Anxiety Disorders

Overview
Occasional anxiety is an expected part of life. You might feel anxious when faced with a
problem at work, before taking a test, or before making an important decision. But anxiety
disorders involve more than temporary worry or fear. For a person with an anxiety disorder,
the anxiety does not go away and can get worse over time. The symptoms can interfere with
daily activities such as job performance, school work, and relationships.

There are several types of anxiety disorders, including generalized anxiety disorder, panic
disorder, and various phobia-related disorders.

Signs and Symptoms

Generalized Anxiety Disorder
People with generalized anxiety disorder (GAD) display excessive anxiety or worry, most
days for at least 6 months, about a number of things such as personal health, work, social
interactions, and everyday routine life circumstances. The fear and anxiety can cause
significant problems in areas of their life, such as social interactions, school, and work.

Generalized anxiety disorder symptoms include:

 Feeling restless, wound-up, or on-edge

 Being easily fatigued
 Having difficulty concentrating; mind going blank
 Being irritable
 Having muscle tension
 Difficulty controlling feelings of worry
 Having sleep problems, such as difficulty falling or staying asleep, restlessness, or
unsatisfying sleep

Panic Disorder
People with panic disorder have recurrent unexpected panic attacks. Panic attacks are sudden
periods of intense fear that come on quickly and reach their peak within minutes. Attacks can
occur unexpectedly or can be brought on by a trigger, such as a feared object or situation.

During a panic attack, people may experience:

 Heart palpitations, a pounding heartbeat, or an accelerated heartrate

 Sweating
 Trembling or shaking
 Sensations of shortness of breath, smothering, or choking
 Feelings of impending doom
 Feelings of being out of control
 People with panic disorder often worry about when the next attack will happen and actively
try to prevent future attacks by avoiding places, situations, or behaviors they associate with
panic attacks. Worry about panic attacks, and the effort spent trying to avoid attacks, cause
significant problems in various areas of the person’s life, including the development of
agoraphobia (see below).

Phobia-related disorders
A phobia is an intense fear of—or aversion to—specific objects or situations. Although it can
be realistic to be anxious in some circumstances, the fear people with phobias feel is out of
proportion to the actual danger caused by the situation or object.

People with a phobia:

 May have an irrational or excessive worry about encountering the feared object or situation
 Take active steps to avoid the feared object or situation
 Experience immediate intense anxiety upon encountering the feared object or situation
 Endure unavoidable objects and situations with intense anxiety

There are several types of phobias and phobia-related disorders:

Specific Phobias (sometimes called simple phobias): As the name suggests, people who
have a specific phobia have an intense fear of, or feel intense anxiety about, specific types of
objects or situations. Some examples of specific phobias include the fear of:

 Flying
 Heights
 Specific animals, such as spiders, dogs, or snakes
 Receiving injections
 Blood

Social anxiety disorder (previously called social phobia): People with social anxiety
disorder have a general intense fear of, or anxiety toward, social or performance situations.
They worry that actions or behaviors associated with their anxiety will be negatively
evaluated by others, leading them to feel embarrassed. This worry often causes people with
social anxiety to avoid social situations. Social anxiety disorder can manifest in a range of
situations, such as within the workplace or the school environment.

Agoraphobia: People with agoraphobia have an intense fear of two or more of the following
situations:

 Using public transportation

 Being in open spaces
 Being in enclosed spaces
 Standing in line or being in a crowd
 Being outside of the home alone

People with agoraphobia often avoid these situations, in part, because they think being able to
leave might be difficult or impossible in the event they have panic-like reactions or other
embarrassing symptoms. In the most severe form of agoraphobia, an individual can become
housebound.
 Separation anxiety disorder: Separation anxiety is often thought of as something that only
children deal with; however, adults can also be diagnosed with separation anxiety disorder.
People who have separation anxiety disorder have fears about being parted from people to
whom they are attached. They often worry that some sort of harm or something untoward will
happen to their attachment figures while they are separated. This fear leads them to avoid
being separated from their attachment figures and to avoid being alone. People with
separation anxiety may have nightmares about being separated from attachment figures or
experience physical symptoms when separation occurs or is anticipated.

Selective mutism: A somewhat rare disorder associated with anxiety is selective mutism.
Selective mutism occurs when people fail to speak in specific social situations despite having
normal language skills. Selective mutism usually occurs before the age of 5 and is often
associated with extreme shyness, fear of social embarrassment, compulsive traits, withdrawal,
clinging behavior, and temper tantrums. People diagnosed with selective mutism are often
also diagnosed with other anxiety disorders.

Risk Factors
Researchers are finding that both genetic and environmental factors contribute to the risk of
developing an anxiety disorder. Although the risk factors for each type of anxiety disorder
can vary, some general risk factors for all types of anxiety disorders include:

 Temperamental traits of shyness or behavioral inhibition in childhood

 Exposure to stressful and negative life or environmental events in early childhood or
adulthood
 A history of anxiety or other mental illnesses in biological relatives
 Some physical health conditions, such as thyroid problems or heart arrhythmias, or caffeine
or other substances/medications, can produce or aggravate anxiety symptoms; a physical
health examination is helpful in the evaluation of a possible anxiety disorder.

Treatments and Therapies

Anxiety disorders are generally treated with psychotherapy, medication, or both. There are
many ways to treat anxiety and people should work with their doctor to choose the treatment
that is best for them.

Psychotherapy
Psychotherapy or “talk therapy” can help people with anxiety disorders. To be effective,
psychotherapy must be directed at the person’s specific anxieties and tailored to his or her
needs.

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) is an example of one type of psychotherapy that can
help people with anxiety disorders. It teaches people different ways of thinking, behaving,
and reacting to anxiety-producing and fearful objects and situations. CBT can also help
people learn and practice social skills, which is vital for treating social anxiety disorder.
Cognitive therapy and exposure therapy are two CBT methods that are often used, together or
by themselves, to treat social anxiety disorder. Cognitive therapy focuses on identifying,
challenging, and then neutralizing unhelpful or distorted thoughts underlying anxiety
disorders. Exposure therapy focuses on confronting the fears underlying an anxiety disorder
to help people engage in activities they have been avoiding. Exposure therapy is sometimes
used along with relaxation exercises and/or imagery.

CBT can be conducted individually or with a group of people who have similar difficulties.
Often “homework” is assigned for participants to complete between sessions.

Medication
Medication does not cure anxiety disorders but can help relieve symptoms. Medication for
anxiety is prescribed by doctors, such as a psychiatrist or primary care provider. Some states
also allow psychologists who have received specialized training to prescribe psychiatric
medications. The most common classes of medications used to combat anxiety disorders are
anti-anxiety drugs (such as benzodiazepines), antidepressants, and beta-blockers.

Anti-Anxiety Medications

Anti-anxiety medications can help reduce the symptoms of anxiety, panic attacks, or extreme
fear and worry. The most common anti-anxiety medications are called benzodiazepines.
Although benzodiazepines are sometimes used as first-line treatments for generalized anxiety
disorder, they have both benefits and drawbacks.

Some benefits of benzodiazepines are that they are effective in relieving anxiety and take
effect more quickly than antidepressant medications often prescribed for anxiety. Some
drawbacks of benzodiazepines are that people can build up a tolerance to them if they are
taken over a long period of time and they may need higher and higher doses to get the same
effect. Some people may even become dependent on them.

To avoid these problems, doctors usually prescribe benzodiazepines for short periods of time,
a practice that is especially helpful for older adults, people who have substance abuse
problems, and people who become dependent on medication easily.

If people suddenly stop taking benzodiazepines, they may have withdrawal symptoms, or
their anxiety may return. Therefore, benzodiazepines should be tapered off slowly. When you
and your doctor have decided it is time to stop the medication, the doctor will help you
slowly and safely decrease your dose.

For long-term use, benzodiazepines are often considered a second-line treatment for anxiety
(with antidepressants being considered a first-line treatment) as well as an “as-needed”
treatment for any distressing flare-ups of symptoms.

A different type of anti-anxiety medication is buspirone. Buspirone is a non-benzodiazepine

medication specifically indicated for the treatment of chronic anxiety, although it does not
help everyone.

Antidepressants

Antidepressants are used to treat depression, but they can also be helpful for treating anxiety
disorders. They may help improve the way your brain uses certain chemicals that control
 mood or stress. You may need to try several different antidepressant medicines before finding
the one that improves your symptoms and has manageable side effects. A medication that has
helped you or a close family member in the past will often be considered.

Antidepressants can take time to work, so it’s important to give the medication a chance
before reaching a conclusion about its effectiveness. If you begin taking antidepressants, do
not stop taking them without the help of a doctor. When you and your doctor have decided it
is time to stop the medication, the doctor will help you slowly and safely decrease your dose.
Stopping them abruptly can cause withdrawal symptoms.

Antidepressants called selective serotonin reuptake inhibitors (SSRIs) and serotonin-

norepinephrine reuptake inhibitors (SNRIs) are commonly used as first-line treatments for
anxiety. Less-commonly used — but effective — treatments for anxiety disorders are older
classes of antidepressants, such as tricyclic antidepressants and monoamine oxidase inhibitors
(MAOIs).

Please Note: In some cases, children, teenagers, and young adults under 25 may experience
an increase in suicidal thoughts or behavior when taking antidepressant medications,
especially in the first few weeks after starting or when the dose is changed. Because of this,
patients of all ages taking antidepressants should be watched closely, especially during the
first few weeks of treatment.

Beta-Blockers

Although beta-blockers are most often used to treat high blood pressure, they can also be
used to help relieve the physical symptoms of anxiety, such as rapid heartbeat, shaking,
trembling, and blushing. These medications, when taken for a short period of time, can help
people keep physical symptoms under control. They can also be used “as needed” to reduce
acute anxiety, including as a preventive intervention for some predictable forms of
performance anxieties.

Choosing the Right Medication

Some types of drugs may work better for specific types of anxiety disorders, so people should
work closely with their doctor to identify which medication is best for them. Certain
substances such as caffeine, some over-the-counter cold medicines, illicit drugs, and herbal
supplements may aggravate the symptoms of anxiety disorders or interact with prescribed
medication. Patients should talk with their doctor, so they can learn which substances are safe
and which to avoid.

Choosing the right medication, medication dose, and treatment plan should be done under an
expert’s care and should be based on a person’s needs and their medical situation. Your doctor
may try several medicines before finding the right one.

You and your doctor should discuss:

 How well medications are working or might work to improve your symptoms
 Benefits and side effects of each medication
 Risk for serious side effects based on your medical history
 The likelihood of the medications requiring lifestyle changes
 Costs of each medication
 Other alternative therapies, medications, vitamins, and supplements you are taking and how
these may affect your treatment; a combination of medication and psychotherapy is the best
approach for many people with anxiety disorders
 How the medication should be stopped (Some drugs can’t be stopped abruptly and must be
tapered off slowly under a doctor’s supervision).

For more information, please visit Mental Health Medications Health Topic webpage. Please
note that any information on this website regarding medications is provided for educational
purposes only and may be outdated. Diagnosis and treatment decisions should be made in
consultation with your doctor. Information about medications changes frequently. Please visit
the U.S. Food and Drug Administration website for the latest information on warnings,
patient medication guides, or newly approved medications.

Support Groups
Some people with anxiety disorders might benefit from joining a self-help or support group
and sharing their problems and achievements with others. Internet chat rooms might also be
useful, but any advice received over the internet should be used with caution, as Internet
acquaintances have usually never seen each other and what has helped one person is not
necessarily what is best for another. You should always check with your doctor before
following any treatment advice found on the internet. Talking with a trusted friend or member
of the clergy can also provide support, but it is not necessarily a sufficient alternative to care
from a doctor or other health professional.

Stress Management Techniques

Stress management techniques and meditation can help people with anxiety disorders calm
themselves and may enhance the effects of therapy. Research suggests that aerobic exercise
can help some people manage their anxiety; however, exercise should not take the place of
standard care and more research is needed.

Join a Study
Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases
and conditions. The goal of clinical trials is to determine if a new test or treatment works and
is safe. Although individuals may benefit from being part of a clinical trial, participants
should be aware that the primary purpose of a clinical trial is to gain new scientific
knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct many studies with patients and healthy
volunteers. We have new and better treatment options today because of what clinical trials
uncovered years ago. Be part of tomorrow’s medical breakthroughs. Talk to your health care
provider about clinical trials, their benefits and risks, and whether one is right for you.

To learn more or find a study, visit:

 NIMH’s Clinical Trials webpage: Information about participating in clinical trials

 Clinicaltrials.gov: Current Studies on Anxiety Disorders: List of clinical trials funded by the
National Institutes of Health (NIH) being conducted across the country
 Join a Study: Adults - Anxiety Disorders: List of studies being conducted on the NIH Campus
 in Bethesda, MD
 Join a Study: Children - Anxiety Disorders: List of studies being conducted on the NIH
Campus in Bethesda, MD

Learn More
Free Brochures and Shareable Resources

 Generalized Anxiety Disorder (GAD): When Worry Gets Out of Control: A brochure on
GAD that explains the signs, symptoms, and treatment
 I’m So Stressed Out!: This fact sheet intended for teens and young adults presents
information about stress, anxiety, and ways to cope when feeling overwhelmed.
 Obsessive-Compulsive Disorder: When Unwanted Thoughts Take Over: A brochure on
OCD that explains the signs, symptoms, and treatments
 Panic Disorder: When Fear Overwhelms: A brochure on panic disorder that explains the
signs, symptoms, and treatments
 Social Anxiety Disorder: More Than Just Shyness: This brochure discusses symptoms,
causes, and treatments for social anxiety disorder (also called social phobia).
 Shareable Resources on Anxiety Disorders: Help support anxiety awareness and education
in your community. Use these digital resources, including graphics and messages, to spread
the word about anxiety disorders.

Multimedia

 NIMH Expert Discusses Managing Stress and Anxiety: Learn about coping with stressful
situations and when to seek help.
 GREAT: Learn helpful practices to manage stress and anxiety. GREAT was developed by Dr.
Krystal Lewis, a licensed clinical psychologist at NIMH.
 Getting to Know Your Brain: Dealing with Stress: Test your knowledge about stress and
the brain. Also learn how to create and use a “stress catcher” to practice strategies to deal
with stress.
 Guided Visualization: Dealing with Stress: Learn how the brain handles stress and practice
a guided visualization activity.

Federal Resources

 Anxiety Disorders (MedlinePlus – also en español)

 Specific Phobias (U.S. Department of Veterans Affairs)

Research and Statistics

 Journal Articles: References and abstracts from MEDLINE/PubMed (National Library of

Medicine).
 Statistics: Anxiety Disorder: This webpage provides information on the statistics currently
available on the prevalence and treatment of anxiety among people in the U.S.