What does anxiety look like?
Anxiety symptoms, such as those noted in the table below, can be normal responses to major stressors such as the COVID-19 pandemic and quarantine. However, if these symptoms persist and/or become functionally impairing they may represent the onset and/or exacerbation of an anxiety disorder such as Post-Traumatic Stress Disorder, Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Panic Attack Disorder and Agoraphobia.
Types of Anxiety Disorders
Rapid onset, discrete, episodes of anxiety/distress/discomfort, accompanied by physical symptoms that are often suggestive of cardiac, endocrine or neurologic disorder. Panic patients become frightened of fear itself and its symptoms. Associated with fear/avoidance of crowds, driving, being closed in, being far from home alone, etc. (agoraphobia). Temporal course of symptoms (sudden onset, rapid progression to a peak, and recovery over 5 to 30 minutes) is as important as enumeration of specific symptoms in diagnosing panic attacks. Agoraphobic fears and avoidance help confirm the diagnosis. Must always be evaluated for depression, substance abuse, and suicidality.
First line treatment: CBT and/or medication (SSRIs). New data and APA guidelines now support CBT as a first line treatment for Panic Disorder.
Screening questions: Have you ever had a spell or attack when all of a sudden you felt frightened, anxious or very uneasy in situations when most people would not be afraid or anxious? In the past 6 months, have you had a spell or attack when for no reason your heart suddenly began to race, you felt faint, or you couldn't catch your breath? Some people have such an unreasonably strong fear of being in a crowd, leaving home alone, traveling on buses, cars or trains, crossing a bridge that they always get very upset in such situation or avoid it altogether. Did you ever go through a period when being in any of these situations frightened you?
Generalized Anxiety Disorder (GAD)
The hallmark of this disorder is chronic, excessive, uncontrollable worry about a broad range of events and activities, ranging from minor events, such as being late to more serious events such as having a serious disease. Patients often recognize that their worry is excessive and struggle with their inability to control it. Difficulty tolerating uncertainty appears to fuel the worry.
Additional symptoms include restlessness, insomnia, poor concentration, fatigue, muscle tension, and irritability. Though GAD can occur in isolation, it is far more common to see it in association with depressive symptoms, or other anxiety disorders. Many patients referred to us with suspected GAD turn out to have major depression with intense, ruminative anxiety.
If you are wondering if you have Generalized Anxiety Disorder, consider the following questions:
- Are you a particularly nervous or anxious person?
- Do you or people who know you well think of you a "worry wort?”
- Do you tend to worry about minor matters, such as being late for appointments?
- When you start worrying, do you jump from one worry to another and think of the worst possible outcomes?
- Do you worry about your worry?
Obsessive-Compulsive Disorder (OCD)
Obsessions are recurrent, intrusive thoughts, disturbing to the patient, but experienced as uncontrollable, often involving fears of harm coming to self or others. Typical examples include obsessive thoughts about germ contamination leading to illness, obsessive thoughts about making mistakes that will lead to harm. Violent, sexual, or blasphemous content is common. Compulsions are repetitive behaviors (e.g., washing, counting, repeating, checking...) that are performed according to certain rules or in a stereotyped fashion. Some patients may resist their compulsions, but usually cannot control them. OCD is the most hidden of the anxiety disorders. Patients must specifically be asked about counting, checking, washing rituals and intrusive, disturbing thoughts.
First line treatment: CBT and medication (SSRIs, often in high doses). Some patients do well without medication. Recovery is often incomplete, but substantial gains are usually possible.
Screening questions: Have you ever been bothered by thoughts that didn't make any sense, and kept coming back to you even when you tried not to have them? Was there ever anything you had to do over and over again and couldn't resist doing, like washing your hands again and again, counting up to a certain number, or checking something several times to make sure that you'd done it right?
Generalized: Excessive anxiety/distress in nearly all situations in which subject to attention, social scrutiny or evaluation
Specific: Anxiety and avoidance of a specific, social performance situation (public speaking, using public restrooms...)
Extremely common, can be severely debilitating, and is often minimized or ignored because social anxiety is "normal". Patients are also generally embarrassed and avoidant, so they often won't disclose their symptoms unless specifically asked. May have panic attacks but they are confined to situations in which the patient may be the center of attention.
First line treatment: CBT. Group CBT is our preferred treatment for those who are candidates for it. Medication is used for patients who are not likely to do well with CBT, such as those with extensively generalized or severe symptoms or co-morbid depression. Try standard SSRIs or Effexor first; MAOIs may be more effective. Beta-blockers have little direct impact on anxiety but can be helpful in performance situations where physical manifestations of anxiety (e.g., sweating, tremor) undermine the performance or become distractions. Some patients need social skills training.
Screening question: Some people have an unreasonably strong fear of doing things in front of other people - like speaking in public, using public rest rooms, eating in public, or even talking to people. Have you had any of these kinds of fears?
Marked fear of specific, circumscribed objects or situations associated with severe distress upon exposure. Nearly all patients experience impairing avoidance. Impairment is often not evident to the patient, as they have incorporated accommodation to the phobia into their lives. Height phobias and claustrophobia are among our most commonly treated phobias. Snake and spider phobias are among the most common in the community but few people with these seek treatment. Blood, illness, and injury phobias are common, impede medical care, and should be treated, though they sometimes keep patients from even visiting the doctor's office.
Treatment - CBT for phobias is simple, quick, and extremely effective. These patients need help overcoming their reluctance to seek treatment.
Screening question: Are there things that you have been especially afraid of, like flying, seeing blood, getting a shot, heights, closed places, or certain kinds of insects or animals?
What are the treatment options?
Psychotherapy is considered first-line treatment for many anxiety disorders. It is also reasonable to start and/or augment with medication for severe symptoms, comorbid depression and/or if there are significant delays/hurdles to starting psychotherapy. SSRI and SNRI medications are safe and appropriate first-line pharmacological options for treating anxiety disorders.
Many variables influence the selection of medication for individual patients. The following is general information regarding beginning treatment.
Most common - sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexparo). These allow a low starting dose (12.5mg of Zoloft, 5mg of Celexa) and slow titration (anxiety patients are very vulnerable to initial activation and worsening of symptoms). Effective ranges: 50-200 mg of Zoloft, 20-40 mg of Celexa, and 10-20 mg of Lexapro. We routinely utilize much higher doses than those previously listed to treat OCD.
Sertraline may have fewer interactions with P450 enzymes. Citalopram (Celexa) and escitalopram (Lexapro) also have low interaction with P450 enzymes. We have experience using fluoxetine (Prozac) in very high doses (up to 120 mg/day), so it is often preferred in treatment-resistant OCD. That said, its long duration of action and tendency to be activating undermine our ability to use it as first line treatment for all anxiety disorders. Given its potent serotonergic properties, high-dose Lexapro (40 mg/day or even higher) is also a reasonable choice for OCD, though it can be activating, as well. Paroxetine is commonly used in primary care contexts, and is less activating and somewhat sedating in some patients. This can be advantageous in selected cases, but it also seems to more often produce weight gain and unusual cognitive effects, as well as higher rates of discomfort during discontinuation efforts.
We rarely use benzodiazepines as first line drugs for these disorders and generally discourage as needed/rescue use. Benzodiazepines remain widely used drugs for panic and other anxiety disorders in both primary care and mental health settings. While they have clear value in some circumstances, we avoid them as first line treatments because they so powerfully reinforce the anxious patient's wish for a simple and quick way to avoid the distressing experience of his or her anxiety. Overcoming this desire to flee distressing circumstances or feelings is the bedrock of CBT and is absolutely critical to successful long-term outcomes. Benzodiazepines often make these efforts more difficult.
Cognitive-Behavioral Therapy (CBT)
Highly specific treatments for each of these anxiety disorders have been developed and have proven efficacy in well-controlled trials. New data and APA guidelines now support CBT as a first line treatment for Panic Disorder. CBT clearly enhances long-term outcomes.
Basic Principles of Cognitive-Behavioral Therapy (CBT) for Anxiety Disorders: Fundamental Law of Anxiety and Exposure Therapy
Anything that triggers anxiety tends to be avoided. If frightening objects or situations are avoided, they will become more frightening over time. If the avoidance is overcome, and frightening objects or situations are repeatedly confronted without leading to the anticipated dangerous outcome, they become less frightening. We call this desensitization, and it can only occur through exposure. Fear of any anxiety arousing object or situation can be desensitized by a properly managed and structured exposure program. When done properly it always works. So, whenever the clinical picture includes anxiety cued by specific objects or situations, exposure principles are important to the treatment.
Cognitive Behavioral Therapy Treatments
Goal 1: Reduce fear of panic attacks themselves.
Primary technique: Cognitive restructuring
Approach: A central issue for most patients with panic disorder is an intense fear of the sensations they experience during a panic attack. These fears often include catastrophic misperceptions that something terrible may happen during a panic attack such as dying, having a heart attack, experiencing a stroke, fainting, smothering, going crazy or losing control. These "catastrophic misinterpretations" contribute to a "fear of fear" cycle that begins to trigger and intensify attacks in response to benign physiological experiences, like increased heart rate from rushing through the mall. Though the grave consequences that they fear never occur, patients are not easily convinced that they won't happen the next time. They continue to believe that they escaped catastrophe by fleeing and the next attack may finally bring it on.
Cognitive therapy is a form of psychotherapy that is used to help patients replace inaccurate, distorted, thinking with more accurate self-statements. In conducting cognitive therapy, the therapist works together with the patient to build a compelling argument that the patient's fears are irrational. Several sources of information are used to help patients think more accurately when their anxiety symptoms increase. One source of information is the patient's personal history of panic attacks. How many panic attacks, both large and small, have they experienced? How many predictions of catastrophe? How many actual catastrophes? A second source of information used to counter distorted thinking is the experiences of other panic disordered patients. How many patients with panic disorder seen at the anxiety clinic? (about 3,000 at last count), How many panic attacks in total? (many thousands) How many predicted catastrophes? (many thousands) How many actual catastrophes? (the answer is none, of course).
Another cognitive procedure is usually referred to as behavioral experiments. This technique is used to counter the commonly held belief that a particular patient's panic attacks are dangerous, different from the panic attacks that other patients experience. Most patients with panic disorder use several strategies in order to control their panic and prevent a catastrophe, including, fleeing the situation, taking a drink of water, eating something, or distracting themselves. During behavioral experiments, patients are asked to allow panic attacks to run their course, without interruption, in order to learn first hand that their panic attacks, like other patient's panic attacks, only seem to signal an impending calamity. So we say, "let the panic attack happen and let yourself experience it, using the cognitive techniques you are taught to help you through it; and it will become less frightening." This is very different from simple reassurance that nothing serious is wrong. Reassurance alone is not helpful and tends to undermine self-esteem. Patients need to know that we understand that they can't just talk themselves out of their fear. But we need to convince them that they can at least put up an argument. If practiced regularly, the cognitive techniques described above are often helpful in reducing the frequency and intensity of attacks.
Goal 2: Reduce fear of the physical symptoms associated with panic or anxiety (reduce anxiety sensitivity)
Technique: Exposure and desensitization to somatic cues
Approach: Systematic, paced, and repetitive exposure to the physical symptoms that they find most frightening. For those focused on cardiac symptoms and fear they are having a heart attack, we use exposure to the sensation of a pounding heart induced by exercise. For those focused on dizziness and fear of fainting, we use exposure to dizziness induced by spinning. For those frightened of lightheadedness or tingling, we use exposure to neurological symptoms induced by hyperventilation. The exposure process (called interoceptive exposure) is taught in session, and then practiced daily by patients in homework assignments.
Goal 3: Reduce fear and avoidance of agoraphobic situations
Technique: Exposure and desensitization
Approach: Systematic, paced, and repetitive exposure to the situations that are frightening and avoided. The exposure process is taught in session and then practiced daily by patients in homework assignments. The principle is very simple. If you are afraid of driving, the solution is to drive. If you are afraid of going to the mall, the solution is to go to the mall. The key is to accumulate sufficient exposure, properly paced, to allow the patient to sit through anxious distress long enough to allow it to extinguish, without removing themselves from exposure to the anxiogenic cues.
Generalized Anxiety Disorder (GAD)
Currently, the most effective treatments for GAD are Cognitive-Behavioral Therapy (CBT), SSRI antidepressants, or the combination of the two.
Cognitive-Behavioral Therapy: There are a number of evidence-based CBT treatments for GAD. The most effective treatment contains the following components:
- Education about worry and GAD
- Exploring positive beliefs about worry. Examples of positive beliefs about worry include, “worry provides motivation,” and “worry keeps me prepared, so if bad things happen I won’t be emotionally blindsided.”
- Increasing tolerance to uncertainty.To increase tolerance for uncertainty, patients are encouraged to seek out rather than avoid uncertain situations. For example, sending an email without checking for mistakes, or making decisions without seeking an abundance of information and seeking reassurance from others that you are making the right decision.
- Learning problem-solving skills to deal with present situations that trigger worry.While people with GAD have adequate problem-solving skills, they see problems as a threat rather than a normal part of life, so treatment seeks to achieve a more adaptive perspective on the problem so that problem solving skills can be more effectively used.
- Imaginal exposure to worries about future hypothetical situations, such as someday getting fired from your job or a loved one dying. While problem solving can address current problems, imaginal exposure is most effective for future hypothetical problems, such as “What if I lose my job some day or a love one dies?” This may involve taking time to imagine these possible events (challenging the urge to avoid which is effective in its own right) and imagine ways to cope with the problems.
Obsessive Compulsive Disorder (OCD)
Exposure and Response Prevention
Cognitive restructuring is less helpful in patients with OCD. The critical ingredient for successful CBT with OCD patients is direct exposure to the situations that trigger the patient's obsessions or compulsive rituals. This technique is referred to as exposure therapy. Simple exposure to fearful stimuli, however, is not enough for these patients. When patients expose themselves to anxiety provoking stimuli they must block any rituals used to prevent the harm that they anticipate as a consequence of the exposure. This technique is referred to as response prevention. Exposure and response prevention are used together in the behavioral treatment of OCD. For example, a patient with contamination fear and washing compulsions must practice repeated and extended exposure to his or her feared sources of contamination (e.g., touching door knobs, the floor, toilet seats) and resist all urges to wash or engage in any other "decontaminating" or anxiety reducing ritual in response to the exposure. At least 20 hours of actual exposure and response prevention are usually necessary for clinically meaningful desensitization to occur.
Obsessions are intrusive, disturbing thoughts that generate anxiety, disrupt functioning, but cannot be controlled by the patient. They often have violent, sexual, or blasphemous content. Patients with pure obsessions (no compulsive behaviors) are more difficult to treat behaviorally, but techniques using prolonged exposure to taped recordings of their obsessions, in their own voices, can be effective in some cases.
Post Traumatic Stress Disorder (PTSD)
Cognitive work: Focuses on helping patients understand their physiological reactivity as an understandable response to traumatic exposure and not evidence they are "going crazy." Also helps them reconstruct their shattered worlds, so they can engage in more realistic assessment of risks, their own competence, and the trustworthiness of other people.
Exposure work: Patients are often highly sensitized to specific cues linked to the traumatic experience. These require systematic exposure and desensitization. All avoidance needs to be addressed, whether it is of places, people, situations, or memories. Because of patients' sensitivities and reactivity, this work requires therapists who are particularly skilled, experienced, and interested in this type of work.
Cognitive restructuring: The cognitive work focuses on distorted expectations of negative social outcomes and hypercritical self-evaluations in social situations. Patients are taught to identify their negative thoughts (e.g. "It would be awful to make a mistake and say the wrong thing;" "I am a loser"), to find ways to concretely test and disconfirm them, with the goal of replacing these thoughts with more accurate self-statements.
Exposure work: The basic principle of graded exposure to increasingly challenging situations, with sufficient duration to allow desensitization to occur, is the same as in all exposure based treatments. The keys to treatment are development of appropriately graded exposure exercises to the patient's personally relevant social cues and compliance with exposure exercises of adequate frequency and duration. Group treatment is particularly useful as it provides a ready context for developing and practicing exposure exercises. Observing and correcting a fellow patient's obviously distorted self-assessments of performance is a powerful way to convince a patient that his or her self-assessments may also be distorted.
Exposure work: This provides the simplest application of the basic principle. Graded exposure inevitably leads to desensitization. The key is developing an appropriate set of graded exposure exercises and obtaining the patients compliance with them. The treatment is very straight forward with easily manipulated phobic objects (e.g., dogs, snakes, spiders, heights, driving) and somewhat more challenging, but still quite feasible, with less easily controlled phobic cues (e.g., airplanes, storms).