Learn About Anxiety

Is Medication right for you?

“..all anxiety disorders have one thing in common: persistent, excessive fear or worry in situations that are not threatening…”

National Alliance on Mental Illness-NAMI [1]

Why is treatment so important? An Anxiety Disorder can significantly interfere with the enjoyment and functioning of life.

It prevents you from realizing your full potential.

Anxieties can range from a general and pervasive sense of worry or unease (Generalized Anxiety Disorder or “GAD,”) to something very specific and completely disabling, like the inability to leave the house (Agoraphobia). This article provides additional information I hope you find helpful to gain insight into the types of medications doctors may use in treating anxiety.

The purpose of this article is not to suggest medication is the only treatment course for Anxiety. It is intended to provide background about medications that a psychiatrist might suggest.

People do experience anxiety without having an Anxiety Disorder. Techniques for managing anxious feelings can be effective whether or not you have an Anxiety Disorder.

 “Anxiety is anticipation of a future threat…[and] includes[s] disorders that share features of excessive fear…the emotional response to real or perceived imminent threat.”  DSM-5 [2]

What is Anxiety?

A person may feel Anxiety is out of control or illogical. It can interfere with sleep, 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 many 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 Anxiety Disorder is made, the next order of business is treatment.

The subject of this article is 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 primary or even only option.

Medications

If medication is a treatment you and your psychiatrist decide to pursue, I hope it is helpful to understand more about how they 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. It is just that they came on the market approved for depression, and nobody wants to say the something long-winded like “antidepressant anti-anxiety agent.”

SSRIs

SSRI’s, 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 which 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 the newer medications. For example, Desyrel (trazadone), Remeron (mirtazapine), Clomipramine (anafranil) , Doxepin (Sinequan) and the MAO-I’s (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 benzo’s 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” or Professional 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
• Medical Licensing Exam (yes, doctors can have an Anxiety Disorder)
• Final Exams, quizzes, any test in an educational setting
• Psychological testing

Inderal

The drug Inderal [4] is used as an anti-anxiety medication. It is not approved by the Food and Drug Administration (FDA) to treat Anxiety, but it is the drug of choice for some doctors to treat syndromes such as public speaking or test-taking anxiety.  Performers or test-takers may find that, for instance, 20-40 milligrams (mg) of this drug an hour or two prior to the anxiety-provoking event does wonders. Inderal also comes in a long acting form (Inderal LA) and if effective, can be given around the clock. Sometimes it is prescribed along with short-acting Inderal when an acute anxiety provoking situation will occur or has the potential to occur.

Because Inderal appears to be more effective specifically in public-speaking and test-taking types of Anxieties [5], the patient and doctor will discuss in advance circumstances that provoke anxiety about a test or speaking situation.

How do Beta Blockers Work and Why are they Helpful for Test-taking and 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, tremo, 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.

 

Clonodine

In the same ballpark as Inderal is clonidine (generic for Catapres), in that it too is an old time cardiovascular drug whose effect on receptors serves to treat anxiety and panic attacks. [6]  It also happens to be the drug of choice for anxiety symptoms associated with opiate withdrawal (heroine, methadone, pain pills, etc.).

Neurontin

Neurontin (gabapentin) has been found in several research studies [7] to be effective for anxiety including social phobia and panic attacks as well as those anxious patients with the diagnosis of bipolar disorder.  It can be used as a stand-alone treatment for anxiety or in combination with other anti-anxiety medications.

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.

Anxiety has been treated with medication for decades with varying success. biblically referenced]  is “ethanol”—commonly called alcohol.)  

Anxiety has been treated with medication for decades with varying success.  Research and the introduction of ever-evolving pharmacological options provides physicians with tools to treat patients struggling with Anxiety Disorders.  Older medications continue to work well for some patients. A combination of medication to manage symptoms and side-effects is one consideration for patient and doctor. 

Anxiety is debilitating and eats into the enjoyment of life we all seek.

You may be settling for a “low normal” when the “new normal” of your potentiality is waiting to be realized once you manage and remove unnecessary anxiety.  If you suspect you have an Anxiety Disorder, the doctor is in—we are here to help.

Similarly, if a treatment program has not been working for you, Dr. Weiss’ mix of clinical experience and medical expertise may shed light on different approaches that might be more successful. 

 

You might be surprised to learn what isn’t Anxiety Disorder

OCD is not an Anxiety Disorder

Obsessive-Compulsive Disorder (including subtypes like Hoarding Disorder, washing one’s hands, or Trichotillomania or hair-pulling) used to be in the Anxiety Disorder realm but now merit their own diagnostic classification in the DSM-5.  Compulsive behavior can be very worrying. A person with OCD may also have an Anxiety Disorder. OCD itself, however, is not an Anxiety Disorder.

PTSD is not an Anxiety Disorder

PTSD also used to be considered an Anxiety Disorder but is now a separate diagnosis because criteria is complex and different from an Anxiety Disorder (though Anxiety is usually a feature of PTSD).

If you’re interested in learning more about PTSD, you might check out this article from the APA.

Endnotes

[1] Anxiety Disorders | NAMI: National Alliance on Mental Illness. (2017, December). National Alliance on Mental Illness. https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Anxiety-Disorders

[2] American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

[3] Off-label use of a drug means it is up to the physician’s discretion to decide if use of a drug is indicated for treatment even if that is not the FDA approved use of the drug. When the FDA has approved an indication, like beta-blockers for cardiovascular conditions, it reflects that that the drug in question has been found effective in a statistically robust clinical trial.  20 years after a pharmaceutical company first files a patent on a drug, it can be released in generic form. The pharmaceutical company may see a considerable decrease in demand for its brand-name medication. Research that is sponsored by the drug company may fall off, with the potential of creating a lack of research about off-label use of a drug.

[4] “Inderal (PROPRANOLOL): USES, Dosage, Side Effects, Interactions, Warning.” RxList, RxList, 23 June 2020, www.rxlist.com/inderal-drug.htm.

[5] Davidson J. R. (2006). Pharmacotherapy of social anxiety disorder: what does the evidence tell us?. The Journal of clinical psychiatry67 Suppl 12, 20–26.

[6] Hoehn-Saric R, Merchant AF, Keyser ML, Smith NVK. Effects of Clonidine on Anxiety Disorders. Arch Gen Psychiatry. 1981;38(11):1278–1282.  doi:10.1001/archpsyc.1981.01780360094011 . 

[7] Frye MA, Ketter TA, Kimbrell TA, et al. A placebo-controlled study of lamotrigine and gabapentin monotherapy in refractory mood disorders. J Clin Psychopharmacol. 2000 Dec;20(6):607-14

Resource:

National Institute of Mental Health public resource about Anxiety Disorders. “Anxiety Disorders.” National Institute of Mental Health, U.S. Department of Health and Human Services, July 2018, www.nimh.nih.gov/health/topics/anxiety-disorders/. Accessed online August 5, 2021

Disclaimer: This article is not intended to be a comprehensive overview of medications used to treat anxiety. This article is not updated on a regular basis and new medications are being released with frequency.

You should consult with your doctor if you believe you might have a medical condition.  

This is not a legal article and is not intended to be relied upon for legal purposes.