US Pharm. 2006;11:HS-3-HS-13.
Anxiety
is a normal reaction that helps people cope with stress associated with daily
life and difficult situations. However, when anxiety becomes irrational and
excessive in day-to-day life, it becomes a disorder. Anxiety disorders are
serious medical illnesses that affect approximately 40 million American adults.
1 These disorders fill people's lives with overwhelming anxiety,
frustration, and fear. Unlike the relatively mild, brief anxiety caused by a
stressful event, such as a business presentation, an examination, or a job
interview, anxiety disorders are chronic and bothersome and can grow
progressively worse.
The good news is that the
majority of these disorders can be treated, and research is focusing on
creating new therapies designed to help people with anxiety disorders lead
productive and satisfactory lives.1 Treatments include medications,
behavioral therapy, and cognitive therapy; relaxation techniques, lifestyle
changes, healthy diet, aromatherapy, exercise, and herbal therapies have also
been recommended for anxiety.
NIH's National Institute of
Mental Health supports scientific investigation into the causes, diagnosis,
treatment, and prevention of anxiety disorders and other mental illnesses.
Anxiety disorders are complex and probably result from a combination of
genetic, behavioral, developmental, and other factors.1,2 This
article provides an overview of panic disorder, anxious depression,
obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD),
social anxiety disorder, specific phobias, and generalized anxiety disorder
(GAD). Each anxiety disorder has its own characteristics, but they are all
bound together by the common theme of excessive, irrational fear and dread.
Types of Disorders
Panic Disorder
Panic disorder
affects about six million adult Americans and is common in both men
and women. It most often begins during late adolescence or early adulthood and
typically manifests as panic attacks or sudden fear due to stressors. Although
many people have one attack and never experience another, those who have panic
disorders should seek treatment before the condition becomes disabling.
Correct diagnosis of this disorder is imperative, as a patient may have it for
years before learning that he or she has a real, but treatable, illness.1
Many people with panic
disorder try to avoid the place or situation in which their first episode or
panic attack occurred. This may seriously interfere with daily activities,
leaving the patient homebound in severe cases. When a patient's life become so
restricted, as happens in about one third of cases of panic disorder, the
condition is called agoraphobia.2 As a patient with
agoraphobia cannot predict when an attack will occur, he or she may develop
intense anxiety between episodes, worrying when and where the next one will
strike. Early treatment of panic disorder can often prevent this disabling
condition.2
A panic attack may start with
a pounding heart, sweats, weakness, faintness, or dizziness. Numbness of the
hands, flushing, and/or chills may follow. Sometimes, people may genuinely
believe they are having a heart attack, losing their mind, or on the verge of
death. Panic attacks can occur at any time, even during sleep. An attack
generally peaks within 10 minutes, but some symptoms may last much longer.
Panic disorder is one of the most treatable of the anxiety disorders, as it
responds to medications or psychotherapy in most cases.
Anxious Depression
Depression and
anxiety disorders are not the same, but they seem similar at first glance.
Both involve the body, mood, and thoughts. In fact, depressive disorders often
accompany anxiety disorders. Depressed people are sad, hopeless, or
disappointed and have difficulty concentrating. They have less energy and are
overwhelmed by the day-to-day activities. In contrast, those with anxiety
disorder experience fear, panic, or anxiety in situations that most people do
not find threatening. Without treatment, anxiety and depression can restrict a
person's ability to work, maintain relationships, or even leave the house.
Because anxiety is so often associated with depressive disorders, it is
essential to treat the underlying depression along with the anxiety. When the
depression is resolved, anxiety symptoms often diminish.3
Obsessive-Compulsive
Disorder
OCD involves
persistent unwanted thoughts (obsessions) and/or repetitive behaviors
(compulsions). A lot of healthy people have some OCD symptoms, such as
doubting that they have locked doors or turned off the oven before leaving the
house; however, in patients with OCD, these behaviors along with others (e.g.,
hand washing, ordering, checking, counting, and silently repeating words) take
longer, cause extreme distress, and interfere with daily life.
OCD affects about 2.2 million
American adults. It strikes men and women in approximately equal numbers and
usually first appears in childhood, adolescence, or early adulthood. One third
of adults with this disorder report having experienced their first symptoms as
children. The course of the disease is variable--symptoms may come and go, ease
over time, or grow progressively worse. Research evidence suggests that OCD
might run in families.1
Depression or other anxiety
disorders may accompany OCD, and some people may develop eating disorders that
affect their general health. In addition, people with OCD may avoid situations
in which they might have to confront their obsessions or use alcohol or drugs
to calm themselves. If OCD becomes severe enough, it can keep a patient from
holding down a job or from carrying out normal responsibilities at home. This
disorder generally responds well to medication or psychotherapy.4
Posttraumatic Stress
Disorder
PTSD may occur in
people who have experienced, witnessed, or been confronted by an event or
events that involved death of others or threatened death or serious injury to
themselves or others.1 In such cases, the person experiences
intense fear, helplessness, or horror. In children, this may cause
disorganized or agitated behavior. PTSD was first brought to public attention
when it was described and diagnosed in war veterans, but it can result from
any number of traumatic incidents, including violent attacks, such as rape;
torture; kidnapping or being held captive; child abuse; serious car or train
accidents; and natural disasters, such as floods or earthquakes. For instance,
the September 11, 2001, terrorist attacks and the tsunami that hit South and
Southeast Asia on December 26, 2004, triggered PTSD in many victims.
Regardless of the triggering
event, PTSD can cause those affected with it to repeatedly remember the trauma
in the form of nightmares, to experience problems with sleep at night and
disorganization during the day, and to avoid certain places or situations that
bring back those memories. In severe cases, the person may have trouble
working or socializing. The disorder is often accompanied by depression,
substance abuse, or one or more other anxiety disorders.5
PTSD affects about 7.7 million
adult Americans, but not every traumatized person experiences full-blown
disease. PTSD is diagnosed only if the symptoms last more than a month. In
those who do develop PTSD, symptoms usually begin within three months of the
trauma and undergo a varying course. Some people recover within six months,
while others have symptoms that last much longer. In some cases, the condition
may be chronic or surface years after the traumatic event. Those with PTSD can
be helped by medications and careful psychotherapy.6
Social Anxiety Disorder
People with social
phobia have a persistent, intense, and chronic fear of being watched and
judged by others and are embarrassed or humiliated by their own actions. Their
fear may be so severe that it interferes with work or school and other daily
activities. Even though their actions may be excessive and unreasonable, they
are unable to overcome their phobia. People with social phobia often worry for
days or weeks in advance of a dreaded situation.
Social phobia can be limited
to only one type of situation--such as speaking in formal or informal
situations--but it may be so broad that people experience symptoms almost
anytime they are around other people, possibly keeping them from going to work
or school on some days. Many people with this illness have difficulty making
and keeping friends. Physical symptoms often accompany the intense anxiety of
social phobia and include blushing, profuse sweating, trembling, nausea, and
difficulty talking.
Social phobia affects about 15
million adult Americans. Women and men are equally affected. The disorder
usually begins in childhood or early adolescence, and there is some evidence
that genetic factors are involved. Social phobia often occurs along with other
anxiety disorders or depression. Substance abuse or dependence may develop in
those who attempt to "self-medicate" their social phobia by drinking or using
drugs. Social phobia can be treated successfully with psychotherapy or
medications.1,7
Specific Phobias
A specific phobia
is an intense, irrational fear of something that poses little or no actual
danger. Some of the more common specific phobias are fear of heights
(altophobia), darkness (lygophobia), fire (pyrophobia), making changes
(tropophobia), water (aquaphobia), flying (aviatophobia), dogs (kynophobia),
and injuries involving blood (hemaphobia). Although adults with phobias
realize that their fears are irrational, they often find that facing, or even
thinking about facing, the feared object or situation brings on a panic attack
or severe anxiety.1,8
Specific phobias affect an
estimated 19 million adult Americans and are twice as common in
women as in men. The causes of specific phobias are not well understood,
although there is some evidence that phobias run in families. Specific phobias
usually appear during childhood or adolescence and persist into adulthood.
If the object of the phobia is
easy to avoid, people with specific phobias may not feel the need to seek
treatment. In some cases, phobias can be disabling and greatly interfere with
daily life, causing people to make important career or personal decisions to
avoid a phobic situation. Specific phobias are highly treatable with carefully
targeted psychotherapy.1,9
Generalized Anxiety Disorder
GAD is associated
with irregular levels of neurotransmitters in the brain. People with GAD
always anticipate disaster, often worrying excessively about health, money,
family, or work. Their fear is much greater than the normal levels of anxiety
that people experience day to day. GAD is chronic and involves exaggerated
worry and tension, even though there is little or nothing to cause it. Simply
the thought of getting through the day provokes anxiety. Generalized or
free-floating anxiety is distinguished from phobia because it is not
triggered by a specific object or situation.
People with GAD usually
realize that their anxiety is more intense than the situation warrants, but
their worries are accompanied by physical symptoms, especially fatigue,
headaches, muscle tension, muscle aches, difficulty swallowing, trembling,
twitching, irritability, sweating, and hot flashes. They have difficulty
concentrating and often have trouble falling or staying asleep.
Unlike other anxiety
disorders, people with GAD do not avoid certain situations as a result of
their disorder. In mild cases, people with the disorder may be able to
function in social settings or on the job; however, severe GAD can be
disabling, making it difficult to carry out even the most ordinary daily
activities.
GAD affects about 6.8 million
adult Americans and about twice as many women as men. The disorder comes on
gradually and can begin at any point, although the risk is highest between
childhood and middle age. It is diagnosed when a person has been worrying
excessively about a number of everyday problems for at least six months. There
is evidence that genetics have a modest role in GAD.
GAD is commonly treated with
medications. As GAD rarely occurs alone, accompanying conditions, such as
anxiety disorder, depression, or substance abuse, must be treated along with
it.9
Treatment of Anxiety
Disorders
Effective therapies
have been developed for each specific anxiety disorder. In general, there are
two types of treatment for anxiety disorders: medication and talk therapy, a
specific type of psychotherapy. The decision to use one or both treatments
depends on the patient, the physician, the particular anxiety disorder, and
any previous treatments. For example, only psychotherapy has been found
effective for specific phobias.
In each case, the treatment
depends upon a number of preliminary findings. The first consideration is
whether symptoms are truly due to an anxiety disorder, and if so, which one.
The next consideration is whether there are any coexisting conditions.
Sometimes alcoholism or another coexisting condition must be treated at the
same time as or before the anxiety disorder.
It is important that the
patient and the health care professionals treating him or her work as a team
to find the best approach. If one treatment does not work, another existing
one may work. Furthermore, new treatments are always being developed.
Medications
Medications will
not cure an anxiety disorder, but they can keep the symptoms under control and
enable the patient to lead a normal and satisfactory life. The major classes
of medications used for various anxiety disorders are discussed below.
Tricyclic
Antidepressants:
These medications were originally approved for treatment of depression, but
they have also been found to be effective for anxiety disorders. They are
initiated at low doses and gradually increased. These drugs are the oldest in
the group; many physicians and patients prefer the newer drugs, as tricyclics
sometimes cause dizziness, drowsiness, dry mouth, and weight gain. When these
problems persist or are bothersome, a change in dosage or a switch in
medications may be needed. In addition, tricyclics take several weeks to show
their effects. Health care professionals should remind patients not to get
discouraged and stop taking these medications before they have had a chance to
work. Tricyclics are useful in treating people with co-occurring anxiety
disorders and depression. Clomipramine, the only antidepressant in its class
prescribed for OCD, and imipramine, prescribed for panic disorder and GAD, are
examples of tricyclics.1,10
Selective Serotonin
Reuptake Inhibitors:
Newer than tricyclics, selective serotonin reuptake inhibitors (SSRIs) have
fewer side effects and are better tolerated. They block reuptake of serotonin
and have fewer effects on histaminergic and muscarinic receptors. Their
once-daily dosing (with the exception of fluvoxamine) enhances compliance even
in the presence of comorbid medical illness. SSRIs have fewer drug
interactions than do older antidepressants, and even the SSRI inhibition of
hepatic cytochrome P-450 enzymes is rarely of clinical importance. An
adjustment in dosage or a switch to another SSRI will usually resolve
bothersome adverse effects.
Fluoxetine, sertraline,
fluvoxamine, paroxetine, and citalopram are among the SSRIs commonly
prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are often
used to treat people who have panic disorder in combination with OCD, social
phobia, or depression. Venlafaxine, a drug closely related to the SSRIs, is
useful for treating GAD. These medications are started at a low dose and
gradually increased until they reach a therapeutic level.1,10
Monoamine Oxidase
Inhibitors: Monoamine
oxidase inhibitors (MAOIs) are the oldest class of antidepressants. Phenelzine
is the most commonly prescribed MAOI and is used to treat panic disorder and
social phobia; tranylcypromine and isoprocarboxazide are prescribed for
anxiety disorders. People who take MAOIs must follow a restrictive diet, as
these medications can interact with foods and beverages that contain a
chemical called tyramine (e.g., cheese, red wine).1,10
Benzodiazepines:
High-potency benzodiazepines relieve symptoms quickly and are associated with
few side effects, although drowsiness can be a problem. People can develop a
tolerance to them and have to continue increasing the dosage to get the same
effect. Benzodiazepines are generally prescribed for short periods of time,
although they are prescribed for six months to a year when they are used to
treat panic disorder. People who have had problems with drug or alcohol abuse
are not usually good candidates for these medications, because they may become
dependent on them.
Some people experience
withdrawal symptoms when they stop taking benzodiazepines, although reducing
the dosage gradually can diminish those symptoms. In some instances, the
symptoms of anxiety rebound after these medications are stopped.
Benzodiazepines include
clonazepam, which is used for social phobia and GAD; alprazolam, which is
prescribed for panic disorder and GAD; and lorazepam, which is also useful for
panic disorder.
Buspirone:
Buspirone, a member of a class of drugs called azipirones, has been
used to treat GAD since 1986. It is not known how buspirone works in the body
to reduce symptoms of anxiety. Possible side effects include dizziness,
headaches, and nausea. Unlike the benzodiazepines, buspirone must be taken
consistently for at least two weeks to achieve an anti-anxiety effect.1,10
Psychotherapy
Psychotherapy
involves talking with a trained mental health professional, such as a
psychiatrist, psychologist, social worker, or counselor, to learn how to deal
with problems such as anxiety disorders.
Cognitive Behavioral
Therapy: Effective
for several anxiety disorders, cognitive behavioral therapy (CBT) is
particularly helpful in treating panic disorder and social phobia. The
cognitivecomponent helps people change thinking patterns that keep them
from overcoming their fears. The behavioral component seeks to change
people's reactions to anxiety-provoking situations. A key element of this
component is exposure, or having people confront the things they fear.
For instance, exposure and response prevention is used to treat people with
OCD. If the person has a fear of dirt and germs, the therapist may encourage
allowing the person's hands to remain dirty without washing for a certain
period. The therapist helps the patient cope with the resultant anxiety. After
the exercise has been repeated a number of times, the anxiety diminishes.
Another behavioral technique is to teach the patient deep breathing as an aid
to relaxation and anxiety management.1
Behavioral therapy must be
directed at the person's specific anxieties. These therapies have no adverse
side effects other than the temporary discomfort of increased anxiety, and
they require that the therapist be well trained in the techniques in order to
produce results.
CBT or behavioral therapy
generally lasts about 12 weeks. Group therapy is particularly effective for
people with social phobia. There is some evidence that the beneficial effects
of CBT last longer than those of medications for people with panic disorder,
OCD, PTSD, and social phobia.1,3
Medication may be combined
with psychotherapy, and for many people, this is the best approach to
treatment. Recurrences of anxiety can also be treated effectively and are
managed in the same way as initial episodes. The skills learned in dealing
with the initial episode can be helpful in coping with future anxiety.
Stress Reduction Techniques
Mind/body breathing
exercises, physical exercise, yoga, tai chi, self-hypnosis, massage, and
meditation are just some of the stress reduction techniques used for anxiety
disorders. People should try these different techniques and determine which
routine they can stick with even when their schedule becomes more hectic.
Conclusion
Many people with
anxiety disorders benefit from joining a self-help group and sharing their
problems and achievements with others. The family is of great importance in
the recovery of a person with an anxiety disorder. If the family tends to
trivialize the disorder or demand improvement without treatment, the affected
person will suffer.
In addition to medication
therapy, stress management techniques, meditation, and psychotherapy are the
cornerstones of therapy in certain anxiety disorders. There is preliminary
evidence that aerobic exercise may be of value, and it is known that caffeine,
refined sugar, illicit drugs, and even some OTC cold medications can aggravate
the symptoms of an anxiety disorder. Pharmacists have a crucial role and an
exceptional opportunity in evaluating their patients' anxiety disorders and
providing counseling to patients taking anxiety medications.
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editor@uspharmacist.com.
Published November 22, 2006