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Sep 7, 2022

Mental Health

Anxiety

Three Major Forms of Anxiety

Anxiety types:Generalized anxiety disorder    Social anxiety   Panic disorder

Learn about anxiety medications: escitalopram    paroxetine    venlafaxine duloxetine    amitriptyline    sertraline    fluoxetine

Anxiety is the most common mental illness in the United States, and possibly even in the world. Everyone feels nervous from time to time, whether it’s nervousness about an upcoming social event, a work presentation, or even something larger like moving to a new city. This feeling is normal. Fear is a common and even healthy emotion to feel on occasion. However, when this nervousness or feeling of being on edge occurs most days and lasts for 6 months or longer, it is no longer a healthy response to a situation and may be classified as an anxiety disorder.

Anxiety is often described as “inappropriate” fear. For example, if you were walking into the woods and came across a bear and felt fear, this would be a healthy response as it tells you that you are in danger and you have to respond quickly to the situation. However, it’s not healthy if you go about your day-to-day life with that same feeling of terror just in case you run into a bear. When this restlessness and anxiety starts to interfere with your life, this is when it is time to seek treatment.

There are many different types of anxiety, with different kinds of symptoms and triggers. The most common form of anxiety is generalized anxiety disorder (GAD), but there is also social anxiety (SA), and panic disorder (PA). There are even more branches of anxiety, but these are the most commonly encountered conditions.

Generalized Anxiety Disorder (GAD)

GAD is the most common of all the anxiety disorders. This anxiety disorder is more “generalized”, as the name implies. It is characterized by an excessive amount of worry and nervousness about multiple different activities or situations on most days for at least 6 months.

Signs and Symptoms

Anxiety can present in many various ways, both mentally and physically. While the mental illness is psychological, it is a real illness and therefore can lead to actual physical symptoms.

Psychological symptoms:
  • Excessive worrying about multiple different things
  • Difficulty in controlling your worrying
  • Feeling restless or on edge
  • Difficulty concentrating
  • Feeling irritable
Physical symptoms:

Because of how intense the psychological symptoms can be, anxiety can begin showing up in physical ways. A physical illness must be ruled out in order for these symptoms to be deemed as caused by anxiety. Common physical symptoms include:

  • Muscle tension and pain
  • Tiredness
  • Stomach pain/nausea
  • Sleeping a lot or very little
  • Fidgeting/being unable to sit still

Diagnosing Generalized Anxiety Disorder

If you are concerned that you might have generalized anxiety disorder, it’s important to speak with your healthcare provider. They will then speak with you about your past and present symptoms and medical history, both physical and mental. They will also ask about family history, as there is a strong genetic component to mental illness.

Before making a diagnosis, your healthcare provider will make sure to rule out any other medical conditions with a medical exam and bloodwork. This is because there are other medical conditions that can present in a similar way to GAD, such as thyroid disease or even diabetes.

Once other medical conditions have been ruled out, your healthcare provider may ask you to fill out a diagnostic tool called the “GAD 7”. This is a survey that assesses the different symptoms associated with anxiety and helps to make a GAD diagnosis. The tool has 7 sections about how you have been feeling and reacting in the past 2 weeks, with each feeling/situation rated on a scale from 0 points (not at all) to 3 points (nearly every day). The sections include “feeling nervous, anxious or on edge”, “becoming easily annoyed or irritable”, and “worrying too much about different things”. The score will then be totaled, and your healthcare provider will use this number to help assess if you have anxiety, and if so, how severe it is.

Once you have been diagnosed with GAD, your healthcare provider will determine the appropriate treatment to follow. With minor anxiety, you will usually begin with psychological treatment including following self-help apps or speaking with a counsellor. If this does not help, or if the anxiety is severe, it is also possible to include medication.

Non-medication Management

There are multiple tiers of non-medication related management of GAD. Many people with anxiety struggle to seek help because they feel nervous about speaking to others about their anxiety. Because of this, many techniques are self-directed and don’t require involvement of others.

Self-directed Management

Resources to learn more about self-directed techniques can be found anywhere; in books, on the internet, and as many people prefer, anxiety reduction apps on smartphones. The type of management that these resources give includes:

  • Learning stress reduction techniques
  • Altering your lifestyle
    —Cutting back on/cutting out caffeine
    —Increase in aerobic exercise
    —Minimize alcohol consumption
    —An effort to maintain a balanced lifestyle (work, school, friends, family balance)
  • Learning grounding techniques
  • Meditation
Professional Mental Health Management

he next step if these techniques are not beneficial would be to involve a mental health professional, such as a counsellor, psychologist, or therapist. Each type of mental healthcare provider has their own benefit, and it’s something you would discuss with your healthcare provider to determine which professional would best fit your needs. The different types of therapy offered by each provider will fit the differing needs of each individual based on their presentation of anxiety. Some types of therapy include, but are not limited to:

  • Cognitive behavioural therapy (CBT)
    —This works to change thought patterns and therefore help reduce anxiety
  • Exposure therapy
    —This involves “facing your fears” in hopes that anxiety causing triggers will no longer cause
  • Interpersonal therapy (IPT)
    —This therapy has a major focus on improving relationships with others and interpersonal aspects of life.
  • Dialectical behavioural therapy (DBT)
    —This is a similar therapy to CBT, but has more of a focus on accepting and then coping with and minimizing extreme emotions
  • Psychodynamic psychotherapy
    —This aims to analyze the roots of what may have caused your anxiety in hopes to be able to then reflect and work through these issues to resolve anxiety.

The next step in treatment for GAD is medication. There are a large number of medications that are available for anxiety, though many of them were originally formulated to treat other mental illnesses. Medication can be used as a “crutch” while in a state of extreme anxiety, in order to help you cope and sort through some of the more difficult aspects of life. Then when you feel as if you have a solid base beneath you, the medication can sometimes be weaned off. Other times, people prefer to stay on medication indefinitely. This is a very personal decision that will be determined between you and your healthcare provider.

Medication for Generalized Anxiety Disorder

The most common medications prescribed for treatment of GAD are antidepressants. They have a similar effect on anxiety as they do depression, which makes them a perfect drug for those with comorbid anxiety and depression, which is very common.

Types of Anti-depressants for Anxiety:

  • SSRIs (serotonin selective reuptake inhibitors)
    • These medications work by stopping the reuptake (and therefore stopping the breakdown) of serotonin and therefore giving it more time to send signals. Serotonin is a “happy” chemical, so having it around longer allows it to have positive effects on your mood and emotions, including reducing anxiety.
    • Examples of SSRIs include escitalopram and paroxetine.
  • SNRIs (serotonin norepinephrine reuptake inhibitors)
    • These medications stop the reuptake of both serotonin and norepinephrine (the fight or flight chemical). The serotonin once again has more time to regulate emotions, but with SNRIs the norepinephrine also helps you react appropriately to stress and anxiety.
    • Examples of SNRIs include venlafaxine and duloxetine.
  • Learn about the difference between SSRIs and SNRIs

  • TCAs (tricyclic antidepressants)
    • These medications are not as common anymore, but act to increase levels of both norepinephrine and serotonin, as well as decrease the amount of acetylcholine (a chemical which regularly increases the sensitivity to external stimulation). In combination, this therefore increases mood regulation while decreasing sensitivity to triggers which would typically cause anxiety.
    • The most common TCA is amitriptyline, which is indicated for the treatment of combination anxiety and depression.
  • MAOIs (monoamine oxidase inhibitors)
    • These medications reduce the amount of monoamine oxidase in your brain, which is a substance that normally breaks down serotonin, norepinephrine, and dopamine (the pleasure chemical). A reduced breakdown of these chemicals therefore allows for better mood regulation and reduced anxiety.
    • The most common MAOI is phenelzine, which is used to treat a combination of depression and anxiety.
Second-line or Adjunctive Medication Therapy
  • Benzodiazepines
    • These are potent anti-anxiety medications used during acute attacks of anxiety as they very effectively calm you down. Benzodiazepines should not be used long-term as they are very addictive and can end up causing more problems than what they were initially prescribed to treat.
    • Common benzodiazepines prescribed to treat anxiety include lorazepam and diazepam.
  • Antipsychotics
    • Antipsychotics are usually prescribed for mental illnesses involving psychotic symptoms like hallucinations and disordered thinking. These medications may also help anxiety by “calming down” the thoughts and prevent overactivity in the brain.
    • Trifluoperazine is the only antipsychotic approved to treat anxiety.
Social anxiety

Social Anxiety Disorder (SAD)

Social Anxiety Disorder is a more specific form of anxiety. Instead of anxiety about many things, the anxiety is centred around social situations and interpersonal relationships. The anxiety is usually centred on being judged by others or being embarrassed while surrounded by others. The anxiety can be felt in all social situations or be specific to certain areas such as parties/gatherings of people. This can have a huge impact on your life as people with social anxiety disorder often begin to avoid social situations as much as possible. This disorder may develop in childhood, but usually becomes most apparent in adolescence. Because of this, people with social anxiety disorder often miss out on important social developmental aspects of adolescence, such as forming close bonds with new friends.

Signs and Symptoms

The signs of social anxiety disorder are similar to GAD, though they tend to appear in social situations rather than being felt as a resting anxiety like with GAD.

A major sign of Social Anxiety Disorder is an avoidance of social situations for fear of being embarrassed as well as holding the belief that others are consistently saying bad things about you.

When in social situations, this anxiety can physically present with:

  • Avoiding eye contact
  • Blushing
  • Excess sweating
  • Trembling
  • Stuttering
  • Rapid heartbeat
  • Nausea

Diagnosing Social Anxiety

Social Anxiety Disorder is diagnosed in a similar fashion to GAD. First, there must be a physical exam to negate any medical condition or substances as being the cause for the anxiety symptoms. There will then be an in-depth discussion about the specific situations in which you are becoming anxious as well as the factors that contribute to your anxiety.

Once your healthcare provider has determined that you do meet the diagnostic criteria for social anxiety, they will begin exploring treatment options.

Non-medication Treatment:

There are once again the self-directed methods for anxiety that may serve some benefit for those with Social Anxiety Disorder. However, these tend to be less beneficial in treating social anxiety than GAD, as there aren’t as many specifically social anxiety-related resources.

A very effective form of treatment for Social Anxiety Disorder is therapy. There are three main types of therapy that seem to work well for social anxiety.

  • Cognitive Behavioural Therapy (CBT)
    • CBT works for social anxiety to alter your ways of thinking and reacting in order to help you feel less anxious in anxiety-inducing situations.
    • Exposure therapy
      Exposure therapy is a part of CBT that is very helpful for SAD treatment. Putting yourself into situations that you would typically avoid or would feel very anxious in should, over time, make those situations seem less terrifying.
  • Acceptance and Commitment Therapy (ACT)
    • This is a therapy method that uses mindfulness and setting realistic goals for yourself to slowly reduce your discomfort in social situations.
  • Group Therapy
    • This is essentially combination therapy by adding a social aspect to the therapy and thus creating exposure therapy within another form of therapy.

Medication to Treat Social Anxiety Disorder

Medication should only be used for Social Anxiety Disorder when therapy is not working or if you need an additional crutch as you work through your therapy. There are fewer medication options that are specific to Social Anxiety Disorder, though some have proven to be quite effective.

The main medications used to treat Social Anxiety Disorder include:

These medications work in the same way for Social Anxiety Disorder as they do for Generalized Anxiety Disorder, reducing the racing thoughts and helping regulate emotions. Other antidepressants, such as TCAs and MAOIs are not indicated for treating social anxiety.

The other option for short-term management of social anxiety is benzodiazepines. Two common benzodiazepines are lorazepam and diazepam. They work to quicky and strongly decrease anxiety for a short period of time during an acute attack of anxiety. These medications should not be used long-term, as they are very addictive and can cause adverse long-term health effects.

Panic disorder

Panic Disorder (PD)

Panic Disorder is another more specialized form of anxiety. It is characterized by sudden, repeated attacks of severe anxiety, referred to as “panic attacks”. A panic attack is a very sudden and severe onset of anxiety symptoms including:

  • Feeling out of control
  • Racing heart
  • Sweating/chills
  • Difficulty breathing and/or speaking
  • Uncontrollable crying
  • Feeling weak, dizzy, or tingly
  • Stomach and/or chest pain

A panic attack is a very scary thing to experience, and because of this, people with panic disorder often live in fear of experiencing another.

Signs and Symptoms of Panic Disorder:

The main sign that you may have panic disorder is having experienced multiple panic attacks. The panic attacks themselves are an indication of panic disorder, but there are other signs in addition including:

  • Feeling out of control, even to the point of fearing death during a panic attack
  • Frequent, intense worries about experiencing another panic attack
  • Avoiding situations or places where a panic attack has occurred
  • Experiencing multiple (previously mentioned) physical symptoms during a panic attack

Diagnosing Panic Disorder:

Panic Disorder can be diagnosed if you have experienced two or more panic attacks, though there is more to take into consideration. Your healthcare provider will discuss with you the different situations in which you have experienced a panic attack, and have you describe what happens when you do experience panic attacks. They will then decide whether or not you meet the criteria.

Non-Medication Treatment:

The main non-medication treatment for Panic Disorder is cognitive behavioural therapy (CBT). This works to change the ways of thinking and behaving before and during a panic attack in order to ideally divert yourself away from a panic attack in the future and therefore decrease the frequency and severity of the attacks.

An important part of CBT for panic disorder treatment is exposure therapy. While this is very difficult, exposing yourself to situations that regularly bring on panic attacks or bring on fear of panic attacks is an important way to re-route your thoughts. Learning that these situations are not actually inherently bad and will not directly cause a panic attack is a very important way to begin reducing their frequency.

Medication Treatment:

There are also a number of medications used to treat panic disorder. Medication is frequently used as a way of decreasing the anxiety long enough to work on yourself to a point where you no longer fear panic attacks. This decrease in fear then decreases the number of attacks you are having.

The main medications used for panic disorder include:

These medications work to increase the organization of thoughts and reduce symptoms of anxiety. This then helps you work through your fear of panic attacks and reduce their frequency.

The other medication treatment option for Panic Disorder is benzodiazepines. These medications work well for panic attacks as they are fast acting anti-anxiety drugs that will calm you right down. The most common benzodiazepine for Panic Disorder is clonazepam. However, these are not medications that can be used long-term as they are addictive and can be dangerous when used in excess. They are very good for dealing with the acute attack, but more work needs to be done apart from the medication to improve the panic attacks.

Summary

Anxiety is a very common mental health condition that effects millions of people worldwide. If you or a loved one is experiencing anxiety and it is interfering with your day-to-day life, it’s important to speak with your healthcare provider about seeking management. Many people feel uncomfortable seeking help for mental illness, but there are very wide range of treatment options, and it’s always possible to find something within your comfort level.

References:
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  4. Ströhle A, Gensichen J, Domschke K. The Diagnosis and Treatment of Anxiety Disorders. Dtsch Arztebl Int. 2018 Sep 14;155(37):611-620. doi: 10.3238/arztebl.2018.0611. PMID: 30282583; PMCID: PMC6206399.
  5. 6. Panic Disorder: When Fear Overwhelms. (2022). Retrieved 25 July 2022, from https://www.nimh.nih.gov/health/publications/panic-disorder-when-fear-overwhelms
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