irrational thoughts and fears, compulsive behaviors or rituals, flashbacks, nightmares or countless frightening physical symptoms. Yet, because of widespread lack of understanding and the stigma associated with these disorders, only about one-third of those who experience this problem are diagnosed and receive treatment.
3. Generalized anxiety disorder affects about 6.8 million Americans and is characterized by excessive worry about a number of life issues like health, work, finances or relationships. The worry is difficult to control and is present more days than not for six months or more.
4. Panic disorder affects about 6 million Americans. It typically strikes in late adolescence or early adulthood. Women are twice as likely as men to develop panic disorder. People with panic disorder may also suffer from depression; in addition, those with panic disorder are more likely to abuse alcohol and drugs. About one-third of people with panic disorder develop agoraphobia, an illness in which they become afraid of being in any place or situation where escape might be difficult or help unavailable in the event of panic-like symptoms or some other unpleasant or embarrassing physical symptom.
5. About 15 million people have social phobia or social anxiety disorder. Social phobia involves fear that a person will embarrass herself or that others will evaluate her negatively. The disorder typically begins in childhood or early adolescence and rarely develops after age 25.
6. About 2.2 million Americans have obsessive-compulsive disorder (OCD). OCD affects men and women with equal frequency.
7. About 7.7 million Americans suffer from post traumatic stress disorder (PTSD). Trauma such as a rape, childhood sexual abuse, military combat or war-related incidents, and natural disasters are common causes. PTSD can develop at any age, including childhood. Depression, alcohol or other substance abuse or another anxiety disorder often accompanies PTSD.
8. Anxiety disorders most often begin in young adulthood, starting mildly and progressing. Generalized anxiety disorder appears to be the most common form of anxiety at older ages. In addition, except for OCD and social anxiety disorder, anxiety disorders strike women at approximately twice the rate of men. A woman's hormonal cycle may affect her anxiety disorder, with symptoms getting worse premenstrually.
9. Anxiety attacks can mimic or accompany diseases of the heart and lungs, but anxiety attacks do not cause heart or lung disease. Anxiety-like symptoms may occur with other medical problems, including epilepsy, hypoglycemia, adrenal-gland tumors and hyperthyroidism. Women can also experience intense anxiety attacks with hot flashes during menopause. Many drugs, including some for high blood pressure, diabetes and thyroid disorders, can produce symptoms of anxiety.
10. Fortunately, treatment for anxiety disorders is, in general, very effective. Early identification and treatment of an anxiety disorder may help you recover more easily and prevent depression. Treatments for anxiety disorders vary and include therapy, particularly cognitive behavioral therapy, and medication. Often the most effective approach for most anxiety disorders is a combination of the two.

Questions to Ask

Review the following Questions to Ask about anxiety disorders so you're prepared to discuss this important health issue with your health care professional.

1. Could my anxiety be caused by an underlying medical condition or medications I'm taking?
2. Can anxiety be treated? What treatments are available?
3. How can I use relaxation techniques or biofeedback to ease my anxiety?
4. Will counseling or therapy help my anxiety? What kind of counseling or therapy do you recommend?
5. Are there any substances I should avoid, or lifestyle habits I should change, to help overcome my anxiety?
6. I need to involve my partner or family member in my treatment. Will you help educate them about my problem and how to help me manage it?

If medication is prescribed

1. How do you expect this medication to help me? When and how should I take it?
2. What are the possible side effects of the medication?
3. How long will it take the medication to work?
4. Should I avoid other medications, alcohol or certain foods while I take this medication?
5. What if this medication doesn't work? Is it safe to stop taking it?
6. How long should I take this medication? How can I avoid becoming dependent on it?

Key Q&A

Organizations and Support

For information and support on coping with Anxiety Disorders, please see the recommended organizations, books and Spanish-language resources listed below.

American Academy of Child and Adolescent Psychiatry (AACAP)
Website: https://www.aacap.org
Address: 3615 Wisconsin Ave., NW
Washington, DC 20016
Phone: 202-966-7300

American Psychological Association
Website: https://www.apa.org
Address: 750 First St., NE
Washington, DC 20002
Hotline: 1 -800-374-2721
Phone: 202-336-5500

Anxiety Disorders Association of America (ADAA)
Website: https://www.adaa.org
Address: 8730 Georgia Avenue, Suite 600
Silver Spring, MD 20910
Phone: 240-485-1001
Email: information@adaa.org

Association for Behavioral and Cognitive Therapies (ABCT)
Website: https://www.abct.org
Address: 305 7th Avenue, 16th Floor
New York, NY 10001
Phone: 212-647-1890

Bazelon Center
Website: https://www.bazelon.org
Address: The Bazelon Center for Mental Health Law
1101 15th Street NW, Suite 1212
Washington, DC 20005
Phone: 202-467-5730
Email: info@bazelon.org

Federation of Families for Children's Mental Health
Website: https://www.ffcmh.org
Address: 9605 Medical Center Drive, Suite 280
Rockville, MD 20850
Phone: 240-403-1901
Email: ffcmh@ffcmh.org

Freedom From Fear
Website: https://www.freedomfromfear.org
Address: 308 Seaview Avenue
Staten Island, NY 10305
Phone: 718-351-1717
Email: help@freedomfromfear.org

Geriatric Mental Health Foundation
Website: https://www.gmhfonline.org
Address: 7910 Woodmont Ave, Suite 1050
Bethesda, MD 20814
Phone: 301-654-7850
Email: web@GMHFonline.org

Guide to College Student Mental Health
Website:https://www.learnpsychology.org/mental-health/

MentalHealth.gov
Website: https://www.mentalhealth.gov
Address: U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201

Mental Health America
Website: https://www.mentalhealthamerica.net
Address: 2000 N. Beauregard Street, 6th Floor
Alexandria, VA 22311
Hotline: 1-800-969-6642
Phone: 703-684-7722

National Alliance on Mental Illness (NAMI)
Website: https://www.nami.org
Address: Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201
Hotline: 1-800-950-NAMI (1-800-950-6264)
Phone: 703-524-7600

National Anxiety Foundation
Website: https://www.lexington-on-line.com/naf.html
Address: 3135 Custer Drive
Lexington, KY 40517

National Institute of Mental Health
Website: https://www.nimh.nih.gov
Address: Science Writing, Press and Dissemination Branch
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892
Hotline: 1-866-615-6464
Phone: 301-443-4513
Email: nimhinfo@nih.gov

National Mental Health Consumers' Self-Help Clearinghouse
Website: https://www.mhselfhelp.org
Address: 1211 Chestnut St., Suite 1207
Philadelphia, PA 19107
Hotline: 1-800-553-4539
Phone: 215-751-1810
Email: info@mhselfhelp.org

Obsessive Compulsive Foundation
Website: https://www.ocfoundation.org
Address: 112 Water Street Suite 501
Boston, MA 02109
Phone: 617-973-5801
Email: info@ocfoundation.org

Books

10 Steps to Take Charge of Your Emotional Life: Overcoming Anxiety, Distress, and Depression Through Whole-Person Healing
by Eve A. Wood

Anxiety, Phobias and Panic Attacks: Your Questions Answered
by Elaine Sheehan

Complete Idiot's Guide to Conquering Fear and Anxiety
by Sharon Heller

An End to Panic - Breakthrough Techniques for Overcoming Panic Disorder
by Elke Zuercher-White

From Panic to Power: Proven Techniques to Calm Your Anxieties, Conquer Your Fears, and Put You in Control of Your Life
by Lucinda Bassett

Mastering Your Moods - Understanding Your Emotional Highs and Lows
by Paul D. Meier, Stephen Arterburn, and Frank B. Minirth

Overcoming Panic Disorder - A Woman's Guide
by Lorna Weinstock, Eleanor Gilman

Seven Keys to Calm
by A.M. Matthews

The Therapy Sourcebook
by Francine M. Roberts

Women & Anxiety: A Step-by-Step Program for Managing Anxiety and Depression
by Helen DeRosis

Spanish-language resources

Medline Plus
US National Library of Medicine
National Institutes of Health
Website: https://www.nlm.nih.gov/medlineplus/spanish/ency/article/001180.htm
Address: 8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Healthier You
Website: https://www.nimh.nih.gov/health/publications/anxiety-disorders-listing.shtml
Address: National Institute of Mental Health
Office of Communications and Public Liaison
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892
Hotline: 1-888-826-9438
Phone: 301-443-4513
Email: nimhinfo@nih.gov