TO CONTROL MY ANXIETY, WILL I HAVE TO TAKE MEDICATIONS ALL MY LIFE?

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How long you need to take medication depends on many factors including the type of anxiety disorder, the presence of other disorders or illness, and whether you've gone through a course of psychotherapy. It also seems that the earlier the disorder started (e.g., age 10 or 11), the more chronic and tenacious the illness may be, and the more likely medications might be needed long-term. Another factor that may suggest a more persistent illness requiring medication is the presence of serious psychiatric disorders among many close relatives.

Fortunately, as a result of comprehensive research studies, physicians have guidelines that recommend the length of medication usage for particular problems with anxiety. The good news is that you do not need to make this call on your own. Let your prescribing doctor and your therapist, if you have one, help you determine if and when you are ready to discontinue your medications. Gradually decreasing the dosage often makes it easier to wean off a medication, and sometimes, this is the only safe way to go.

Further, there are psychotherapies that have been shown to treat anxiety disorders effectively. In fact, certain types of therapy have proven superior to medication in the long-term treatment of some anxiety disorders (e.g., cognitive-behavioral therapy for panic disorder). This may be because the skills learned in cognitive-behavioral therapy help an individual cope with panic on his own. Moreover, these skills are with him for the long-term and not discontinued like medications.

In pursuing psychotherapy for the treatment of anxiety, the individual should be prepared to assume responsibility for tackling the problem. Neither a prescribing physician nor a psychotherapist offers a magic remedy to remove anxiety. Ultimately, the patient must face her fears and demonstrate to herself that she will survive in spite of them.

It is not unusual to stop medicines and go many years without a return of anxiety symptoms, only to have them appear again. Do not despair. This often stems from severe stress or the development of another mental or physical disorder. With proper evaluation and treatment—a course of medications and/or psychotherapy—it is common to see anxiety symptoms diminish again.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD 

IF I STOP TAKING AN ANTIANXIETY MEDICINE, WILL I GET ANXIOUS AGAIN?

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If nothing else has changed, you may become anxious again. The reason is that most anxiety disorders are chronic and wax and wane over time. You may feel better with the anxiety medication, and then assume you are ready to stop your treatment, only to find that the anxiety returns. Here are some important exceptions:

Sometimes, our anxiety is associated with a life crisis—e.g., disaster, loss of a loved one—and will resolve on its own whether or not we use medication to aid our adjustment. In these cases, stopping the medications after a few months may not lead to increased anxiety.

If you have completed a successful course of psychotherapy while on medication, you may not experience a return of symptoms when you stop the medicine. Many factors contribute to the production of anxiety symptoms, including past experiences, your defenses, avoidance behaviors, and the way you think. These factors can often be identified in psychotherapy and remedied accordingly.

If you decide to stop your medications, talk to your physician about how to do so. As noted earlier, some anxiety medications are dangerous to stop abruptly.

 Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD 

WHAT SHOULD I BE AWARE OF IF I DECIDE TO TAKE MEDICATION OF MY ANXIETY?

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When considering medication for the treatment of anxiety, here are some suggestions.

1.When you tell your doctor about medications you are already using, make sure to include any over-the-counter drugs or alternative medicines, such as herbal supplements. Although we may think of these medicines as harmless, some can cause serious problems when combined with prescription medication.

2.If the prescribing doctor is new to you, make sure he or she is aware of any medical conditions—such as cardiac problems, high blood pressure, low blood pressure, pregnancy, nursing, and addictions—that could complicate your treatment.

3.Ask your doctor how the medication works and what to expect when you take the drug. What are the intended effects, and what are the side effects?

4.Find out what side effects signal the need for medical attention.

5.As much as we like to think of doctors as magicians, they rely on you to let them know what works and doesn't work. Sometimes, the initial prescription and dosage are just right for you. Other times, you need to work with your doctor to figure out the right dosage of the right medication. The process can sometimes feel discouraging, but stick with it. The rewards are worth it.

6.Ask your doctor up front how you would go about stopping the medication if it would need to be discontinued. It can be dangerous to stop certain medicines abruptly, and these need to be tapered off slowly under your doctor's supervision.

7.Follow your doctor's directions for when and how to take your medications, and expect the best.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD 

WHAT ARE THE LONG TERM SIDE EFFECTS OF MEDICATIONS ADVERTISED ON TELEVISION LIKE ZOLOFT AND PAXIL?

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The long-term side effects of the SSRIs, like Zoloft and Paxil, are fairly benign for adults. In general, they may cause weight gain or interference with sexual function. In some cases, sleep disturbance may be a long-term effect. A few people also complain of losing their normal range of emotions and may describe their feelings as numb.

When SSRIs are combined with a number of other drugs, other concerns may arise, such as the increased risk of liver toxicity. This risk is most likely in a small subset of the population (about 5 to 10%) who has a genetic predisposition to poor metabolism of medications.

Women who want to become pregnant or breast-feed should consult with their physicians or pharmacists regarding taking any of these medications. There can be adverse consequencess on the developing fetus or the nursing child. The long-term effects of these drugs on children and adolescents are less well-known.

Of course, if a person develops other illnesses and/or takes other kinds of medicines, the side effect profile might change considerably. Again, it is wise to consult with your physician.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

WHAT NEW DRUGS ARE BEING STUDIED FOR ANXIETY? HOW ARE RESEARCHERS HOPING TO IMPROVE ON CURRENT MEDICATION?

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Researchers are trying to develop new drugs that combine the benefits of benzodiazepines (the fast action) with the benefits of the SSRIs (effectiveness with fewer side effects). Parallel to new brain research, drug studies are focusing on the receptor for the body's natural tranquilizer, GABA. While GABA's anxiety-inhibiting effect was the basis for the development of the benzodiazepines, new research is zooming in on the receiving center for GABA and identifying specialized subunits—sort of like different lines coming into a phone center. Whereas benzodiazepines, like Valium, work across all the subunits at once, new drugs aim to specify which combinations of subunits to activate. Several pharmaceutical research labs are currently trying to produce fast-acting anxiety medications that don't include the addictive potential, sedation, memory impairment, or lack of coordination associated with existing benzodiazepines.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

MY DOCTOR MENTIONED THAT DRUGS LIKE NEURONTIN AND INDERAL ARE BEING USED TO TREAT ANXIETY? ARE THEY SAFE? WHAT ARE THE SIDE EFFECTS?

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Neurontin (gabapentin), an anticonvulsant, is a relatively safe medication, and is popular with psychiatrists and patients because it doesn't require monitoring of blood levels, as do other anticonvulsants. The side effects of Neurontin include dizziness, blurred vision (diplopia), lack of balance (ataxia), sleepiness (somnolence), and fatigue. Patients are advised not to drive or operate complex machinery until they have enough experience with the drug to know that it will not affect their performance. Another warning with Neurontin is that very rarely, the sudden discontinuation of the medication could result in a seizure.

Inderal (propranolol), a beta-blocker, is usually safe to use, but requires medical supervision. As with any prescription drug, don't be tempted to use a pill offered by a friend or family member. Inderal is not safe for individuals with asthma or severe breathing problems, as it can worsen these conditions. Side effects of Inderal include slowing of heart rate (bradycardia), lowered blood pressure (hypotension), cardiac arrhythmia, congestive heart failure for those at risk, depression, fatigue, lightheadedness, nausea, vomiting, diarrhea, and cramping.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

WHAT ARE THE SIDE-EFFECTS OF THE SSRI AND SSRI-LIKE ANTIDEPRESSANTS?

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Initial side effects of SSRIs often include mild nausea, loose bowel movements, anxiety, headache, and sweating. They usually disappear after a few weeks. Individuals taking SSRIs for an extended period of time may complain of weight gain. With some of the SSRIs, it is not uncommon to have sexual dysfunction. This is a later side effect and may remain until the medication is discontinued. For men, it may mean low desire, difficulty achieving an erection, trouble ejaculating, or delayed ejaculation (which is why this class of drugs is used in treating premature ejaculation). For women, it may mean low desire, trouble lubricating, or difficulty having an orgasm. Some people complain of sedation with these medications. It is usually helpful to have them taken before bedtime if that occurs. An additional side effect of the SSRIs is that patients occasionally report very vivid dreams.

The most harmful side effect, though rare, is serotonin syndrome. It is most likely to occur if two or more serotonergic medications are used simultaneously. Although there are isolated examples of this syndrome with one SSRI, the most important combination of drugs to avoid is that of an SSRI and an MAOI. Serotonin syndrome starts out with lethargy, restlessness, confusion, flushing, sweating, tremor, and sudden jerking of the feet. It can progress to increased temperature, generalized muscle rigidity, kidney failure, and even death.

In general, however, the side effects of the SSRIs are easier to tolerate than those of the tricyclics or the MAOIs. SSRIs are also much safer to use and are less dangerous if someone overdoses on them.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

WHAT ARE THE SIDE EFFECTS OF THE TRICYCLIC AND MAOI ANTIDEPRESSANTS?

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The side effects of the tricyclics are many, and some can be dangerous. Initially, patients can experience dry mouth, constipation, urinary retention, orthostatic hypotension (sudden lowering of blood pressure upon standing up), blurred vision, tachycardia (increased heart rate), and rarely, cardiac arrhythmias (with high doses). In the long-run, it is common to see weight gain and sexual dysfunction. If one overdoses on these medicines, the result can be fatal.

Common side effects of the MAOIs include orthostatic hypotension, headache, insomnia, weight gain, sexual dysfunction, peripheral edema (swelling), and afternoon sleepiness. If taken with certain forbidden foods or beverages (ones that contain tyramine—including aged cheeses, smoked meats, and certain wines), blood pressure can escalate and lead to a hypertensive crisis and possible stroke. Individuals taking these medications must be on a restricted diet.

Sedation is common in these medications, and some of them help individuals sleep better. Unfortunately, anxiety symptoms may worsen on initiation of these medicines—and any other antidepressants. The initial doses are best started low and slowly increased to therapeutic doses to keep this side effect to a minimum. Some doctors will start patients on a combination of an antidepressant and a benzodiazepine. It takes several weeks for the antidepressant to have an antianxiety or antidepressant effect. The benzodiazepines work quickly and can help the patient until the antidepressant kicks in.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

OF THE MEDICATIONS CURRENTLY AVAILABLE FOR ANXIETY, WHICH ARE HAVING THE MOST SUCCESS?

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The most popular medications for the treatment of anxiety are the newest class of antidepressants, the SSRIs—Prozac, Zoloft, Paxil, Lexapro, and Celexa. Some of the non-SSRI antidepressants (for instance, Effexor) are also promising.

Since the 1960s, the stand-by medicines for anxiety have been the benzodiazepines, known by names such as Valium, Librium, Ativan, Xanax, and Klonopin. They are quite effective and work quickly. They can also be sedating and are often used to help with insomnia. The biggest disadvantage of these drugs is that some people can become psychologically and/or physiologically dependent on them. Sometimes, a person may get a “buzz” from one of these drugs and subsequently abuse it like alcohol or other intoxicating substances. If a person becomes physiologically addicted, sudden withdrawal has been known to lead to seizures and even death. A subtler side effect of these drugs is a very slight loss of memory.

Unlike the benzodiazepines, the SSRIs were designed to treat depression. However, abundant research and clinical practice have shown that they are also effective in combating many forms of anxiety. Today, SSRIs are considered the first-line medication treatment for anxiety. Whereas SSRIs take longer to work—sometimes several weeks—they don't lead to marked physiological dependence. Sudden discontinuation of some SSRIs is associated with uncomfortable withdrawal-like symptoms, although rarely associated with seizures or death. Additionally, SSRIs do not produce an intoxicated feeling, and they generally do not impair memory. Unfortunately, SSRIs are usually more expensive because most of the patents on these drugs have not expired. Older antidepressants, such as tricyclics and monoamine oxidase inhibitors, can be effective in treating anxiety and are often less expensive. The downside is that they are loaded with side effects and are less safe than the SSRIs.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

I'VE HEARD THAT BENZODIAZEPINES HAVE MANY SIDE EFFECTS. WHAT ARE THEY? IS BusPAR A GOOD ALTERNATIVE?

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Benzodiazepines can promote calmness by increasing the level of GABA in your brain. However, they can also produce sedation and grogginess, lack of balance, and impaired memory. Other risks of use include:

1.    Excess muscle relaxation that can compromise breathing in people who have lung disease (respiratory suppression)

2.    Accident proneness, especially if combined with alcohol

3.    Psychological and/or physiological dependence for some individuals

4.    Recovering alcoholics who use benzodiazepines may lose control of their abstinence behavior.

Lowering the dose of the medicine can reduce some of these side effects.

Whereas benzodiazepines work on GABA, Buspirone, or BuSpar, is known as a partial 5HT agonist—this means it helps to increase the level of serotonin in your brain. It can be a good alternative for those concerned about the addictive potential of the benzodiazepines. BuSpar has the following advantages: it does not interact with alcohol to promote intoxication, lead to dependency, or cause impairment of mechanical performance like driving a car. In contrast to the quick action of the benzodiazepines, however, BuSpar can take several weeks to work, gradually reducing anxiety over time. BuSpar's side effects include nausea, headache, nervousness, insomnia, dizziness, and lightheadedness.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

WHAT ARE THE ADVANTAGES AND DISADVANTAGES OF USING THESE DRUGS?

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Let's look at each type of medication and their advantages and disadvantages:

I. Antidepressants

Examples: Tricyclics: Elavil, Tofranil, Norpramin, Pertofrane, Pamelor, Sinequan

MAOIs: Nardil, Parnate

SSRIs: Prozac, Paxil, Zoloft, Celexa, Luvox, Lexapro

Other: Effexor, Remeron, Cymbalta

Good News:

Generally effective

Not addictive like benzodiazepines

Tricyclics are particularly inexpensive

Bad News:

Can take weeks to months to work (usually two to six weeks)

Anxiety can become worse before it gets better

Temporary side effects: headache, sweating, dizziness, insomnia

Temporary and sometimes ongoing sexual side effects, e.g., loss of sex drive or inability to have erection or climax

Tricyclics and MAOIs can be unsafe, if not lethal, due to numerous side effects

II: Benzodiazepines

Examples: Valium, Librium, Xanax, Ativan, Klonopin

Good news:

They offer immediate relief, usually within hours

Excellent sleep aides, especially if used to initiate sleep

Bad news:

Can have sedative effect; if the dose is too high, intoxication can result

They are more likely to produce a psychological dependence and sometimes a physiological dependence—especially if you have a history of alcohol dependence

Certain types of benzodiazepines (those with a short half-life) can produce withdrawal and possibly seizure if stopped abruptly after several months; although this is a rare event, it can be life-threatening

III. BuSpar

Good News:

Doesn't lead to dependency

Sometimes used successfully to restore sexual functioning impaired by antidepressants

Bad News:

Effective with fewer individuals than the benzodiazepines

Takes three to four weeks to work

IV. Anticonvulsants

Example: Neurontin

Good News:

Seems to be effective at calming anxiety

Improves sleep

Bad News:

Side effects include sleepiness, dizziness, and “brainfog”

V. Beta-Blockers

Example: Inderal

Good News:

Reduces physical “fight-or-flight” symptoms, such as increased heart rate, sweating, shaking, and shortness of breath

Helpful in calming performance anxiety before public speaking or test-taking

 Bad News:

Very short-term effect

Physical effects, such as slowed heart rate, can be problematic

VI. Antihistamines

Examples: Benadryl, Vistaril

Good News:

Calming, sedating effect

Non-addictive, so there is less concern about potential for dependence

Bad News:

Not as effective as other medications for anxiety

Side effects include drowsiness, dry mouth, constipation, and urinary retention.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

CAN MEDICATION TREAT ANXIETY?

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Yes, several medications can treat anxiety, and each has its own benefits and drawbacks. The type of medication used is often determined by the kind of anxiety disorder a person has.

There are two categories of effective medicines along with a few medications that are in a class by themselves. Antidepressants and benzodiazepines are the two major categories. Antidepressants, now considered a first-line medication treatment for anxiety, are divided into four categories, including: (a) the original and rarely used tricyclics ; (b) the monoamine oxidase inhibitors (MAOIs); (c) the newer and more commonly used selective serotonin reuptake inhibitors (SSRIs); and (d) drugs similar to the SSRIs, such as Effexor.

In addition to these categories of drugs, an antianxiety medicine called BuSpar is available, and certain medications used to treat other conditions have been applied to the treatment of anxiety. Anticonvulsants, like Neurontin, are gaining popularity in their use by psychiatrists, although these medications are not well-studied as antianxiety agents. Beta-blockers, like Inderal, are another class of medications commonly utilized. Finally, antihistamines, such as Benadryl and Vistaril, are used in some cases to treat anxiety.

If you are considering medications, it is important to consult with a physician or psychiatrist who is experienced in prescribing medications for the treatment of anxiety. Treatment of an anxiety disorder may require a different dosage of a medication than indicated for other disorders. For example, a higher dosage of an SSRI may be needed for the treatment of obsessive-compulsive disorder than for the treatment of depression.

 Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

IF I SUFFER FROM ANXIETY, IS MY BRAIN DIFFERENT THAN OTHER PEOPLE'S?

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Over the years, researchers have attempted to identify brain chemicals and structures that may be involved in anxiety. Below are some of their findings.

A chemical in the brain called serotonin has been linked to several human functions, such as mood, sleep, memory, and appetite. Serotonin is active in a number of areas of the brain, including the amygdala , a structure that controls fear and anxiety responses. Research has suggested that people with anxiety disorders may suffer from a deficiency of serotonin. This may be why a class of antidepressants called SSRIs (selective serotonin reuptake inhibitors), which increase the level of serotonin in the brain, have been successful in the treatment of anxiety disorders. The amygdala itself is currently the focus of much research on anxiety disorders, and findings suggest that emotional memories stored in this portion of the brain may contribute to phobias.

Another promising area of continued investigation involves the brain amino acid GABA , short for gamma-aminobutyric acid. Evidence suggests that GABA may be deficient in people who suffer from anxiety. Research has shown that decreases in GABA can promote anxiety, restlessness, racing thoughts, and difficulty sleeping. By offsetting the effects of an excitement-producing brain chemical known as glutamate, GABA works to tone down brain activity and keep you calm. Benzodiazepines help boost the effect of the GABA in your brain. New research is focusing on the specific sites where GABA is received, and working to identify the functions of each of these sites. This opens up the possibility of developing medications that activate the good aspects of GABA without promoting addictive side effects.

Modern brain technology allows us to look at differences in how brains function. Through imaging technology, we can observe blood flow to certain areas of the brain, and notice differences in the size of structures within the brain. In addition to the amygdala, researchers have focused on the hippocampus , a part of the brain that helps to encode information into memories. Studies have shown that the hippocampus can be up to 25% smaller in people who have undergone severe stress because of child abuse or military combat. This may explain why these individuals experience flashbacks, fragmented memories, and difficulty recalling details of the events.

It is encouraging that the more we learn about brain structure and function in people with anxiety disorders, the more we may be able to treat these concerns with better medications and therapies.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

WHEN DO ANXIOUS PEOPLE USUALLY COME IN FOR TREATMENT?

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The point at which an anxious person seeks help often depends on the specific anxiety disorder, the person's personality, and what's going on in the environment. Here are some general observations:

1.    A person having a panic attack often seeks treatment in response to the attack, thinking she is either losing her mind or having a heart attack. She will typically rush to the emergency room to have it checked out and treated, without recognizing the problem as an anxiety disorder until it is diagnosed. People with panic attacks don't go long without seeking help.

2.    By contrast, people with obsessive-compulsive disorder may go years without seeking help, feeling ashamed of the problem and keeping it a secret.

3.    People with generalized anxiety disorder often accept their worrying as normal. Sometimes they develop somatic symptoms—body symptoms that are manifestations of anxiety. They might feel tension headaches, upset stomachs or bowels, muscle aches, tightness in their chests, and shallow breathing, all of which may be signs of anxiety. Many people who wouldn't see a doctor for worry will see one for somatic symptoms. Often, when a worrier has a particularly difficult life challenge or dilemma, the somatic symptoms are triggered.

4.    People with specific phobias may not seek treatment until the phobia clearly interferes with functioning in a more profound way. For example, someone with a fear of flying may not come in for help until he knows he must fly somewhere for his job.

5.    People with social phobias can have a very troublesome time getting help, as they are fearful of doing things in front of others that will cause them humiliation.

6.    Whether people seek help for acute stress disorder or posttraumatic stress disorder depends on how disruptive the symptoms are to their functioning. Just the thought of talking or thinking about the trauma again can be extremely unsettling, so people avoid seeking help. Often, PTSD sufferers initially attend treatment at the urging of loved ones—more to satisfy someone else than themselves.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

PEOPLE TELL ME THAT I THINK TOO NEGATIVELY. WHAT'S THAT ABOUT AND HOW CAN I CHANGE MY THINKING?

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Many people are in the habit of thinking negatively, but this habit can be altered. Diminishing negative thinking takes a willingness to question old, unhelpful, inaccurate ideas, and practice new, more helpful, accurate ones. Rational Emotive Behavior Therapy (REBT) and Cognitive Therapy , the two main foundations for cognitive-behavioral therapy, provide detailed explanations about the influence of overly negative thinking, as well as strategies for change.

REBT, developed by Albert Ellis, identifies 4 main types of irrational beliefs that all humans hold. These irrational beliefs generate extreme negative emotions and lead to more harmful behaviors. People do better when they challenge their irrational beliefs and develop more rational thinking (see chart ).

Cognitive therapy, founded by Aaron Beck, also holds that all people regularly make “thinking mistakes” known as cognitive distortions. Sticking with distorted thinking tends to make feelings worse; developing more realistic, balanced thinking tends to improve emotions and problem-solving. Here are some of the common thinking mistakes identified (source: Cognitive Therapy: Basics and Beyond by Judith Beck), with examples and alternatives:

Irrational Beliefs(lead to anxiety, panic, anger, rage, fury, and depression with less effective problem-solving) Demandingness  I should not have anxiety. The world should be fair and easy. Global Self/Other Ratings I'm no good. He's a jerk. Low Frustration Tolerance Because I don't like this, I can't stand it. Awfulizing  Because I don't like feeling anxious, that means it's awful, terrible, and horrible.

Rational Alternatives(lead to concern, irritation, sadness, or disappointment, with more effective problem-solving) Preferences  I wish I didn't have to struggle with anxiety, but I can face it. I wish the world were fair and easy, but it doesn't have to be. Behavior Ratings (Not Judging the Worth of a Person I made a bad decision; I'm not bad. He behaved poorly during our talk. Improved Frustration Tolerance I don't like this, but I can stand it. De-awfulizing Dealing with anxiety is a nuisance, but not horrible or awful.

All-or-Nothing Thinking: You see things in only two categories (good/bad, right/wrong, anxious/not anxious) without considering that there are “gray areas” or “in-betweens.”

Being anxious means being miserable vs. Being anxious is inconvenient.

Catastrophizing: You assume that the worst will happen without realizing that other, less upsetting outcomes might be more likely.

I'll never learn to manage my fears vs. I can learn to manage my fears if I work at it.

Emotional Reasoning: You think something is true just because you feel it is true (this is actually a very strong belief that you hold and you're sure you're right even if there is no evidence for your belief).

I know he's going to break up with me vs. He's told me he's very happy with me. There's no evidence that he wants to break up at this time.

Mind-Reading: You assume you know what someone else is thinking even without them telling you.

They think I'm a loser vs. I have no way of knowing what they're thinking.

Personalization: You think you are the reason that something bad happened or someone reacted negatively without taking other more likely explanations into account.

He didn't say hello because I've upset him in some way vs. He didn't say hello because he was distracted by his work.

Should/Must Statements: You have a “demand” for how things should be (e.g., your behavior, someone else's behavior) and you exaggerate how bad it is if things don't go the way you expect them to.

I shouldn't be this anxious—it's awful vs. Feeling anxious is often a hassle, but I can still enjoy my life.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

I CONSTANTLY TRY TO FIGURE OUT WHY I'M SO ANXIOUS. DO I NEED TO KNOW WHY IN ORDER TO MAKE THINGS BETTER?

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It's not surprising that you would want to understand why you feel so anxious. All people are information-processors—we like to comprehend the reasons behind events so that our world feels more predictable and manageable. Insight into “why” can help you identify old patterns and let them go. You could pursue an insight-oriented type of therapy (psychodynamic or psychoanalytic) and explore sources of anxiety in your personal history and relationships, which may help heal old wounds and free up energy for behavior change. The downsides to this approach are the time it takes and the cost. So, the question may really be, “How much insight do you need before making changes in your thinking and behavior?”

The alternative is to directly address the thinking and behaviors that are causing you problems (which can be done in cognitive-behavioral therapy, or CBT). This approach takes less time and asserts that, even if you completely understand the why behind your anxiety, you still need to make changes in your thinking and behaviors in order to get better.

Regarding your “why” question, we have found that people are anxious because of a combination of factors. Some of those factors include:

1.    Biological predisposition to emotional disturbance

2.    Family history of anxiety

3.    Individual temperament or personality characteristics

4. Social learning history (e.g., overprotective parents; unpredictable, volatile household)

5.   Environmental factors/stress (e.g., troubled marriage, job loss, illness)

6.Thinking (e.g., “I can't cope; I have no control; something terrible is going to happen.”)

7.Behaviors (e.g., avoiding problems, not getting adequate sleep, not speaking up for yourself, overextending yourself)

Perhaps the above list will help you identify some of the sources of your anxiety and free you to move forward with doing something about your anxiety. For many people, constantly asking “why?” is a distraction or avoidance technique that keeps them from facing the responsibility of making changes. Sometimes insight comes after you make changes! Ultimately, it is up to you to decide how much energy and time you want to put into exploring the “why” question. Remember, however, insight is important, but it is rarely enough for an improved quality of life.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

HOW DO I KNOW IF MY THERAPIST IS QUALIFIED?

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Mental health professionals can be identified in two different ways: (1) by level of education, and (2) by type of license. The level of education is usually represented by the letters directly following the person's name, and includes the following abbreviations (average years of education beyond college in parentheses):

MD: Medical Doctor (8-10 years)

DO: Doctor of Osteopathy (8-10 years)

PhD: Doctor of Philosophy (4-8 years)

PsyD: Doctor of Psychology (4-6 years)

MA: Master of Arts (2-4 years)

MS: Master of Science (2-4 years)

MSW: Master of Social Work (2-4 years)

MEd or EdD: Master/Doctor of Education (2-4 or 4-6 years)

MDiv/MMin or DDiv/DMin: Master/Doctor of Divinity/Ministry (2-4 or 4-6 years)

BSN or RN: Psychiatric Nurse (0-4 years)

The second set of initials after the professional's name refers to the license that person holds. In order to obtain a license, professionals are required to obtain a certain number of hours of supervised experience, to demonstrate an understanding of the ethical requirements of their profession, and to pass a test showing their competence in the field. Whereas MDs and DOs do not typically code their license in a second set of initials, those who have completed psychiatry residency and board certification identify themselves as psychiatrists You can ask any doctor which “boards” he or she is certified by. A doctoral degree from a graduate school (i.e., PhD) is usually required for licensure as a psychologist.

Here is a sampling of the license names and abbreviations associated with other professions:

Licensed Clinical Social Worker: LISCW

Licensed Marriage And Family Therapist: LMFT

Licensed Professional Counselor: LPC

Certified Pastoral Counselor: varies (check the website for the American Association of Pastoral Counselors at aapc.org).

This list does not cover every license issued to therapists. These vary by state, as do the titles and abbreviations for the license.

Beyond these quick indicators, it is up to you to find out the professional's areas of expertise and reputation, and to be honest with yourself about whether you trust and like your therapist. Usually a therapist will frame the first session or sessions as a “consultation” for the purpose of evaluating your problems as well as the “fit” between client and therapist. Sometimes people check out a few therapists before making a decision. Also, keep in mind that the “letters” after a clinician's name do not always indicate their expertise or qualification to treat a certain problem—you want to know what experience the clinician you see has in treating anxiety disorders in general, and your specific disorder in particular. Also, clinicians in supervised training programs may provide excellent service. Explore your options carefully.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

HOW MUCH DOES PSYCHOTHERAPY COST?

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The costs of psychotherapy vary according to the discipline of the professional and the insurance policy held by the patient, as well as the region of the country. Usually psychiatrists (medically-trained physicians) have the highest fees, followed in sequence by doctoral-level psychologists, master's-level psychologists, counselors, social workers, and psychiatric nurses. We say usually because the clinician's experience and reputation also factor into the equation and can compensate for differences in education. Psychiatrists have a medical degree and can conduct physical exams, order lab tests, and prescribe medicines. Not all psychiatrists provide psychotherapy-many refer patients to other mental health professionals for this treatment. On the other hand, there are some psychiatrists who refer patients out for medication management and focus exclusively on providing psychotherapy.

Health insurance companies differ in the amount of mental health coverage they provide, so it is wise to look at your specific plan. Most policies limit the number of sessions they will pay for per year. Twenty to twenty-six appointments per year is a common number, but every policy is different. If you rely on a managed care network, you may need to choose your therapist from a list of approved providers.

Fees may range from $50 to $200 a session, where each session lasts 45 to 60 minutes. When insurance does not cover the cost of therapy, some clinicians offer what they call a “sliding fee scale,” which bases your fee on your income. Other low-cost alternatives may be available, including university counseling centers, nonprofit clinics, and therapy training centers. It is always helpful to find out about your insurance coverage and your therapist's payment policies before starting treatment. This will save you any uncomfortable surprises, and help your therapy to progress more smoothly.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

HOW LONG DOES PSYCHOTHERAPY USUALLY TAKE?

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Psychotherapy for an anxiety disorder usually involves weekly sessions and can often be completed within a few months. Some therapies are shorter still, and others may take a year or more. The length is dependent on the type of therapy and the type of anxiety disorder, as well as the presence of complicating factors. Here are some factors that affect therapy length:

1. The cognitive-behavioral therapies are typically shorter than the psychodynamic ones. This is because cognitive-behavioral approaches focus on direct changes in thinking and behavior, whereas psychodynamic approaches take a broader approach and help resolve conflicts leading to problems.

2. The more longstanding the anxiety disorder, the longer it may take to have success.

3. If a patient has medical or additional psychiatric disorders, the therapy may take longer. When the anxiety co-occurs with a personality disorder, treatment might be more complicated and require a longer duration.

4. If consistent attendance at therapy sessions is a problem due to financial limitations, social or professional obligations, or the illness itself, the therapy may take longer.

One good predictor of therapy duration is how well the patient and the therapist get along with one another after two or three meetings. If they are comfortable with one another, the therapy is often more efficient and successful. It is also very important to develop a goal list with your therapist in the beginning stages of your meetings. What are you expecting to accomplish by attending therapy? The more specific your answer to this question, the better. A concrete goal list can serve as a roadmap for showing you what your targets are in therapy. Monitoring progress as you attend your therapy sessions is also vital.

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD

WHAT TYPES OF PSYCHOTHERAPY ARE MOST COMMONLY USED TO TREAT ANXIETY?

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The research consistently favors cognitive-behavioral therapy (CBT) as the most effective treatment for the various anxiety disorders. Psychodynamic therapy has a long history, but less research backing. A newer therapy called Eye Movement Desensitization and Reprocessing (EMDR) remains controversial, but is recognized as a treatment option for trauma-based anxiety disorder. Group therapy has also been used extensively with trauma victims as well as socially phobic individuals. Other approaches include clinical hypnosis and marital and family therapy. Whereas numerous other therapies exist, the above are most often discussed in the literature.

Because of its relevance to anxiety disorders, we will discuss CBT in more detail here.

Cognitive-behavioral therapy focuses on changing the thoughts (cognitions) and behaviors that maintain anxiety. The “cognitive” part involves the identification and modification of irrational, unhelpful thoughts (“It's terrible!”) that contribute to anxiety. Once the client learns to evaluate perceived threats more realistically, and through practice adopts more accurate beliefs (“It's inconvenient, but I can deal with it”), she can reduce her level of anxiety. An important foundation of CBT is the idea that our feelings and behaviors are not determined by actual events, but rather by our beliefs or thoughts about the events. Much of the work of CBT also focuses on addressing behaviors and providing exercises and assignments to help the client make changes in his day-to-day life (e.g., less avoidance, more pleasurable activities).

One of the most potent techniques in CBT is exposure therapy This approach involves exposing the client—in gradual steps—to whatever it is that is triggering his anxiety (e.g., traumatic memory, phobic stimulus). At each step, the client's anxiety is allowed to peak and then diminish before advancing to the next step, until the client can be in the presence of the trigger with little or no anxiety. Research has consistently found exposure to be a key element in the effective treatment of anxiety.

Therapies that focus on interpersonal relationships , such as couples', family, and group therapy, may also be valuable. With these types of interventions, people come to better understand how to communicate clearly and resolve differences better. Individuals may also be taught some specific skills to ease anxiety in social situations.

Therapists who use a psychodynamic approach help you become aware of secret and forbidden wishes, as well as the hidden defenses you use to repress these wishes. This approach may take several months to years. The forbidden wishes (meaning we think punishment will happen if we think or feel or act on them) are thought to be part of all of us and to generate anxiety when we become aware of them. Psychodynamic therapists believe that we can reduce anxiety and assume more control over our decisions by reevaluating and accepting these forbidden wishes. The psychodynamic approach, which draws its support from case studies, parent-child observation, and conventional wisdom, is much less structured and thus difficult to research.  

Source: The Anxiety Answer Book by: Laurie A. Helgoe, PhD, Laura R. Wilhelm, PhD, Martin J. Kommor, MD