Learning that you have an anxiety disorder may bring relief (finally having a name for your struggles), more questions (why me?) and more worry (not knowing what to do next). The good news is that anxiety disorders are among the most treatable.
According to Peter J. Norton, Ph.D, Director of the Anxiety Disorder Clinic at the University of Houston and co-author of The Anti-Anxiety Workbook, anxiety disorders have success rates that make other researchers jealous. The key is to get the right treatment and stick with it.
Here’s a look at what effective treatment entails, including the ins and outs of psychotherapy and medication, plus tips for finding a qualified therapist, managing panic attacks and more.
- Anxiety disorders aren’t that serious. This myth persists because “anxiety is a universal and normative emotion,” said Risa Weisberg, Ph.D, Assistant Professor (research) and Co-Director of the Brown University Program for Anxiety Research at Alpert Medical School. However, anxiety “can be a hugely distressing and impairing symptom.”
- “I can overcome this on my own.” In her research on anxiety disorders in primary care, Weisberg found that nearly half of primary care patients with anxiety disorders weren’t taking medication or attending therapy. When asked about their reasons for not engaging in treatment, one of the most common answers was that they didn’t believe in receiving these treatments for emotional problems. Anxiety disorders have a chronic course and “the bottom line is that good treatments exist, so there is no reason to suffer on your own,” Weisberg said.
- Anxiety disorders are a character defect. “Anxiety has a genetic and neurological basis,” said Tom Corboy, MFT, Director of the OCD Center of Los Angeles.
- “I need medication in order to improve.” Though medication can be effective in treating anxiety disorders, “research suggests that in many cases, cognitive-behavioral therapy (CBT) is better or just as good as CBT plus medication,” said Jon Abramowitz, Ph.D, Associate Professor at the University of North Carolina at Chapel Hill and Director of the UNC Anxiety and Stress Disorders Clinic. CBT teaches patients the skills for lasting benefits.
Disclosing Your Diagnosis
You may be unsure about sharing your diagnosis with others. Corboy suggested discussing your anxiety with individuals you trust, who have your best interests in mind. If you’re considering telling a significant other, wait “until that person has earned your trust,” he said.
A great deal of research over the past 10 to 15 years has shown that CBT is the most effective treatment for most anxiety disorders, Corboy said, making it the first line of treatment. Research also has shown that selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants and benzodiazepines are effective in treating anxiety.
Doctors usually prescribe SSRIs and SNRIs first because they’re effective, can treat depression — which often co-occurs — and tend to be better tolerated. According to the scientific literature, there’s a higher rate of relapse with medication, Norton said. The key is to supplement medication with CBT, said Peter Roy-Byrne, M.D., Professor and Chief of Psychiatry at the University of Washington at Harborview Medical Center. In fact, medication is sometimes used to facilitate psychotherapy.
The first step in CBT is to understand your anxiety, Abramowitz said. You and the therapist will work together to gain insight into how your thoughts and behaviors fuel your anxiety. “People with anxiety tend to jump to conclusions and overestimate,” he said. Behavior such as regularly rehearsing what you’re about to say actually feeds your anxiety, nourishing the belief that you can’t think on your feet and you’re a poor public speaker.
Cognitive restructuring helps patients identify their thoughts and expectations and modify problematic patterns, Abramowitz said. He pointed out that cognitive restructuring “is not the power of positive thinking; it’s the power of logical thinking.”
In exposure therapy, another CBT technique, therapists help patients face their fears in various contexts in a systematic and safe way. Together, you and your therapist create a hierarchy, listing the least anxiety-provoking situation to the greatest, and work your way up, confronting each situation.
Most CBT programs consist of 8 to 15 weekly sessions, Norton said. When individuals start to experience gains varies. At his clinic, Norton typically sees patients improve the most from the 5th to 7th session of their 12-week program. However, there’s no universal standard for staying in therapy. Weisberg recommended that patients continue with CBT until they fully understand and have mastered the above skills to manage their anxiety.
Preventing and Overcoming a Lapse
It’s not uncommon to experience a resurgence of symptoms—a lapse—after treatment, especially during stressful times, Abramowitz said. “We want people to recognize that this is entirely normal.” CBT helps clients recognize signs of an impending episode so that they can take action to prevent it, Norton said. Usually, this involves creating a plan with a series of signs — like not leaving the house for two days — and actionable steps — like reviewing your anxiety workbook or calling your old therapist.
“This helps prevent a lapse from turning into a relapse,” Norton said. Whereas a lapse is a hiccup — like having a double cheeseburger when trying to eat healthy — a full relapse involves reverting to old patterns, where anxiety and avoidance dominate your life, he said. If you do experience a relapse, you may need several booster sessions.
So the work doesn’t just stop at the end of therapy. Norton likened this to reaching a healthy weight: You don’t stop exercising and eating well after getting to your goal weight. Norton helps his patients develop long-term plans for managing and challenging their anxiety. For a socially anxious person, part of the plan may include signing up for Toastmasters, an organization that helps members develop their public speaking and leadership skills in a nonthreatening environment.
Common Challenges in Psychotherapy
- Lack of time and energy. Weisberg’s research found that a large proportion of patients believed that they were too busy for psychotherapy. Corboy sees many successful clients who work 60 to 70 hours a week while raising families. Yet, others might have so much on their plate — barely making ends meet, no babysitter — that they can’t attend therapy in the first place. Norton usually refers these patients to a psychiatrist for pharmacological treatment and asks them to stay in touch as things ease up. For patients who have milder symptoms, Norton recommends purchasing a self-help anxiety workbook—preferably one grounded in CBT—and creating their own hierarchy. Some workbooks still rely heavily on relaxation techniques, which are a good way to reduce anxiety in the moment but not long-term, Norton said.
- Active participation. In the beginning, patients may not be used to actively learning and practicing new skills. CBT requires a strong commitment and lots of work outside of therapy, Abramowitz said.
- Tackling anxiety head-on. To effectively treat anxiety, you have to be willing to confront your fears, so you may feel worse before you feel better. This means challenging anxiety “on a regular basis, between sessions,” Corboy said. The one hour in therapy pales in comparison to the other 167 hours in a week.
If you’re having an especially difficult time applying the skills you learn in therapy, discuss it with your therapist. It might be that the exposure task is too frightening at this time, and your therapist may need to adapt it. Also, “it may be empowering to realize that avoidance is actually a choice,” Weisberg said. “Although no one chooses to have an anxiety disorder, they do choose to avoid certain things.” Weisberg works with patients to help them decide if they’d rather experience anxiety for several weeks during exposure therapy or live without ever doing a particular task. Facing your fears in the present leads to a calmer future, Abramowitz said.
Finding a Therapist
Because CBT is the gold standard for treating anxiety disorders, it’s important to find a therapist who’s well-trained in the technique and has extensive experience working with patients with anxiety disorders. Here are several suggestions for finding a qualified therapist:
- Visit the therapist finders at the Association for Behavioral and Cognitive Therapy for CBT-trained therapists and the Anxiety Disorders Association of America. Therapists listed on ADAA don’t necessarily specialize in CBT. Also, check whether your local university offers special services, which tend to be inexpensive treatments that use cutting-edge techniques, Norton said.
- Familiarize yourself with CBT. Dr. Roy-Byrne suggested reading a CBT patient manual from the series Treatments that Work. This will give you a good idea about what to expect from treatment and the kinds of questions to ask therapists.
- When speaking with a therapist on the phone, ask how he or she will treat your anxiety disorder, Abramowitz said. Does it line up with what you’ve read? He suggested also asking: How many patients with anxiety disorders have you worked with? What kind of training have you had in treating anxiety disorders and CBT? Attending several workshops isn’t enough. “You don’t learn CBT in a day; it takes years,” Abramowitz said.
The type of anxiety disorder, its severity, the presence of co-occurring disorders and level of distress typically will guide the medication you’re prescribed, the starting dose and the length of treatment. For someone with panic disorder, physicians usually prescribe a low dose of a SSRI — lower than that for depression or social anxiety disorder — because these patients are particularly sensitive to the effects of medication, said Michael R. Liebowitz, M.D., Professor of Clinical Psychiatry at Columbia University and Managing Director of The Medical Research Network.
In principle, patients take medication for about a year, but in practice, this can be longer, Dr. Roy-Byrne said. If someone is experiencing stress and still has some co-occurring anxiety, phobic or depressive symptoms, it’s very likely he or she will relapse after stopping medication, he said. Some anxiety disorders, such as obsessive-compulsive disorder (OCD), generally take longer to treat, Dr. Liebowitz said.
For more information on medication, see here. If you can’t afford medication, consider participating in clinical trials. In Dr. Liebowitz’s studies, participants receive six months of free treatment after completing the clinical trials.
Concerns about Medication
Concerns about side effects and withdrawal are common. Patients often worry that taking medication is somehow artificial, and some turn to herbal supplements and drugs like marijuana, Dr. Liebowitz said. The truth is exactly opposite: Medication serves as a correction. It doesn’t introduce new chemicals into the brain, but instead alters the level of certain neurotransmitters, Dr. Liebowitz said.
SSRIs, the first line of treatment, can cause insomnia, sexual dysfunction and weight gain. If a medication is helpful, the prescribing physician can help you work around these side effects. One way is to adjust the time you take the medication: If you’re experiencing insomnia, you may take medication during the day or at night if you’re drowsy, Dr. Liebowitz said. If weight gain is an issue, you may need to watch your calories and exercise regularly.
“Because medication causes neurochemical changes in the brain, you may experience some withdrawal symptoms after discontinuing use, as the brain re-adjusts itself to the lack of medication,” Dr. Roy-Byrne said. This is true of all medication, he said, not just that for psychiatric disorders.
Abruptly discontinuing medication can have fairly potent effects, even with SSRIs, according to Dr. Liebowitz. Slowly tapering off the dose under a physician’s guidance reduces these problems.
Dr. Liebowitz recalled helping a patient taper off 40 mg of Paxil. The patient gradually went from 40 mg to 10 mg without trouble; however, going from 10 to 0 caused the patient dizziness and discomfort. After informing Dr. Liebowitz, he and the patient agreed to adjust the dose to 10 mg every second day for several weeks. Communicating with your doctor about your progress and any problems is vital to your treatment.
In addition to tapering off the medication, your physician may prescribe another medication to ease discontinuation syndrome. For patients taking Paxil, Dr. Roy-Byrne adds Prozac. They stop taking Paxil but continue taking Prozac for about six weeks before quickly tapering off this over a few days. (Prozac has a very short half-life, or the time it takes for a drug to lose half its activity in the bloodstream, thus making it ideal in such situations.) Using this technique can eliminate withdrawal symptoms, Dr. Roy-Byrne said.
And it may not be withdrawal after all. Patients can mistake the original anxiety for withdrawal symptoms. “If you stop an anxiety drug, the anxiety may come back, and with the passage of time, it could be worse than before,” Dr. Roy-Byrne said.
Tips for Taking Medication
- Before. Weisberg has seen many patients accept a prescription without asking many questions or without knowing what symptoms or disorder the medication is supposed to be treating. Remember that you and your prescribing physician are a “health care team,” she said. Before taking medication, Dr. Roy-Byrne and Dr. Liebowitz suggested asking the following:
- What is my diagnosis?
- What are my treatment options, including medication and psychotherapy?
- How will I know if this medication is working?
- What are the side effects, and what do I do if I experience them?
- When will the medication start to work?
- How long will I have to take it?
- If I take it for X amount of time, what’s the likelihood of reducing symptoms?
- What are the dose requirements?
- Will you be monitoring me throughout the course of this medication?
- When will you talk to me next?
- During. Dr. Roy-Byrne has patients keep track of symptoms and side effects using a rating scale. Recording your reactions to medication lets you and your doctor know if you’re getting better, whether your health problem is anxiety or high blood pressure. “I want to know if you’re 20, 40, 60 percent better, so I can know what to do next,” Dr. Roy-Byrne said. He also has his patients monitor their symptoms before they start medication, so they don’t attribute natural changes in their anxiety to the medication. “This is consistent with ‘measurement-based care,’ which is becoming the state-of-the-art approach to monitoring treatments and their outcomes,” he said.
- Other tips. Avoid skipping your medication and make sure you don’t run out, Dr. Liebowitz said. If you go away for the weekend and leave your pills at home, call your physician for an emergency prescription. For additional advice, see here.
Managing Panic Attacks
Patients can suffer panic attacks with any anxiety disorder. Corboy suggested four steps in managing them:
- Accept the anxiety. Individuals with an anxiety disorder become exceedingly sensitive to anxiety. “At the first hint of anxiety, they often become terrified that a panic attack is imminent,” Corboy said. Accepting that anxiety exists doesn’t mean liking it or resigning yourself to being anxious forever; “it just means accepting reality as it is.”
- Challenge distorted thoughts. People often interpret a panic attack as a significant threat, but it’s important to realize that “nothing catastrophic is going to occur as a result of being anxious or even panicking.”
- Breathe. Instead of hyperventilating, which energizes anxiety, “make a point of consciously breathing.”
- Resist the urge to flee. Running away from anxiety only reinforces the idea that you’re unable to handle it and that escaping the situation is your best solution. Instead, a long-term solution is to “learn that we can tolerate the discomfort, that it won’t hurt us and that it will naturally dissipate over time if we sit with it.”
Pitfalls and Pointers
You may hit some snags as you work toward managing your anxiety. Here’s a list of common ones and practical solutions for them:
- Keeping symptoms to yourself. A primary care physician can’t make a proper diagnosis or treatment recommendation without having all the information.
“If you have been feeling uncontrollably worried, anxious, fearful, have been having panic attacks, or have found that you are avoiding things that are important to you or to those around you because of fear – tell your doctor,” Weisberg said.
- Fighting anxiety as if it were your adversary. It’s important to understand that anxiety is a helpful response and a normal part of life, Abramowitz said.
- Masking it. Whether it’s alcohol, illicit drugs or benzodiazepines (such as Xanax or Ativan), these substances offer short-term relief and are akin to running away from anxiety, Abramowitz said. Because benzodiazepines quell anxiety quickly and strongly, they can increase avoidance and impair your ability to overcome anxiety-provoking situations, Dr. Roy-Byrne said.
Instead of pursuing what maintains your anxiety — avoidance — face your fears directly with the help of a therapist.
- Giving up too quickly. Whether it’s medication or CBT, these interventions “can take a while to work,” Weisberg said. “Keep your long-term goals clearly in mind, giving each treatment enough time and effort.”
- Being too motivated. Jumping in head-first isn’t recommended either, Norton said. Instead of sprinting through treatment, give it time to sink in and strike a balance.
- Have realistic expectations. It’s unrealistic to think that you’ll eliminate anxiety forever. Instead, realize that you’ll be able to manage symptoms and stop avoiding certain situations.
- See stress as normal. It’s normal to feel stressed. You can’t fight stress, but you can work through it, Abramowitz said.
- Adopt a balanced approach. Rather than overestimating the magnitude of a situation, “step back and look at things in a more objective light,” Abramowitz said. Instead of thinking that you’ll lose your savings in today’s shaky economy, consider that the market will return and focus on the steps you can control to manage your money.
- Adopt an anxiety-free lifestyle. In The Anti-Anxiety Workbook, Norton includes the ingredients for an anxiety-free life: adequate sleep; a balanced diet (think food pyramid, not diets that delete food groups); exercise and a solid support system, all of which are powerful in decreasing anxiety. Like a pricey car that needs high-grade gasoline to run optimally, our incredibly efficient body functions better with the right nutrients, Norton said.
How we treat our bodies also directly affects anxiety sensations. Being out of shape can make your heart race even when you’re just walking. Caffeine and poor nutrition can amplify anxiety, producing jitteriness and trembling. Simply curtailing one’s caffeine intake can be helpful, Norton said.
For more information on anxiety disorders, see Psych Central’s resources at http://psychcentral.com/disorders/anxiety/
Tartakovsky, M. (2009). Living with an Anxiety Disorder. Psych Central. Retrieved on October 2, 2014, from http://psychcentral.com/lib/living-with-an-anxiety-disorder/0002118
Last reviewed: By John M. Grohol, Psy.D. on 30 Jan 2013
Published on PsychCentral.com. All rights reserved.