Syndromes of Anxiety and Their Treatment

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Your body and mind contain complex structures to alert you to danger and respond to it effectively. There are many ways for these systems and structures to malfunction. As a result, there are many different syndromes of anxiety, each with its own unique etiology, pathogenesis, and constellation of symptoms. Each syndrome requires a different approach.

Biological Causes of Anxiety It is important to rule out any medical causes of anxiety. Thyroid disorders, hypoglycemia, Cushing's disease, and pheochromocy-toma, a rare tumor of the adrenal gland, can cause symptoms similar to anxiety. You should consider a medical exam if your anxiety does not have an obvious cause.

Many drugs cause anxiety. Work with your doctor to avoid theophylline preparations used for asthma. Avoid decongestants like pseudoephedrine (Sudafed) and phenylephrine, as they invariably make people more anxious. The recreational drug that worsens anxiety the most is caffeine. Don't forget that caffeine is in sodas and chocolate, not just coffee and tea. Although you may feel calmer when you first drink alcohol, it causes a rebound anxiety when it wears off that may last for some days. The act of smoking may be a habit that relaxes you, but the nicotine in tobacco worsens anxiety. Cocaine, hallucinogenics, and amphetamines can make people acutely anxious during the period of intoxication.

Anxiety in a Crisis Sudden events like the death of a family member, physical illness, being fired, or involvement in a natural disaster can distress you and overwhelm your ability to cope. You may develop symptoms of anxiety, even though you've never had them before. Symptoms are generally limited to anxious thoughts and a feeling of apprehension, although you may be agitated and unable to sleep.

If your natural supports are insufficient to help you regain your equilibrium, psychotherapy is the treatment most likely to be of help. It can help you to express your feelings about the event so that you are able to make productive changes that allow you to move on in your life.

Benzodiazepines can be quite helpful in crises like these. They start working within thirty minutes, and the side effects of impaired memory and muscle coordination are usually negligible. They can also help you get to sleep. They are habit-forming if taken longer than four weeks, though, so try to limit your use.

Anxiety that arises as a result of a crisis may persist long after the crisis is over. If it does, you can help yourself the most if you maintain a good diet, eliminate caffeine and alcohol, and exercise regularly. You should definitely see a therapist to help you sort out your reaction to what happened and why you've become stuck. SSRIs or TCAs may help you feel less anxious, though they can take weeks to become effective.

Panic Disorder The syndrome of panic disorder consists of "panic attacks," the sudden onset of intense fearfulness accompanied by palpitations, shortness of breath, sweating, chest pain, nausea, and fears of dying or having a heart attack. Panic attacks can occur in a variety of situations and psychiatric disorders but most commonly occur in people who suffer from anxiety. The attacks themselves last from a few minutes to a few hours and are extremely unpleasant and intensely distressing. The worry about having another attack can be as disabling as the attacks themselves, especially if your worrying leads you to stay home and avoid anything that may precipitate an attack.

If you have panic disorder, you will benefit from eating a proper diet, eliminating caffeine and other drugs, exercising regularly, and practicing relaxation techniques. Psychotherapy can help you work on issues in your current life and past experiences that contribute to your anxiety. You may see a therapist for just a few sessions to help you during your current difficulties, or work for months or years on the underlying issues that led to your anxiety in the first place.

The treatment of panic disorder with medications can be divided into an acute and maintenance phase. Benzodiazepines provide the fastest and most effective relief. They are a poor choice for extended treatment, however, because of their addictive qualities and the heightened level of general anxiousness experienced with chronic use. SSRIs and TCAs take some weeks to become effective, but once this period is over, they generally provide lasting relief without daily anxiety. MAOIs are effective long-term, but their side effects are more troubling. Antipsy-chotics, antihistamines, beta-blockers, buspirone, and trazodone are generally ineffective for panic disorder.

Although some people rely on medications for years, the constant worry about having another attack takes its toll. It's hard to enjoy life and vigorously pursue all that it has to offer if you are constantly monitoring your level of anxiety and shaping what you do depending on how anxious it makes you feel. Psychotherapy and relaxation techniques may require more effort than medications, but they provide genuine long-lasting relief from anxiety so that you make your life as meaningful and satisfying as possible.

Phobias A phobia is an intense fear of objects such as animals or insects, environmental situations such as storms or water, or situations such as crowded or open spaces.

A single phobia, such as a fear of dogs, is generally best treated with behavioral therapy. The feared object isn't around enough to make treatment with medication useful or sensible.

Social phobia, which is a fear of embarrassment in social or performance situations, is experienced by 10 to 20 percent of the population. Behavioral psychotherapy aimed at helping you maintain calm in increasingly public situations is the most beneficial treatment. SSRIs and TCAs aid many people. Beta-blockers can help you feel calm for a specific event but will not work when taken on a daily basis.

Agoraphobia is a fear of being unable to escape from a crowded place. It often accompanies panic disorder, although some people experience agoraphobia without ever having a panic attack.

Benzos can make it easier to leave home. Having a pill in your pocket can fortify your courage to face the world. However, it is easy to become dependent on them. You then wind up spending enormous amounts of your mental energy assessing your current level of anxiety, how anxious you will be in the next two hours, and how anxious you'll be if you take a dose, a double dose, or skip it altogether. Anxiety, reinforced by the chronic use of benzos, can become a compass telling you where you can go and what you can do. Life gradually becomes a chore as you give up more and more of your activities. Try not to fall into the trap of chronic benzos just because they seem to help you at first.

SSRIs and TCAs help many people with agoraphobia. MAOIs can be helpful, too, but their side effects are more troubling. The side effects of antipsychotics make them a poor choice for phobias. The other medications are ineffective.

Posttraumatic Stress Disorder (PTSD) PTSD occurs after a traumatic experience that is potentially life-threatening. Symptoms include reexperiencing the event through intrusive recollections, nightmares, flashbacks, avoidance of people and situations similar to the events of the trauma, and persistent symptoms of increased arousal such as insomnia, hypervigilance, and an exaggerated startle response.

A sensible diet, the elimination of caffeine, alcohol, and drugs of abuse, regular exercise, and relaxation techniques can help you to gain some measure of control over the symptoms of PTSD. You may find psychotherapy helps to free you from the influence of the trauma in your life, though this work can be painful, difficult, and time-consuming.

There are no medications to "cure" PTSD, but they can minimize the intensity of some of the symptoms. SSRIs can lessen the intensity of anxiety, flashbacks, and improve sleep. TCAs and MAOIs can do the same thing but tend to cause more side effects. Benzos can minimize the anxiety and improve sleep, but are habit-forming and tend to lose their effectiveness after some months. You will go through a period of intense anxiety due to withdrawal effects if you stop them after months or years of use, so avoid their use for longer than four weeks. Antipsychotics in small doses can be helpful if your symptoms are truly overwhelming and other medications and treatments have proved inadequate. The other drugs listed above are usually ineffective.

Generalized Anxiety Disorder The major feature of this syndrome is excessive anxiety and worry about a number of activities and events in your life. You may find it difficult to control the worry and may notice chronic restlessness, easy fatiguability, difficulty concentrating, irritability, muscle tension, or insomnia.

A sensible diet, the elimination of caffeine, alcohol, and drugs of abuse, regular exercise, and relaxation techniques can help you feel somewhat more relaxed on a day-to-day basis. Psychotherapy may help you directly address the issues in your life that lead you to be anxious.

SSRIs and TCAs provide some benefit on a long-lasting basis and are probably the best first choice. Benzodiazepines are often used for this syndrome. They offer the most relief initially, but carry the problems associated with addiction: ineffectiveness over time with a rebound in symptoms if they are tapered off or stopped. Buspirone helps some people, but its effects are so mild most people experience minimal relief. Small doses of Trazodone can help but may make you tired. The side effects of antipsychotics make them a poor choice. The other medications are ineffective.

Obsessive-Compulsive Disorder (OCD) The syndrome of OCD is extremely distressing. When severe, it can impair work, relationships, and any semblance of a normal life. Obsessions, persistent intrusive thoughts, are invariably present. Common obsessions include persistent fear of contamination by germs and repeated doubts about such things as turning off the stove. Compulsions are repetitive behaviors or mental acts performed to reduce anxiety about some dreaded event or situation. Handwashing and checking rituals are common.

Although behavior therapy provides some people with partial relief, the most effective treatment is medication. Fluvoxamine (an SSRI) and clomipramine (a TCA) were the first two medications that research proved could be beneficial. Other SSRIs and TCAs have subsequently been shown to provide significant aid as well. Other medications and treatments generally provide no benefit.

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