AnxietyDisorders

NationalInstitute of Mental Health

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES • National Institutes of Health
National Institute of Mental Health

Anxiety Disorders

AnxietyDisorders affect about 40 million American adults age 18

years and older (about 18%) in a given year,1 causing them to be filled

with fearfulness and uncertainty. Unlike the relatively mild, brief anxi

ety caused by a stressful event (such as speaking in public or a first

date), anxiety disorders last at least 6 months and can get worse if

they are not treated. Anxiety disorders commonly occur along with

other mental or physical illnesses, including alcohol or substance abuse,

which may mask anxiety symptoms or make them worse. In some

cases, these other illnesses need to be treated before a person will

respond to treatment for the anxiety disorder.

Effective therapies for anxiety disorders are available, and research

is uncovering new treatments that can help most people with anxiety

disorders lead productive, fulfilling lives. If you think you have an anxiety

disorder, you should seek information and treatment right away.
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Thisbookletwill:

describe the symptoms of anxiety disorders,

explain the role of research in understanding the causes of these

conditions,

describe effective treatments,

help you learn how to obtain treatment and work with a doctor or

therapist,and

suggest ways to make treatment more effective.

Thefollowinganxietydisordersarediscussedinthisbrochure:

panic disorder,

obsessive­compulsive disorder (OCD),

post­traumatic stress disorder (PTSD),

social phobia (or social anxiety disorder),

specific phobias,and

generalized anxiety disorder (GAD).

Each anxiety disorder has different symptoms, but all the symptoms

cluster around excessive, irrational fear and dread.
p a n i c d i s o r d e r 3

PanicDisorder
 

“For me, a panic attack

is almost a violent

experience.I feel

disconnected from

reality.I feel like I'm

losing control in a

very extreme way.

My heart pounds

really hard,I feel

like I can’t get my

breath, and there’s an

overwhelming feeling

that things are crashing in on me.”

“It started 10 years ago,when I had

just graduated from college and

started a new job.I was sitting in

a business seminar in a hotel and

this thing came out of the blue.

I felt like I was dying.”

“In between attacks, there is

this dread and anxiety that

it’s going to happen again.

I’m afraid to go back to places

where I’ve had an attack.

Unless I get help, there soon

won’t be anyplace where I can

go and feel safe from panic.”

Panicdisorder is a real illness that can be successfully treated. It is
 

characterized by sudden attacks of terror, usually accompanied by a
 

pounding heart, sweatiness, weakness, faintness, or dizziness. During
 

these attacks, people with panic disorder may flush or feel chilled;
 

their hands may tingle or feel numb;and they may experience
 

nausea, chest pain, or smothering sensations. Panic attacks usually
 

produce a sense of unreality,a fear of impending doom, or a fear
 

of losing control.
 

A fear of one’s own unexplained physical symptoms is also a symptom
 

of panic disorder. People having panic attacks sometimes believe
 

they are having heart attacks, losing their minds, or on the verge of
 

death.They can’t predict when or where an attack will occur,and
 

between episodes many worry intensely and dread the next attack.
 

Panic attacks can occur at any time, even during sleep.
 

An attack usually peaks within 10 minutes, but some symptoms
 

may last much longer.
 
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Panic disorder affects about 6 million American adults1 and is twice

as common in women as men.2 Panic attacks often begin in late

adolescence or early adulthood,2 but not everyone who experiences

panic attacks will develop panic disorder. Many people have just

one attack and never have another.The tendency to develop

panic attacks appears to be inherited.3

People who have full­blown, repeated panic attacks can become

very disabled by their condition and should seek treatment before

they start to avoid places or situations where panic attacks have

occurred. For example, if a panic attack happened in an elevator,

someone with panic disorder may develop a fear of elevators that

could affect the choice of a job or an apartment,and restrict where

that person can seek medical attention or enjoy entertainment.

Some people’s lives become so restricted that they avoid normal

activities, such as grocery shopping or driving.About one­third

become housebound or are able to confront a feared situation only

when accompanied by a spouse or other trusted person.2 When

the condition progresses this far, it is called agoraphobia, or fear of

open spaces.

Early treatment can often prevent agoraphobia, but people with

panic disorder may sometimes go from doctor to doctor for years

and visit the emergency room repeatedly before someone correctly

diagnoses their condition.This is unfortunate, because panic disorder is one of the most treatable of all the anxiety disorders,

responding in most cases to certain kinds of medication or certain

kinds of cognitive psychotherapy,which help change thinking patterns that lead to fear and anxiety.

Panic disorder is often accompanied by other serious problems,such

as depression, drug abuse, or alcoholism.4,5These conditions need to

be treated separately. Symptoms of depression include feelings of sadness or hopelessness, changes in appetite or sleep patterns, low

energy, and difficulty concentrating. Most people with depression

can be effectively treated with antidepressant medications, certain

types of psychotherapy, or a combination of the two.
o b s e s s i v e - c o m p u l s i v e d i s o r d e r 5

Obsessive­Compulsive Disorder (OCD)
 

“I couldn’t do anything without rituals.	 

They invaded every aspect of my life.	 

Counting really bogged me down.I would

wash my hair three times as opposed to once

because three was a good luck number and

one wasn’t.It took me longer to read because
 

I’d count the lines in a paragraph.When I set

my alarm at night,I had to set it to a number

that wouldn't add up to a ‘bad’ number.”

“I knew the rituals

didn’t make sense,

and I was deeply

ashamed of them,

but I couldn’t seem

to overcome them

until I had therapy.”

“Getting dressed in the morning was tough, because I

had a routine, and if I didn’t

follow the routine,I’d get

anxious and would have to

get dressed again.I always
 

worried that if I didn't do

something, my parents were

going to die.I’d have these

terrible thoughts of harming

my parents.That was completely irrational, but the

thoughts triggered more

anxiety and more senseless

behavior. Because of the

time I spent on rituals,

I was unable to do a lot of

things that were important

to me.”

People with obsessive­compulsive disorder (OCD) have persistent, upsetting thoughts (obsessions) and use rituals (compulsions) to

control the anxiety these thoughts produce. Most of the time, the

rituals end up controlling them.

For example, if people are obsessed with germs or dirt, they may

develop a compulsion to wash their hands over and over again. If

they develop an obsession with intruders, they may lock and relock

their doors many times before going to bed. Being afraid of social

embarrassment may prompt people with OCD to comb their hair

compulsively in front of a mirror—sometimes they get “caught” in

the mirror and can’t move away from it. Performing such rituals is

not pleasurable. At best, it produces temporary relief from the

anxiety created by obsessive thoughts.

Other common rituals are a need to repeatedly check things, touch

things (especially in a particular sequence), or count things. Some

common obsessions include having frequent thoughts of violence

and harming loved ones, persistently thinking about performing

sexual acts the person dislikes, or having thoughts that are
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prohibited by religious beliefs. People with OCD may also be

preoccupied with order and symmetry, have difficulty throwing

things out (so they accumulate), or hoard unneeded items.

Healthy people also have rituals, such as checking to see if the stove

is off several times before leaving the house.The difference is that

people with OCD perform their rituals even though doing so

interferes with daily life and they find the repetition distressing.

Although most adults with OCD recognize that what they are

doing is senseless, some adults and most children may not realize

that their behavior is out of the ordinary.

OCD affects about 2.2 million American adults,1 and the problem

can be accompanied by eating disorders,6 other anxiety disorders, or

depression.2,4 It strikes men and women in roughly equal numbers

and usually appears in childhood,adolescence, or early adulthood.2

One­third of adults with OCD develop symptoms as children,

and research indicates that OCD might run in families.3

The course of the disease is quite varied. Symptoms may come and

go, ease over time, or get worse.If OCD becomes severe, it can keep

a person from working or carrying out normal responsibilities at

home. People with OCD may try to help themselves by avoiding

situations that trigger their obsessions, or they may use alcohol or

drugs to calm themselves.4,5

OCD usually responds well to treatment with certain medications

and/or exposure­based psychotherapy, in which people face

situations that cause fear or anxiety and become less sensitive

(desensitized) to them. NIMH is supporting research into new

treatment approaches for people whose OCD does not respond

well to the usual therapies.These approaches include combination

and augmentation (add­on) treatments, as well as modern

techniques such as deep brain stimulation.
p o s t-t r a u m a t i c s t r e s s d i s o r d e r 7

Post­TraumaticStressDisorder (PTSD)
 

“I was raped when I was 25 years old.For a long time,I

spoke about the rape as though it was something that

happened to someone else.I was very aware that it had

happened to me, but there was just no feeling.

“Then I started having flashbacks.They kind of came

over me like a splash of water.I would be terrified.

Suddenly I was reliving the rape. Every instant was

startling.I wasn't aware of anything around me,I was

in a bubble, just kind of floating.And it was scary.

Having a flashback can wring you out.

“The rape happened the week before Thanksgiving,

and I can’t believe the anxiety and fear I feel every year

around the anniversary date.It’s as though I’ve seen a

werewolf.I can’t relax,can’t sleep, don’t want to be with

anyone.I wonder whether I’ll ever be free of this terrible

problem. ”

Post­traumatic stress disorder (PTSD) develops after a

terrifying ordeal that involved physical harm or the threat of physical harm.The person who develops PTSD may have been the one

who was harmed, the harm may have happened to a loved one, or

the person may have witnessed a harmful event that happened to

loved ones or strangers.

PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such

as mugging, rape, torture, being kidnapped or held captive, child

abuse, car accidents, train wrecks, plane crashes, bombings, or natural

disasters such as floods or earthquakes.

People with PTSD may startle easily, become emotionally numb

(especially in relation to people with whom they used to be close),

lose interest in things they used to enjoy, have trouble feeling

affectionate, be irritable, become more aggressive, or even become

violent.They avoid situations that remind them of the original

incident,and anniversaries of the incident are often very difficult.

PTSD symptoms seem to be worse if the event that triggered

them was deliberately initiated by another person,as in a mugging

or a kidnapping.
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Most people with PTSD repeatedly relive the trauma in their

thoughts during the day and in nightmares when they sleep.

These are called flashbacks. Flashbacks may consist of images,

sounds, smells, or feelings,and are often triggered by ordinary

occurrences, such as a door slamming or a car backfiring on the

street.A person having a flashback may lose touch with reality and

believe that the traumatic incident is happening all over again.

Not every traumatized person develops full­blown or even minor

PTSD. Symptoms usually begin within 3 months of the incident

but occasionally emerge years afterward.They must last more than

a month to be considered PTSD.The course of the illness varies.

Some people recover within 6 months, while others have symptoms

that last much longer. In some people, the condition becomes

chronic.

PTSD affects about 7.7 million American adults,1 but it can occur

at any age, including childhood.7Women are more likely to develop

PTSD than men,8 and there is some evidence that susceptibility to

the disorder may run in families.9 PTSD is often accompanied by

depression, substance abuse, or one or more of the other anxiety

disorders.4

Certain kinds of medication and certain kinds of psychotherapy

usually treat the symptoms of PTSD very effectively.
s o c i a l p h o b i a 9

Social Phobia (Social Anxiety Disorder)

“In any social situation,

I felt fear.I would be anxious

before I even left the house,

and it would escalate as

I got closer to a college

class, a party, or whatever.

I would feel sick in my

stomach—it almost felt like

I had the flu.My heart would

pound,my palms would get

sweaty, and I would get this

feeling of being removed

from myself and from

everybody else.”

“When I would walk into a room full

of people,I’d turn red and it would

feel like everybody’s eyes were on

me.I was embarrassed to stand off

in a corner by myself, but I couldn’t

think of anything to say to anybody.

It was humiliating.I felt so clumsy,

I couldn’t wait to get out.”

Social phobia,also called social anxiety disorder, is diagnosed

when people become overwhelmingly anxious and excessively selfconscious in everyday social situations. People with social phobia

have an intense, persistent,and chronic fear of being watched and

judged by others and of doing things that will embarrass them.

They can worry for days or weeks before a dreaded situation.This

fear may become so severe that it interferes with work, school,and

other ordinary activities,and can make it hard to make and keep

friends.

While many people with social phobia realize that their fears about

being with people are excessive or unreasonable, they are unable to

overcome them. Even if they manage to confront their fears and

be around others, they are usually very anxious beforehand,are

intensely uncomfortable throughout the encounter,and worry

about how they were judged for hours afterward.
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Social phobia can be limited to one situation (such as talking to

people, eating or drinking, or writing on a blackboard in front of

others) or may be so broad (such as in generalized social phobia)

that the person experiences anxiety around almost anyone other

than the family.

Physical symptoms that often accompany social phobia include

blushing, profuse sweating, trembling, nausea,and difficulty talking.

When these symptoms occur, people with social phobia feel as

though all eyes are focused on them.

Social phobia affects about 15 million American adults.1Women

and men are equally likely to develop the disorder,10 which usually

begins in childhood or early adolescence.2There is some evidence

that genetic factors are involved.11 Social phobia is often accompanied by other anxiety disorders or depression,2,4 and substance abuse

may develop if people try to self­medicate their anxiety.4,5

Social phobia can be successfully treated with certain kinds of

psychotherapy or medications.
s p e c i f i c p h o b i a s 11

Specific Phobias
 

“I'm scared to death of flying,and I never do it anymore. I used to start

dreading a plane trip a month before I was due to leave.It was an

awful feeling when that airplane door closed and I felt trapped. My

heart would pound,and I would sweat bullets.When the airplane would

start to ascend,it just reinforced the feeling that I couldn't get out.

When I think about flying,I picture myself losing control, freaking out,

and climbing the walls,but of course I never did that.I'm not afraid of

crashing or hitting turbulence.It's just that feeling of being trapped.

Whenever I’ve thought about changing jobs,I've had to think,‘Would

I be under pressure to fly?’These days I only go places where I can

drive or take a train.My friends always point out that I couldn’t get off

a train traveling at high speeds either, so why don’t trains bother me?

I just tell them it isn’t a rational fear.”

A specific phobia is an intense,irrational fear of something

that actually poses little or no threat. Some of the more common

specific phobias are heights, escalators, tunnels, highway driving,

closed­in places, water, flying, dogs, spiders,and injuries involving

blood. People with specific phobias may be able to ski the

world’s tallest mountains with ease but be unable to go above

the fifth floor of an office building.While adults with phobias

realize that these 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.

Specific phobias affect around 19.2 million American adults 1

and are twice as common in women as men.10They usually appear

in childhood or adolescence and tend to persist into adulthood.12

The causes of specific phobias are not well understood, but there is

some evidence that the tendency to develop them may run in families.11

If the feared situation or feared object is easy to avoid, people with

specific phobias may not seek help; but if avoidance interferes with

their careers or their personal lives, it can become disabling and

treatment is usually pursued.

Specific phobias respond very well to carefully targeted

psychotherapy.
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GeneralizedAnxietyDisorder (GAD)
 

“I always thought I was just a worrier.

I’d feel keyed up and unable to relax.

At times it would come and go, and at

times it would be constant. It could

go on for days. I’d worry about what

I was going to fix for a dinner party

or what would be a great present for

somebody. I just couldn’t let

something go.”

“When my problems were at their worst,

I’d miss work and feel just terrible about it.

Then I worried that I'd lose my job.My life
 

was miserable until I got treatment.”
 

“I'd have terrible sleeping

problems.There were times

I'd wake up wired in the

middle of the night.I had

trouble concentrating, even

reading the newspaper or

a novel. Sometimes I'd feel

a little lightheaded.My

heart would race or pound.

And that would make me

worry more.I was always

imagining things were

worse than they really

were.When I got a stomachache,I’d think it

was an ulcer.”

People with generalized anxiety disorder (GAD) go
 

through the day filled with exaggerated worry and tension, even
 

though there is little or nothing to provoke it.They anticipate disaster
 

and are overly concerned about health issues, money, family problems, or difficulties at work. Sometimes just the thought of getting
 

through the day produces anxiety.
 

GAD is diagnosed when a person worries excessively about a
 

variety of everyday problems for at least 6 months.13 People with
 

GAD can’t seem to get rid of their concerns, even though they
 

usually realize that their anxiety is more intense than the situation
 

warrants.They can’t relax, startle easily,and have difficulty
 

concentrating. Often they have trouble falling asleep or staying
 

asleep. Physical symptoms that often accompany the anxiety
 

include fatigue, headaches, muscle tension, muscle aches, difficulty
 

swallowing, trembling, twitching, irritability, sweating, nausea,
 

lightheadedness, having to go to the bathroom frequently, feeling
 

out of breath,and hot flashes.
 
g e n e r a l i z e d a n x i e t y d i s o r d e r 13

When their anxiety level is mild, people with GAD can function

socially and hold down a job.Although they don’t avoid certain

situations as a result of their disorder, people with GAD can have

difficulty carrying out the simplest daily activities if their anxiety

is severe.

GAD affects about 6.8 million American adults,1 including twice

as many women as men.The disorder develops gradually and can

begin at any point in the life cycle,although the years of highest

risk are between childhood and middle age.2 There is evidence

that genes play a modest role in the disorder.13

Other anxiety disorders, depression, or substance abuse2,4 often

accompany GAD, which rarely occurs alone. GAD is commonly

treated with medication or cognitive­behavioral therapy, but cooccurring conditions must also be treated using the appropriate

therapies.
14 n a t i o n a l i n s t i t u t e o f m e n t a l h e a l t h

TreatmentofAnxietyDisorders

In general,anxiety disorders are treated with medication, specific

types of psychotherapy, or both.14Treatment choices depend on

the problem and the person’s preference. Before treatment begins,

a doctor must conduct a careful diagnostic evaluation to determine whether a person’s symptoms are caused by an anxiety disorder or a physical problem. If an anxiety disorder is diagnosed, the

type of disorder or the combination of disorders that are present

must be identified,as well as any coexisting conditions, such as

depression or substance abuse. Sometimes alcoholism, depression,

or other coexisting conditions have such a strong effect on the

individual that treating the anxiety disorder must wait until the

coexisting conditions are brought under control.

People with anxiety disorders who have already received treatment

should tell their current doctor about that treatment in detail. If

they received medication, they should tell their doctor what medication was used, what the dosage was at the beginning of treatment, whether the dosage was increased or decreased while they

were under treatment, what side effects occurred,and whether the

treatment helped them become less anxious. If they received psychotherapy, they should describe the type of therapy, how often

they attended sessions,and whether the therapy was useful.

Often people believe that they have “failed” at treatment or that

the treatment didn’t work for them when, in fact, it was not given

for an adequate length of time or was administered incorrectly.

Sometimes people must try several different treatments or combinations of treatment before they find the one that works for them.

Medication

Medication will not cure anxiety disorders, but it can keep them

under control while the person receives psychotherapy. Medication

must be prescribed by physicians, usually psychiatrists, who can

either offer psychotherapy themselves or work as a team with psychologists, social workers, or counselors who provide psychotherapy.The principal medications used for anxiety disorders are antidepressants,anti­anxiety drugs,and beta­blockers to control some of

the physical symptoms.With proper treatment, many people with

anxiety disorders can lead normal, fulfilling lives.
a n x i e t y d i s o r d e r s 15

Antidepressants

Antidepressants were developed to treat depression but are also

effective for anxiety disorders.Although these medications begin

to alter brain chemistry after the very first dose, their full effect

requires a series of changes to occur; it is usually about 4 to 6

weeks before symptoms start to fade. It is important to continue

taking these medications long enough to let them work.

SSRIs

Some of the newest antidepressants are called selective serotonin

reuptake inhibitors, or SSRIs. SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other neurotransmitters, helps brain cells communicate with one another.

Fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®),

paroxetine (Paxil®),and citalopram (Celexa®) are some of the

SSRIs commonly prescribed for panic disorder, OCD, PTSD,and

social phobia. SSRIs are also used to treat panic disorder when it

occurs in combination with OCD, social phobia, or depression.

Venlafaxine (Effexor®),a drug closely related to the SSRIs, is used

to treat GAD.These medications are started at low doses and gradually increased until they have a beneficial effect.

SSRIs have fewer side effects than older antidepressants, but they

sometimes produce slight nausea or jitters when people first start

to take them.These symptoms fade with time. Some people also

experience sexual dysfunction with SSRIs, which may be helped

by adjusting the dosage or switching to another SSRI.

Tricyclics

Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD.They are also started at low doses

that are gradually increased.They sometimes cause dizziness,

drowsiness, dry mouth,and weight gain, which can usually be corrected by changing the dosage or switching to another tricyclic

medication.

Tricyclics include imipramine (Tofranil®), which is prescribed for

panic disorder and GAD,and clomipramine (Anafranil®), which is

the only tricyclic antidepressant useful for treating OCD.
16 n a t i o n a l i n s t i t u t e o f m e n t a l h e a l t h

MAOIs

Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications.The MAOIs most commonly prescribed for

anxiety disorders are phenelzine (Nardil®),followed by tranylcypromine

(Parnate®),and isocarboxazid (Marplan®), which are useful in treating panic disorder and social phobia. People who take MAOIs

cannot eat a variety of foods and beverages (including cheese and

red wine) that contain tyramine or take certain medications, including some types of birth control pills, pain relievers (such as Advil®,

Motrin®, orTylenol®), cold and allergy medications,and herbal

supplements; these substances can interact with MAOIs to cause

dangerous increases in blood pressure.The development of a new

MAOI skin patch may help lessen these risks. MAOIs can also

react with SSRIs to produce a serious condition called “serotonin

syndrome,” which can cause confusion, hallucinations, increased

sweating, muscle stiffness, seizures, changes in blood pressure or

heart rhythm,and other potentially life­threatening conditions.

Anti­Anxiety Drugs

High­potency benzodiazepines combat anxiety and have few side

effects other than drowsiness. Because people can get used to them

and may need higher and higher doses to get the same effect,

benzodiazepines are generally prescribed for short periods of time,

especially for people who have abused drugs or alcohol and who

become dependent on medication easily. One exception to this

rule is people with panic disorder, who can take benzodiazepines

for up to a year without harm.

Clonazepam (Klonopin®) is used for social phobia and GAD,

lorazepam (Ativan®) is helpful for panic disorder,and alprazolam

(Xanax®) is useful for both panic disorder and GAD.

Some people experience withdrawal symptoms if they stop taking

benzodiazepines abruptly instead of tapering off,and anxiety can

return once the medication is stopped.These potential problems

have led some physicians to shy away from using these drugs or to

use them in inadequate doses.

Buspirone (Buspar®),an azapirone, is a newer anti­anxiety medication

used to treat GAD. Possible side effects include dizziness, headaches,

and nausea. Unlike benzodiazepines, buspirone must be taken

consistently for at least 2 weeks to achieve an anti­anxiety effect.
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a n x i e t y d i s o r d e r s 17

TA K I N G M E D I C AT I O N S

Before taking medication for an anxiety disorder:

Ask your doctor to tell you about the effects and side effects of the drug.

Tell your doctor about any alternative therapies or over­the­counter medications

you are using.

Ask your doctor when and how the medication should be stopped. Some drugs

can’t be stopped abruptly but must be tapered off slowly under a doctor’s supervision.

Work with your doctor to determine which medication is right for you and

what dosage is best.

Be aware that some medications are effective only if they are taken regularly and

that symptoms may recur if the medication is stopped.

Beta­Blockers

Beta­blockers, such as propranolol (Inderal®), which is used to treat

heart conditions, can prevent the physical symptoms that accompany certain anxiety disorders, particularly social phobia.When a

feared situation can be predicted (such as giving a speech),a doctor

may prescribe a beta­blocker to keep physical symptoms of anxiety

under control.

Psychotherapy

Psychotherapy involves talking with a trained mental health

professional, such as a psychiatrist, psychologist, social worker, or

counselor, to discover what caused an anxiety disorder and how

to deal with its symptoms.

Cognitive­BehavioralTherapy

Cognitive­behavioral therapy (CBT) is very useful in treating anxiety disorders.The cognitive part helps people change the thinking

patterns that support their fears,and the behavioral part helps

people change the way they react to anxiety­provoking situations.

For example, CBT can help people with panic disorder learn that

their panic attacks are not really heart attacks and help people with

social phobia learn how to overcome the belief that others are always

watching and judging them.When people are ready to confront

their fears, they are shown how to use exposure techniques to

desensitize themselves to situations that trigger their anxieties.
18 n a t i o n a l i n s t i t u t e o f m e n t a l h e a l t h

People with OCD who fear dirt and germs are encouraged to get

their hands dirty and wait increasing amounts of time before washing them.The therapist helps the person cope with the anxiety that

waiting produces;after the exercise has been repeated a number of

times, the anxiety diminishes. People with social phobia may be

encouraged to spend time in feared social situations without giving

in to the temptation to flee and to make small social blunders and

observe how people respond to them. Since the response is usually

far less harsh than the person fears, these anxieties are lessened.

People with PTSD may be supported through recalling their traumatic event in a safe situation, which helps reduce the fear it produces.

CBT therapists also teach deep breathing and other types of exercises

to relieve anxiety and encourage relaxation.

Exposure­based behavioral therapy has been used for many years to

treat specific phobias.The person gradually encounters the object

or situation that is feared, perhaps at first only through pictures or

tapes, then later face­to­face. Often the therapist will accompany

the person to a feared situation to provide support and guidance.

CBT is undertaken when people decide they are ready for it and

with their permission and cooperation.To be effective, the therapy

must be directed at the person’s specific anxieties and must be

tailored to his or her needs.There are no side effects other than

the discomfort of temporarily increased anxiety.

CBT or behavioral therapy often lasts about 12 weeks. It may be

conducted individually or with a group of people who have similar

problems. Group therapy is particularly effective for social phobia.

Often “homework” is assigned for participants to complete between

sessions.There is some evidence that the benefits of CBT last

longer than those of medication for people with panic disorder,

and the same may be true for OCD, PTSD,and social phobia.

If a disorder recurs at a later date, the same therapy can be used to

treat it successfully a second time.

Medication can be combined with psychotherapy for specific

anxiety disorders,and this is the best treatment approach for

many people.
a n x i e t y d i s o r d e r s 19

Howto GetHelpforAnxietyDisorders

If you think you have an anxiety disorder, the first person

you should see is your family doctor.A physician can determine

whether the symptoms that alarm you are due to an anxiety disorder,another medical condition, or both.

If an anxiety disorder is diagnosed, the next step is usually seeing a

mental health professional.The practitioners who are most helpful

with anxiety disorders are those who have training in cognitivebehavioral therapy and/or behavioral therapy,and who are open to

using medication if it is needed.

You should feel comfortable talking with the mental health professional you choose. If you do not, you should seek help elsewhere.

Once you find a mental health professional with whom you are

comfortable, the two of you should work as a team and make a

plan to treat your anxiety disorder together.

Remember that once you start on medication, it is important not

to stop taking it abruptly. Certain drugs must be tapered off under

the supervision of a doctor or bad reactions can occur. Make sure

you talk to the doctor who prescribed your medication before you

stop taking it. If you are having trouble with side effects, it’s possible that they can be eliminated by adjusting how much medication

you take and when you take it.

Most insurance plans, including health maintenance organizations

(HMOs), will cover treatment for anxiety disorders. Check with

your insurance company and find out. If you don’t have insurance,

the Health and Human Services division of your county government may offer mental health care at a public mental health center

that charges people according to how much they are able to pay. If

you are on public assistance, you may be able to get care through

your state Medicaid plan.
Ways to Make Treatment More Effective

Many people with anxiety disorders benefit from joining a

self­help or support group and sharing their problems and achievements with others. Internet chat rooms can also be useful in this

regard, but any advice received over the Internet should be used

with caution,as Internet acquaintances have usually never seen

each other and false identities are common.Talking with a trusted

friend or member of the clergy can also provide support, but it is

not a substitute for care from a mental health professional.

Stress management techniques and meditation can help people

with anxiety disorders calm themselves and may enhance the effects

of therapy.There is preliminary evidence that aerobic exercise may

have a calming effect. Since caffeine, certain illicit drugs,and even

some over­the­counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided. Check with your

physician or pharmacist before taking any additional medications.

The family is very important in the recovery of a person with an

anxiety disorder. Ideally, the family should be supportive but not

help perpetuate their loved one’s symptoms. Family members

should not trivialize the disorder or demand improvement without

treatment. If your family is doing either of these things, you may

want to show them this booklet so they can become educated allies

and help you succeed in therapy.

20 n a t i o n a l i n s t i t u t e o f m e n t a l h e a l t h
a n x i e t y d i s o r d e r s 21

The Role of Research in Improving the Understanding

andTreatment of Anxiety Disorders

NIMH supports research into the causes, diagnosis, prevention,and treatment of anxiety disorders and other mental illnesses.

Scientists are looking at what role genes play in the development

of these disorders and are also investigating the effects of environmental factors such as pollution, physical and psychological stress,

and diet. In addition, studies are being conducted on the “natural

history” (what course the illness takes without treatment) of a

variety of individual anxiety disorders, combinations of anxiety

disorders,and anxiety disorders that are accompanied by other

mental illnesses such as depression.

Scientists currently think that, like heart disease and type 1

diabetes, mental illnesses are complex and probably result from a

combination of genetic, environmental, psychological,and developmental factors. For instance,although NIMH­sponsored studies

of twins and families suggest that genetics play a role in the development of some anxiety disorders, problems such as PTSD are

triggered by trauma. Genetic studies may help explain why some

people exposed to trauma develop PTSD and others do not.

Several parts of the brain are key actors in the production of fear

and anxiety.15 Using brain imaging technology and neurochemical

techniques, scientists have discovered that the amygdala and the

hippocampus play significant roles in most anxiety disorders.

The amygdala is an almond­shaped structure deep in the brain

that is believed to be a communications hub between the parts of

the brain that process incoming sensory signals and the parts that

interpret these signals. It can alert the rest of the brain that a threat

is present and trigger a fear or anxiety response. It appears that

emotional memories are stored in the central part of the amygdala

and may play a role in anxiety disorders involving very distinct

fears, such as fears of dogs, spiders, or flying.
22 n a t i o n a l i n s t i t u t e o f m e n t a l h e a l t h

The hippocampus is the part of the brain that encodes threatening

events into memories. Studies have shown that the hippocampus appears to be smaller in some people who were victims

of child abuse or who served in military combat.16,17 Research will

determine what causes this reduction in size and what role it plays

in the flashbacks, deficits in explicit memory,and fragmented

memories of the traumatic event that are common in PTSD.

By learning more about how the brain creates fear and anxiety, scientists may be able to devise better treatments for anxiety disorders.

For example, if specific neurotransmitters are found to play an

important role in fear, drugs may be developed that will block

them and decrease fear responses; if enough is learned about how

the brain generates new cells throughout the lifecycle, it may be

possible to stimulate the growth of new neurons in the hippocampus in people with PTSD.18

Current research at NIMH on anxiety disorders includes studies

that address how well medication and behavioral therapies work in

the treatment of OCD, and the safety and effectiveness of medications for children and adolescents who have a combination of

anxiety disorders and attention deficit hyperactivity disorder.
a n x i e t y d i s o r d e r s 23

Citations

1.	 Kessler RC, ChiuWT, Demler O,Walters EE.

Prevalence, severity,and comorbidity of twelvemonth DSM­IV disorders in the National

Comorbidity Survey Replication (NCS­R). Archives

of General Psychiatry. 2005; 62(6):617–627.

2.	 Robins LN, Regier DA, eds. Psychiatric Disorders in

America: the Epidemiologic Catchment Area Study. New

York:The Free Press, 1991.

3.	 The NIMH GeneticsWorkgroup. Genetics and mental

disorders, NIH Publication No. 98­4268. Rockville,

MD: National Institute of Mental Health, 1998.

4.	 Regier DA, Rae DS, NarrowWE, et al. Prevalence

of anxiety disorders and their comorbidity with

mood and addictive disorders. British Journal of

Psychiatry Supplement.1998;34:24–28.

5.	 Kushner MG, Sher KJ, Beitman BD.The relation

between alcohol problems and the anxiety disorders.

American Journal of Psychiatry. 1990;147(6):685–695.

6.	 Wonderlich SA, Mitchell JE. Eating disorders and

comorbidity: Empirical, conceptual,and clinical

implications. Psychopharmacology Bulletin.

1997;33(3):381–390.

7.	 Margolin G, Gordis EB.The effects of family and

community violence on children. Annual Review of

Psychology. 2000;51:445–479.

8.	 Davidson JR.Trauma:The impact of post­traumatic

stress disorder. Journal of Psychopharmacology.

2000;14(2 Suppl 1):S5–S12.

9.	 Yehuda R. Biological factors associated with susceptibility to posttraumatic stress disorder. Canadian

Journal of Psychiatry. 1999;44(1):34–39.

10.	 Bourdon KH, Boyd JH, Rae DS, et al. Gender differences in phobias: Results of the ECA community

survey. Journal of Anxiety Disorders. 1998;2:227–241.

11.	 Kendler KS,Walters EE,Truett KR, et al.A twinfamily study of self­report symptoms of panic­phobia and somatization. Behavior Genetics.

1995;25(6):499–515.

12.	 Boyd JH, Rae DS,Thompson JW, et al. Phobia:

Prevalence and risk factors. Social Psychiatry and

Psychiatric Epidemiology. 1990;25(6):314–323.

13.	 Kendler KS, Neale MC, Kessler RC, et al.

Generalized anxiety disorder in women.A population­based twin study. Archives of General Psychiatry.

1992;49(4):267–272.

14.	 Hyman SE, Rudorfer MV.Anxiety disorders. In:

Dale DC, Federman DD, eds. Scientific American

Medicine. Volume 3. NewYork: Healtheon/WebMD

Corp., 2000, Section 13, SubsectionVII.

15.	 LeDoux J. Fear and the brain:Where have we been,

and where are we going? Biological Psychiatry.

1998;44(12):1229–1238.

16.	 Bremner JD, Randall P, ScottTM, et al. MRI­based

measurement of hippocampal volume in combatrelated posttraumatic stress disorder. American Journal

of Psychiatry. 1995;152:973–981.

17.	 Stein MB, Hanna C, Koverola C, et al. Structural

brain changes in PTSD: Does trauma alter neuroanatomy? In:Yehuda R, McFarland AC, eds.

Psychobiology of posttraumatic stress disorder.Annals of the

NewYork Academy of Sciences, 821. NewYork: New

York Academy of Sciences, 1997.

18.	 Gould E, Reeves AJ, Fallah M, et al. Hippocampal

neurogenesis in adult OldWorld primates. Proceedings

of the National Academy of Sciences USA.

1999;96(9):5263–5267.
24 n a t i o n a l i n s t i t u t e o f m e n t a l h e a l t h

For More Information on Anxiety Disorders

Visit the National Library of Medicine’s

MedlinePlus http://www.nlm.nih.gov/medlineplus

En Español, http://medlineplus.gov/spanish

For Information on

Clinical Trials for Anxiety Disorders

NIMH ClinicalTrialsWeb page

http://www.nimh.nih.gov/health/trials/index.shtml

National Library of Medicine ClinicalTrials Database

http://www.clinicaltrials.gov

Information from NIMH is available in multiple formats.

You can browse online, download documents in PDF,and

order paper brochures through the mail. If you would like

to have NIMH publications, you can order them online at

http://www.nimh.nih.gov. If you do not have Internet

access and wish to have information that supplements this

publication, please contact the NIMH Information

Resource Center at the numbers listed below.

National Institute of Mental Health

ScienceWriting, Press & Dissemination Branch

6001 Executive Boulevard

Room 8184, MSC 9663

Bethesda, MD 20892­9663

Phone: 301­443­4513 or

1­866­615­NIMH (6464) toll­free

TTY: 301­443­8431 or

1­866­415­8051 toll­free

FAX: 301­443­4279

E­mail: nimhinfo@nih.gov

Web site: http://www.nimh.nih.gov
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

National Institutes of Health

NIH Publication No. 09 3879

2009