What Is Anxiety?

A person may feel anxiety is out of control or illogical. It can interfere with sleep or even get in the way of work or family life because a person’s anxious thoughts prevent them from concentrating on other tasks. There are other examples of ways anxiety changes from “feelings” to something more seriously detrimental to life-functioning. An anxiety disorder might be helped by medication—a decision to be made with your psychiatrist.

Before diagnosing an anxiety disorder, psychiatrists consider criteria described in the DSM-5 (Diagnostic and Statistical Manual 5th edition published by the American Psychiatric Association). ^[2]

Common anxiety disorders include

• Generalized Anxiety Disorder
• Phobias (including Social Phobias, Agoraphobia, or specific types of phobias like a fear of blood, flying, or spiders)
• Panic Disorder

Treatment

Once the diagnosis of an anxiety disorder is made, the next order of business is treatment.

The subject of this article addresses medication, though that is by no means the only treatment available for an anxiety disorder.

Non-Medication Treatment

Before discussing psychiatric medication treatment for an anxiety disorder, it is crucial to understand that the treatment for the underlying disorder includes non-chemical options. For example, types of psychotherapy or counseling, as well as ancillary treatments like meditation, relaxation techniques, exercise, and nutrition are key to enhancing effective medication treatment, as well as allowing medication weaning if possible.

If medication treatment is started and the patient does not undertake treatment for the underlying problem, then when the medications are stopped the anxiety symptoms are likely to reappear, making it crucial to include non-medication treatment for the anxiety disorder. 

If medication treatment is started and the patient does not undertake treatment for the underlying problem, then when the medications are stopped the anxiety symptoms may reappear, making it crucial to include non-medication treatment for the anxiety disorder. 

Medication is not always the only or even primary option.

Medications

If medication is a treatment you and your psychiatrist decide to pursue, it is helpful to understand more about how these medications work.

Anti-anxiety medications can be grouped into a few categories:

Antidepressants That Help With Anxiety

Antidepressants may also address anxiety in addition to depression. In fact, these antidepressants are sometimes called “anti-anxiety agents.” Not all antidepressants treat anxiety, but it is important to know that the term “antidepressant” doesn’t limit the benefits of the drug to treat anxiety.

In fact, the term “antidepressant” is an anachronism in that many of these medications are approved by the FDA (Food and Drug Administration) to treat various anxiety disorders. They may continue to be known as “antidepressants” rather than a long-winded name such as “antidepressant anti-anxiety agent.”

SSRIs

SSRIs, like Prozac, Paxil and Zoloft are approved by the FDA to treat anxiety and depression. SSRI stands for ‘selective serotonin reuptake inhibiter’–a mouthful. What is important is that they can be effective in treating anxiety. Most SSRIs are readily available in an economic generic form: Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), Celexa (citalopram), Lexapro (escitalopram). New medications are released frequently. Not all are available in generic form. To list them all is impractical, but you get the idea.

Another class of antidepressants that can help anxiety by affecting serotonin (and other neurotransmitters) are termed “dual reuptake inhibiters” or “serotonin-norepinephrine reuptake inhibitors (SNRIs)”. These include Cymbalta (duloxetine), Effexor (venlafaxine), and Pristiq (desvenlafaxine).  Neurotransmitters, and the role they play in how we feel, needs its own article. Watch this space. Suffice to say, the relationship between the brain, anxiety, and depression is complex, as is the science behind the medications that treat them.

Older Antidepressants That are Still Used Effectively for Depression and Anxiety

Older antidepressants are still prescribed because they may be more effective for some patients than newer medications. For example, Desyrel (trazadone), Remeron (mirtazapine), Clomipramine (anafranil), Doxepin (Sinequan) and the MAO-Is (Marplan, Nardil, and Parnate) are all utilized (“off-label”)^[3] for anxiety treatment. So even though they are not officially “approved” by the FDA for anxiety, studies show, and clinical experience demonstrates, their efficacy. (It is possible that by the time a drug was proven to be effective for an off-label treatment, the drug had “gone” generic, was inexpensively available, and no drug company put forth the time, effort and money to get it approved as profits would not be realized.)

Benzodiazepines: Relaxing Drugs That Treat Anxiety Disorders

Benzodiazepines are a class of medication that have a relaxing effect, like Ativan, Xanax, Klonopin/Clonazepam, or Valium.  Benzodiazepines are sometimes called “benzos” for short.

Benzos can be addictive and require close monitoring by a psychiatrist—who is a licensed physician. Non-benzodiazepine alternatives exist though they may not be as effective. Discuss all options with your Psychiatrist.

Patients who may be at risk to become dependent on the potentially addictive benzos include, for example, beta-blockers like Inderal (generic propranolol), Neurontin (gabapentin) and Buspar (buspirone).

Anti-Anxiety Medications That Target a Particular Type of Anxiety

Public Speaking and Test-Taking Anxiety

Any situation where a person is anxious because they must speak in front of others can trigger anxiety associated with an anxiety disorder. Anxiety symptoms are mainly in the form of bodily sensations like sweating, heart racing and palpitations, etc. It is also normal for a person to experience anxiety in these situations without having an anxiety disorder. However, a person with an anxiety disorder may become disabled by their anxiety. This can occur in any walk of life.

Public Speaking

• Speech, before other students and teachers
• “Stage fright” (including, but not limited to, musicians and actors prior to a performance)
• Presentation at work in front of colleagues and your boss
• Professional presentation in a formal setting like a club or organization
• Speech at a conference, alone or on a panel
• Religious presentations such as a sermon, or Bar or Bat Mitzvah require a person to stand before others and a speak on a topic
• A person who must take the stand in a trial. This includes witnesses, plaintiffs or defendants, expert witnesses…anyone who might be speaking in Court, testifying at a deposition or the attorney posing questions in this setting.

Test-Taking Anxiety

Any test can trigger anxiety. An anxiety disorder may make it impossible to succeed by passing a test without medication and other treatment.

• SAT or ACT
• Bar exam
• GMAT (Graduate School)
• Medical licensing exam (yes, doctors can have an anxiety disorder)
• Professional licensing exams. Virtually hundreds of professionals are required to take exams to be qualified to pursue their career
• Final exams, quizzes, any test in an educational setting
• Psychological testing

How Do Beta Blockers Work and Why Are They Helpful for Test-taking and Public Speaking?

Beta blockers, like Inderal, work by blocking beta receptor sites in the nervous system and body in general. They are used to treat high blood pressure and heart conditions, but it is now recognized that they decrease the physical symptoms of anxiety (e.g., palpitations, accelerated heart rate, sweating, tremors, and other symptoms due to adrenaline over-activity in the adrenals and elsewhere).

Intuitive reasoning is how a person deals with stress and fear if they are not disabled by anxiety. Studies show that when intuitive reasoning is replaced by anxiety, bodily symptoms occur first, at which point the subconscious mind detects that the person has become anxious. Physicians report that Inderal administered shortly before the event can be helpful, although the research is still ongoing to discover the true underlying nature of anxiety and its cure.

Buspar (Buspirone)

Buspar is an old-time drug approved by the FDA for treatment of anxiety, particularly GAD or generalized anxiety disorder.  It is a good example of just how complex these drug mechanisms of action can be and the difficulty in extrapolation to clinical effect.  For instance, Buspar works on several of the serotonin receptors as well as dopamine receptors.  Effects impact various parts of the nervous system from the more primitive brainstem to the higher level functioning neocortex.