How can psychiatry help with anxiety?

At its core, anxiety is a natural human response. We developed it to protect us from perceived threats. It’s our brain’s way of preparing and alerting us for a “fight or flight” response. 

Today’s triggers for anxiety have evolved since the time our ancestors depended on this mechanism for survival during danger and stress. 

What is anxiety?

When anxiety becomes chronic and persistent, people can develop what we diagnose as Generalized Anxiety Disorder. They experience excessive worry and apprehension about different areas of their lives, including work, health, relationships, and daily routines. The state of heightened arousal can be distressing and impair their ability to function optimally. 

Many medical aspects make up anxiety:

• Neurotransmitters—Anxiety involves complex interactions between neurotransmitters in the brain. The main neurotransmitters implicated in anxiety disorders are serotonin, gamma-aminobutyric acid (GABA), and norepinephrine. Imbalances in these chemicals can contribute to the development and maintenance of anxiety symptoms.
• The amygdala—This almond-shaped region deep within the brain plays a crucial role in processing emotions and detecting potential threats. In individuals with anxiety disorders, the amygdala may be overly sensitive, leading to exaggerated fear responses even in non-threatening situations.
• Genetics—Research suggests that there is a genetic component to anxiety disorders. Certain genetic variations may increase an individual's vulnerability to developing anxiety, although environmental factors play a significant role as well.
• Stress and trauma—Prolonged exposure to stress and traumatic experiences can shape the brain's response to anxiety. Such events may cause alterations in brain circuitry, amplifying anxiety responses even after the triggering events have passed.
• Medical conditions and substance use—Anxiety can also be a symptom of certain medical conditions or a result of substance use and withdrawal. Identifying and addressing these underlying issues is essential in the therapeutic process. 

What do psychiatrists look for when diagnosing anxiety?

First, we look to differentiate between fear and anxiety. Often used interchangeably, distinguishing between the two informs how we tailor for appropriate therapeutic outcomes. 

Fear is a response to an immediate and concrete threat. 

Anxiety is a more generalized feeling of unease about future events. Notable symptoms manifest emotionally, mentally, as well as physically. Symptoms include: 

• Excessive worry—Typically persistent and uncontrollable about various aspects in life. Usually disproportionate to actual threat. 
• Difficulty concentrating—Cognitive functioning might be impaired and impacts school, work, or other areas of life. 
• Irritability—Small stressors can provoke intense emotional reactions, which can in turn lead to conflicts in interpersonal relationships. 
• Restlessness—Feeling “on edge” or keyed up,” and finding it difficult to relax. The restlessness is a manifestation of heightened arousal associated with anxiety. 
• Muscle tension—Physical symptoms such as muscle tension and stiffness can lead to somatic complaints such as pain or discomfort.
• Fatigue—Persistent mental preparation to “fight or flee” can be mentally and physically draining, which leads to feelings of fatigue and exhaustion even when no physically demanding tasks were performed.
• Sleep disturbances—Difficulty falling asleep, and trying to maintain sleep can then exacerbate feelings of fatigue and impair overall well-being. 

Establishing a differential diagnosis

It is important not to predetermine a client's diagnosis and to remain unbiased by any previous diagnosis. Approaching each client through a new lens helps refine their presentation more accurately, as client presentations can often change with time and circumstance.

Establishing a differential diagnosis early and ruling out other causes of anxiety is critical. 

First, I work on ruling out any medical causes of perceived anxiety. For example: 

• Thyroid disorders—Hyperthyroidism can lead to increased heart rate, palpitations, and nervousness. Hypothyroidism can cause fatigue, irritability, and feelings of unease. 
• Cardiovascular disorders—Conditions such as arrhythmia, angina, and heart failure can trigger anxiety like symptoms, such as chest pain, shortness of breath, and the sensation of impending doom. Often, these symptoms feel like panic attacks. 
• Respiratory conditions—Chronic obstructive pulmonary disease or asthma can lead to breathing difficulties and feeling of panic, especially during exacerbations. 
• Neurological disorders—Conditions such as epilepsy, brain tumors, and multiple sclerosis can cause anxiety secondary to disruptions in brain functions or fear of experiencing neurologic events. 
• Endocrine disorders—Disruptions in the body’s hormonal balance can contribute to anxiety.
• Vitamin and mineral deficiencies—Lack of vitamins and minerals such as B12, magnesium, or iron can lead to symptoms like fatigue, irritability, and nervousness, resembling anxiety. 
• Chronic pain—Conditions such as fibromyalgia or migraines can be associated with anxiety due to ongoing physical and emotional burden. 
• Autoimmune diseases—Certain conditions like lupus or rheumatoid arthritis can have neuropsychiatric manifestations, including anxiety. 
• Medication side effects—Some medications may induce or worsen anxiety symptoms. This includes corticosteroids, stimulants, and even certain antidepressants and antipsychotics. 
• Substance use and withdrawal—Substance can be as benign as caffeine, prescriptions such as stimulants, or other substances, all of which can trigger anxiety. People can also experience rebound anxiety due to withdrawal from benzodiazepines or alcohol. 

Once I am confident that what the client has is an anxiety disorder and that the anxiety isn’t due to another condition, it is time to review my differential for the anxiety disorder. 

Generalized anxiety disorder 

GAD tends to be chronic, diffuse, and exaggerated worry about routine aspects of life. 

Panic disorder

This disorder shares some symptoms with GAD, such as excessive worry and anxiety. However, its hallmark is the occurrence of unexpected panic attacks. These manifest as intense episodes of fear accompanied by physical sensations such as palpitations, sweating, trembling, and shortness of breath. GAD on the other hand is a more chronic worry. 

Social anxiety disorder 

People with social anxiety disorder experience intense fear and anxiety in social situations, especially if it involves scrutiny or potential embarrassment. Per the name, GAD is more generalized and isn’t tied to social situations. 

Specific phobias

Phobias typically involve an irrational fear of a particular object or situation, such as heights, spiders, flying, or small enclosed spaces to name a few. 

Obsessive compulsive disorder 

OCD is characterized by intrusive and distressing thoughts or obsessions as well as repetitive behaviors performed to alleviate anxiety, called compulsions. GAD isn’t tied to specific thoughts or compulsions. 

Post traumatic stress disorder

A key distinction of this form of anxiety results from exposure to traumatic events. Symptoms can include flashbacks, nightmares, and emotional numbing, which are not common in GAD. 

What kind of treatment options are available for someone with anxiety? 

I believe therapy should always be a component of managing anxiety disorders. Evidence-based therapies such as Cognitive Behavioral Therapy, exposure therapy, and mindfulness-based therapies have demonstrated effectiveness in treating anxiety disorders. 

By identifying and challenging negative thought patterns, cognitive distortions, and guiding clients through gradual exposure to feared situations and fostering moment awareness, therapists add tools to our client’s toolbox for managing their anxiety. 

The first tenant in medicine is “Do No Harm.” My approach to treatment is to start with the least invasive, evidence-based, effective treatment option. 

For clients already in therapy for anxiety disorders who need further intervention, typically adding an SSRI is the least invasive treatment or option. SSRIs are FDA-approved and serve as a first line treatment for most anxiety disorders.

If SSRIs are ineffective, intolerable, or the client does not want to use it as part of their treatment plan—usually due to concerns about side effects—I’ll have a discussion with them. I walk them through the risks, benefits, and potential side effects of alternative options, and allow the client autonomy to play a significant role in their treatment planning.

Managing with medication

There are several options for treating anxiety with medication. Again, treatment depends on what the client wants to do as well as what works for them. Here is what we might use to treat anxiety. 

• Selective Serotonin Reuptake Inhibitors (SSRIs) serve as first line medication for most anxiety disorders. They increase the availability of serotonin, which is a neurotransmitter that aids in regulating mood and emotions. 
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) increase the levels of serotonin and norepinephrine, providing another option for managing symptoms. 
• Benzodiazepines provide short-term relief for acute anxiety or panic attacks. Ideally, they should be prescribed for short durations due to risk of dependence and withdrawal symptoms. 
• Buspirone is an anxiolytic medication that has a less potent effect compared to benzos and is more favorable when risk of dependence is a concern. 
• Beta blockers such as propranolol are often used to manage blood pressure and heart conditions. They can also be used on an as-needed basis, such as for situational anxiety and for events such as public speaking. They help control physical symptoms of anxiety such as trembling and a rapid heart rate.
• Antihistamines such as hydroxyzine also help provide a calming and anxiolytic effect, since histamine, a chemical messenger, has a role in anxiety and arousal in addition to an immune response. Hydroxyzine is often used as needed for anxiety, panic attacks, or insomnia. 
• There are many other classes of medications that can be used for anxiety, and newer treatments offer promising options for treating anxiety moving forward. Some of these include ketamine-assisted therapy, transcranial magnetic stimulation, deep brain stimulation, cannabinoids, and neurofeedback to name a few. 

Monitoring the effects of treatment

During treatment, I meet with clients to observe that the path we’ve taken is working for them and to make changes if necessary. 

There are several different reasons why we may need to change course. Over time, medications or the dosage can become less effective. Clients may experience side effects later on, such as changes in weight or sex drive. Clients might also have trouble with compliance—meaning they have difficulty taking medications correctly or at all. 

If it’s time to change course, we discuss dose adjustment, augmentation to add another medication, or changing the medication/treatment altogether to try a different path. Once again, the client's comfort level and preferences should be taken into account after discussing risks, benefits and potential side effects of alternative options.  

What I look for in terms of the effectiveness of treatment are:

1. Safety
2. Tolerability
3. Effectiveness

Safety is first, because some medications can have concerning, unintended effects—most of which are fairly uncommon, such as suicidal ideation, severe allergic reactions, and other effects. 

Clients need to be able to tolerate the medication. They may have difficulty with compliance over time if they experience unpleasant side effects, including nausea, abdominal pain, headaches, drowsiness, sexual side effects, weight gain, etc. 

Of course, we look to see that the treatment is effective. We want to see a reduction of presenting symptoms and improved functioning in the client’s daily life. I also look for subjective and objective improvement. Subjective improvement comes from the client’s feedback, and objective improvement comes from evidence-based tracking. 

Collaborating with therapists

Again, when working with a client through anxiety, I strongly recommend that they also engage in therapy.  Therapists often have more frequent and longer sessions with their clients, allowing a better and more intimate understanding of their psychological make-up and socioeconomic factors. 

I work with therapists on UpLift as a team, sharing notes about our clients to provide them with better care. And if any of my teammates have questions about our shared client’s anxiety or want to discuss their anxiety treatment, I’m happy to coordinate.