Anxiety

*The information on this website is not intended to diagnose, treat, cure or prevent any disease.

What is Anxiety?

Anxiety is a condition characterized by worrying, distress, anticipation of bad news or events, or being excessively afraid. It is an uncomfortable condition with many psychosomatic manifestations. Anxiety can lead to more intense emotional reactions like panic attacks. Anxiety can be a normal feeling and even beneficial feeling at different points in life (for example, anxiety about taking an important test, or before an important presentation), but when it becomes persistent, inappropriate, or impedes normal life activities, it can be a sign of an anxiety disorder.

There are multiple kinds of anxiety disorders, and they can manifest in many different ways. Generalized anxiety disorder (GAD), obsessive-compulsive disorders (OCD), panic disorder, specific phobias, post-traumatic stress disorder (PTSD), separation anxiety, and social anxiety disorder (SAD) are all different types of anxiety disorders. Anxiety disorders are the most commonly diagnosed mental illness in the United States, with some type of anxiety issue affecting 1 in 5 people.

Generalized anxiety disorder results in chronic worrying more than half of the days in a 6-month period or longer. There is an irrational expectation of adverse events, outcomes, or worst-case scenarios. GAD often results in physical manifestations such as headaches, tension in muscles, tiredness, nausea, and trembling. Left untreated, GAD can also result in or exacerbate symptoms of depression, and the two disorders are often related.

Social anxiety disorder is a relative common condition which makes it difficult for individuals to interact in social situations, especially with unfamiliar people. There is a fear of being judged, making a good impression, or embarrassing themselves. As a result, many people affected with SAD avoid social interactions as much as possible, and it can become a very isolating condition.

Obsessive compulsive disorder is characterized by intrusive, repetitive thoughts or physical habits. For people who have OCD, these habits or rituals seem impossible to break, despite lacking any rational or practical basis.

Panic disorder, as the name implies, results in sudden panic attacks which occur suddenly and unpredictably. Strong feelings of fear or terror results in serious physical manifestations like elevated heart rate, chest pain, hyperventilation, dizziness, feelings of being disconnected from reality, and fear of impending death.

Phobias are another type of anxiety disorder characterized by an intense, irrational fear of something. Some phobias may rarely be issues, or are usually avoidable (such as ophidiophobia – the fear of snakes) while others can be completely debilitating, difficult to avoid, or majorly affect a person’s ability to live a normal life. Examples of these phobias may include agoraphobia (fear of situations in which it may be difficult to escape or they are overly exposed), mysophobia (fear of germs), or cynophobia (fear of dogs).

Separation anxiety is most commonly seen in children. It is the result of an irrational fear of being separated from a person (usually a parent), home environment, or being kidnapped. Although it is mostly seen in children, it also occurs in adults as well.

Post-traumatic stress disorder is a consequence of a major traumatic experience. These can include near death experiences, or severe stress encountered in circumstances such as war, rape, abuse, or other dangerous situations. People with PTSD often suffer from flashbacks and/or nightmares, and may have regular emotional disturbances or experience depression.

It is not uncommon for people to suffer from multiple anxiety disorders at the same time. Approaches to treatment and recommendations will vary depending on the underlying disorder.

Common Symptoms

Specific symptoms of anxiety may vary from person to person, but most anxiety disorders will include at least some of the symptoms listed below:

Feelings of nervousness
Nausea
Restlessness
Tension
Nausea
Jitteriness
“Butterflies in stomach” sensation
Hyperventilation
Sweating
Difficulty concentrating
Intrusive, repetitive thoughts
Rapid heart rate
Headaches
Sleeplessness
Panic

Diagnosis

The most helpful information in diagnosing anxiety disorders will be a patient’s medical history and symptoms. By asking appropriate questions, a physician can likely make a diagnosis of anxiety disorder, but they may also run some lab tests to determine if there is an underlying medical condition resulting in feelings of anxiety. To assess anxiety levels, you may be asked to fill out a questionnaire. There are multiple questionnaires which are used clinically. The questionnaire chosen may depend on the specific anxiety disorder you are suspected to have.

Hamilton Anxiety Scale: This is one of the oldest and most widely used surveys to quantify the severity of anxiety. It is short at only 14 questions long, but must be administered by a mental health professional to be considered valid.
Yale-Brown Obsessive-Compulsive Scale (YBOCS): This is a longer version of the QIDS survey listed above. Rather than 16 questions, this is a 30-question survey which provides similar information to establish a “score” and gauge severity of depression. Both surveys are clinically-validated.
Generalized Anxiety Disorder Scale: This is a brief, 7-question test for GAD to determine how frequently you have feelings of anxiety.
Beck Anxiety Inventory: A questionnaire to determine the severity of anxiety. This survey contains 21 questions which ask a person to rate severity of symptoms.
Social Phobia Inventory (SPIN): A questionnaire aimed at assessing severity of social anxiety.
Penn State Worry Questionnaire: This questionnaire helps distinguish between social anxiety and generalized anxiety disorders.

Additional lab work may be recommended to ensue there are not other underlying conditions leading to feelings of anxiety. This may include both routine bloodwork as well as diagnostic imaging tests such as MRI or CT scan. Other diagnostics that do not apply to everyone but may be conducted include:

Advanced imaging (such as CT or MRI)
Infectious Disease Testing (Lyme, Epstein-Barr, etc.)
Cancer Screening (Bloodwork, Imaging, Biopsies)

Treatment Options

Treatment for depression will depend greatly on individual patient, and not every approach can be applied to all patients. Some patients may benefit greatly from anti-depressant medications, while medication may not be appropriate or effective for others. Often, a combination of pharmaceutical approaches and non-pharmaceutical approaches are used in the management of depression. As there are many non-pharmaceutical supplements which have neurotransmitter activity, it is always important to discuss with a doctor what combinations can be safely used together. Many pharmaceutical and non-pharmaceutical options modulate serotonin in the brain, and using these agents in combination can result in a serious and possibly fatal condition called “serotonin syndrome.”

Pharmaceuticals and Medical Procedures:

There are many different medications which can be helpful in treating anxiety. Many of these medications are primarily used as anti-depressants, however they also often have effects on feelings of anxiety.

Antidepressants

- Selective serotonin reuptake inhibitors (SSRIs): This is perhaps the most commonly prescribed class of antidepressants, and includes drugs like Prozac (fluoxetine), Zoloft (sertraline), Lexapro (escitalopram), and Paxil (paroxetine) among others. They are believed to work by increasing serotonin levels in the brain without impacting other neurotransmitters. Depending on your specific combination of symptoms, different SSRIs may be considered most appropriate. Despite being antidepressants, many of these medications are effective for a variety of anxiety disorders. These medications can take weeks to begin showing effects. While they can be incredibly helpful to many people, they also often carry side effects which may make long-term therapy difficult, such as sexual dysfunction, weight gain, or feeling dull.
- Serotonin and norepinephrine reuptake inhibitors (SNRIs): These drugs increase both norepinephrine and serotonin levels in the brain. Drugs in this class include Effexor (venlafaxine) and Cymbalta (duloxetine). These drugs can also cause a diverse range of side effects including sexual dysfunction, loss of appetite, fatigue, or difficulty sleeping.
- Tricyclic antidepressants: These are older and less frequently prescribed medications due to their undesirable side effect profile. However, in some patients they may be helpful for those who have not responded to other classes of medications. Examples include nortriptyline, amitriptyline, imipramine, doxepin, and desipramine.
- Monoamine oxidase inhibitors (MAOIs): These medications prevent the breakdown of norepinephrine, serotonin, and dopamine by the enzyme monoamine oxidase. Like tricyclic anti-depressants, they are often reserved for patients who are resistant to other treatments. Because this medication inhibits an important enzyme that degrades excessive neurotransmitters, it is important for patients on these medications to avoid foods which contain excessive tyramine (an amino) acid, which causes release of epinephrine and norepinephrine. Excessive tyramine levels can result in extremely elevated blood pressure, which can have serious consequences. Foods high in tyramine include fermented products such as alcoholic beverages and aged cheeses.
Benzodiazepines: These are anxiolytic drugs which affect the gamma-amino butyric acid (GABA) receptors in the brain. They work quickly and are commonly prescribed, particularly as a rescue drug to relieve acute anxiety. Unfortunately, these drugs can be addictive. Examples include Valium (diazepam), Xanax (alprazolam) and Ativan (lorazepam).
Beta Blockers: This is a class of medications most commonly prescribed for cardiovascular reasons, however they can also help relieve some of the physiologic effects of anxiety, preventing a feed-forward cycle. They work best as a situational drug prior to an expected anxiety-inducing event, such as public speaking.
Buspirone: This is an anxiolytic medication which can be used on a regular, ongoing basis. It may take several weeks for positive effects to be observed.
Deep Brain Stimulation (DBS): In this procedure, an electrode is implanted in the brain and delivers electrical currents. By interrupting neuro-signaling, DBS can help regulate moods. It can be an effective treatment for OCD.
Transcranial Magnetic Stimulation (TMS): Magnetic pulses are transmitted into the brain, affecting neurotransmitter function. This may be effective for multiple types of anxiety disorders, including panic disorder, PTSD, and social anxiety disorder.
Vagus Nerve Stimulation: Stimulation of the vagus nerve can help reduce the fight-or-flight response that can be so overwhelming in anxiety disorders.
Electroconvulsive Therapy (ECT): Another electrical-impulse based therapy which may be helpful in breaking neurologic cycles leading to anxiety and panic.

Non-pharmaceutical options:
There are a broach range of non-pharmaceutical options, and some, such as psychotherapy, may be more important/effect than medications, although many people find optimum benefit by combining these approaches.

Psychotherapy/Cognitive Behavioral Therapy: This is an extremely important component for many people managing severe anxiety. By developing techniques which promote calm, positive thoughts, and limit anxiety-inducing thoughts, many people benefit greatly from CBT.
- Exposure Therapy: This strategy involves desensitization to an anxious stimulus through repeated exposure. Over time, the stimulus becomes less threatening and eventually does not instill fear and anxiety. Nowadays, this can sometimes be accomplished through virtual reality simulations.
- Eye Movement Desensitization and Reprocessing (EMDR): This approach can help relieve anxiety related to past traumatic experiences. Selective memories are invoked during this therapy, and specific eye movements are induced by asking the patient to track an object or the therapist’s hand. This is thought to help with processing of past traumatic events and allow cognitive healing. This has been particularly effective for PTSD patients.
- Art Therapy: Art therapy can work as a type of mindfulness and outlet for anxieties and fears.
Mind Body Techniques:
- Mindfulness/Meditation: Practicing mindfulness can be very helpful for many people who struggle with anxiety. This is a healthy coping mechanism which can be useful for self-exploration, introspection, and inducing a state of calmness. Guided meditation techniques can be useful for people trying to establish daily practice.
- Journaling: Keeping track of daily events and moods can provide an outlet for expressing emotions, rather than containing and dwelling upon them.
- Yoga: Providing exercise while simultaneously practicing focused techniques which are similar to meditation can help tremendously. As yoga is also often a group activity, this can also help provide socialization and support.
- Acupuncture: Acupuncture is applied to many health issues. May people find it helps induce states of relaxation.
- Hypnotherapy: This can be helpful for some people who are open to it and have high levels of suggestibility. The power of suggestion can be used to help improve or establish healthy habits or break the cycle of negative thoughts and emotions.
- Reflexology: This is a technique which applies pressure to various points on the feet or hands to help relieve anxiety.
- Guided Imagery: Similar to meditation, guided imagery encourages an individual to create a mental landscape of relaxation and peace. This can serve as a way to mentally escape and self-induce calmness and relaxation.
- Aerobic Exercise: Exercise is an important part of being healthy, and leads to release of adrenaline and other hormones which improve mood. Regular exercise can improve sleep patterns, increase self-esteem, and provide an outlet for nervous energy.
- Emotionally Focused Transformations (EFT): EFT uses a combination of acupressure and focused words to modulate emotions and thoughts.
- Faster Emotional Focused Transformations (Faster EFT): This is a modified EFT-technique which aims to change negative memories in more positive memories.
Supplements:
- Valerian Root: This is often used as a sleep-aid; however, it may work by relieving anxiety as well. A small study found it significantly lowered anxiety when compared to a placebo in people with generalized anxiety disorder.
- Ashwagandha: Also known as “Indian ginseng,” Ashwagandha has long been used as an “adaptogen.” These are supplements which are supposed to be helpful in managing stress. It has numerous studies supporting its use in anxiety and stress-related issues.
- CBD Oil: Oil derived from the marijuana plant, cannabidiol oil, does not contain THC but contains other cannabinoids which can exert a calming effect on the body. The legality of these compounds may vary depending on your locality, however they are increasingly available and generally don’t require a prescription.
- Passionflower: This herb has been traditionally used by Native Americans and in Peru for medicinal purposes. It has a calming effect and may boost levels of GABA, the calming neurotransmitter in the brain.
- Chamomile: Chamomile tea has a long history of use for relieving anxiety and calming the mind. It can also be taken in capsule form and has scientific studies backing its use for anxiety.
- Kava Kava: This plant has been used for centuries on the island of Fiji for relaxation. The roots of the plant can be ground up and strained in water to produce a drink which short-term anxiolytic effects.
- Omega-3 fatty acids: Deficiencies in omega-3’s has been found in patients suffering from anxiety, and supplementation may be helpful in treatment.
- L-Theanine: This is an amino acid which is found in green tea. It can have a calming effect in some people, and may be helpful when used in combination with caffeine to maintain calmness while increasing alertness.
- Melatonin: Sometimes called the sleep hormone, melatonin is important for regulating sleep/wake cycles. It can have a calming effect and help induce sleep at night.
- Vitamins D: Vitamin D may be associated with depression, especially those who are thought to be suffering from seasonal affective disorder.
- St. John’s Wort: This naturally-occurring herb has been long-used to treat depression, but may also be helpful for anxiety. It has decent scientific evidence to support it. It is believed to increase serotonin levels in the brain (possibly by functioning as an SSRI), and has been found in some studies to be as effective as the SSRI medication sertraline. It may relieve anxiety through similar mechanisms as prescription SSRIs. However, St. John’s Wort may also be associated with the development of cataracts, and combination with some anti-depressant medications or other supplements may increase the risk of serotonin syndrome. It is recommended to discuss the use of St. John’s Wort with a doctor, even though it is over-the-counter.
- Bacopa: An adaptogen like ashwagandha, bacopa may also help relieve anxiety and improve mechanisms for coping with stress. It may also improve memory and promote growth of neurons, as well.
- Magnesium: Magnesium supplementation may be helpful in the treatment of anxiety. It can induce a calming effect and may help with sleep as well.
- Lavender Oil/Silexan: Lavender has a well-known calming effect, and may be especially helpful for those who suffer from anxiety in combination with depression. A specific lavender oil extract (trade name Silexan) has been studied and found to be helpful in improving depression scores and seems to be as effective as the medication lorazepam (a benzodiazepine) at reducing anxiety.
- Ginkgo biloba: This has found some utility in people with anxiety by inducing a calming effect. The mechanism is unclear, so like other supplements listed, be used cautiously in the presence of prescription medications.
- Lemon Balm: Similar to lavender oil, lemon balm has a calming effect and may be helpful in relieving anxiety.
- Rhodiola: A natural herb with reported anxiety-relieving effects.
- Probiotics: Intestinal bacteria generate many compounds which either act directly as neurotransmitters or are later metabolized into neurotransmitters. Imbalance in gut bacteria can have detrimental impacts on the brain and psychology.
Aromatherapy: Essential oils can be effective at promoting calm and relaxed mentation.
Massage therapy: This may improve relaxation, tension, and anxiety.
Ecotherapy: Simply spending time in nature can help induce a state of calm relaxation. Removing yourself from the overstimulation of modern life can be an important alternative therapy for anxiety.
Dietary Modifications:
Incorporate more foods with anxiety-fighting compounds
Eat a balanced diet high in vegetables
Mediterranean Diet
Chelation therapy:

Heavy metals may be linked to generalized anxiety disorder and panic disorder. Chelation therapy attempts to remove these metals from the body.

Prevention

Preventing the development of anxiety can be challenging, as it can develop for unclear reasons. For other people, traumatic experiences may be the root of anxieties, or prior bad experiences. The best approaches to preventing anxiety are a clear focus on mind and body wellness. Creating time for yourself outside of work and allowing yourself opportunities to enjoy social events, be with family, and relax can be helpful at preventing some types of anxiety. Eating a well-balanced, healthy diet, exercising and getting plenty of sleep can help prevent the development of anxiety.

Many of the mind-body techniques which can be used to treat anxiety are also helpful in the prevention of anxiety. Mindfulness meditation, keeping a journal, and exposure to nature can all help prevent the development of anxiety. Additionally, avoiding or reducing alcohol and caffeine intake can go a long way towards preventing or reducing anxiety as well. Many people with substance abuse disorders develop anxiety issues related to the disturbances in the brain’s natural chemistry.

If you experience a traumatic or challenging event, being proactive by finding a therapist and discussing your feelings and emotions can be helpful. These types of events are not always avoidable in life, so when they happen, it is important to seek help in processing them in a healthy way.

Causes

The number one cause of anxiety is underlying, unmanaged stress. This stress can originate from work, difficult relationships, financial issues, the death of loved ones, or traumatic events. Anxiety can also arise from other causes, such as a side effect of certain medications (particularly stimulant medications such as those used for ADHD), or from use of drugs like cocaine, methamphetamines, alcohol, or even something as simple as caffeine. Many people with anxiety will self-medicate themselves with alcohol due to its generally calming effect, but over time this will exacerbate anxiety and lead to other related issues such as depression.

Stress from past traumatic events also can play a major role in anxiety. Post-traumatic stress disorder commonly has anxiety as a component to the condition, and it may trigger by certain things, such as loud sounds, enclosed areas, or other things which may relate to the traumatic event.

Sometimes, anxiety can be a manifestation of other medical conditions, such as a heart attack, stroke, dementia, MS, or Huntington’s Disease. There are also theories that some cases of anxiety (and depression) may be related to certain infectious diseases. Viral diseases implicated include influenza, herpes simplex, HIV, varicella-zoster (chickenpox virus), and hepatitis C. The mechanism behind viral infections and anxiety is not completely clear. In some instances, a severe infection may simply lead to hospitalization events which result in PTSD, or the psychological impact of HIV may lead to social anxiety disorders.

Bacterial disease may also be an issue. Lyme disease, which is transmitted via ticks, has been associated with panic disorders, depression, and other mental illnesses. If you live in a region in which Lyme disease is common, you should consider testing, as the treatment may require antibiotic therapy in order to fully relieve the anxiety.

There are also likely genetic components to anxiety disorders as well. A family history of anxiety is considered a risk factor for conditions like obsessive compulsive disorder. This risk increases with exposure to traumatic or stressful events in life. It may be an aberrant reaction to try and establish control within one’s life, when everything else seems to be out of control. OCD and other anxiety disorders may also occur in conjunction with other mental health issues.

Heavy metal toxicity may also be a factor for many people. Metals like mercury and lead accumulate within the central nervous system and can lead to a wide variety of neurologic signs, including anxiety. It is important to be aware of your own risk factors for heavy metal exposure, such as municipal drinking water, amalgam fillings, lead paint, etc. If this may be a possible cause for you, chelation therapy may be needed to help relief your signs.

Clinics for Management of Anxiety

Anxiety disorders are incredibly common in the United States, and there is likely a clinic near you that can help you begin to manage these conditions.

Standard Clinics

Johns Hopkins Psychiatry and Behavioral Sciences

University of California San Francisco Psychiatry Clinic

McLean Hospital (Belmont, MA)

Massachusetts General Hospital

New York Presbyterian Hospital

Alternative Clinics