Psychotherapy techniques :

Generally, anxiety disorders are treated with medications, specific types of psychotherapy, or both. Treatment choices depend on the symptoms and the preference of the doctor and patient.

Psychotherapy: Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor, to discover what causes an anxiety disorder and how to deal with its symptoms.

Cognitive-Behavior Therapy (CBT): Many therapists use a combination of cognitive and behavior therapies, this is often referred to as CBT. Cognitive-behavioral therapy is based on the scientific fact that thoughts cause feelings and behaviors, not external things, like people, situations, and events. The benefit of this fact is that an individual can change the way they think to feel and act better even if the situation causing the problem does not change.

Relaxation Techniques: Relaxation Techniques help individuals develop the ability to more effectively cope with the stresses that contribute to anxiety, as well as with some of the physical symptoms of anxiety. The techniques taught include breathing re-training and exercise.

Anti-anxiety medications :

Benzodiazepines: Benzodiazepines are fast-acting sedatives that typically relieve anxiety symptoms within 30 minutes to one hour. The rapid relief when using benzodiazepines makes them very effective when taken during a panic attack or another overwhelming anxiety episode.

Unfortunately, benzodiazepines can be addictive. If taken regularly for more than a couple of weeks, physical and psychological addiction is likely to occur. Benzodiazepine may create tolerance, with larger doses needed to achieve the same effect, and serious withdrawal symptoms can occur when going off the medication, including increased anxiety, depression, and insomnia. Some benzodiazepines, including diazepam (Valium®) have a longer half-life in the body, meaning they stay in the body longer. The addictive potential is why benzodiazepines are usually recommended only for short-term. To minimize the withdrawal reaction, it is important to slowly taper off these medications.

Some examples of benzodiazepines include alprazolam (Xanax®), chlordiazepoxide (Librium®), clonazepam (Klonopin®), clorazepate (Tranxene®), lorazepam (Ativan), oxazepam (Serax), diazepam (Valium). Clonazepam (Klonopin®) is commonly used for social phobia and GAD, lorazepam (Ativan®) is used for panic disorder, and alprazolam (Xanax®) is useful for both panic disorder and generalized anxiety disorder (GAD).

Most common side effects include drowsiness, impaired coordination, fatigue, confusion and disorientation, dizziness, decreased concentration, short-term memory problems, dry mouth, blurred vision, and irregular heart beat.

Azapirones: Azapironeswere developed more recently than benzodiazepines, and are anti-anxiety drugs prescribed for GAD and obsessive compulsive disorder (OCD). Compared to benzodiazepines, the azapirones are slow acting, taking from two to four weeks to provide anxiety symptom relief. Advantages of these drugs over benzodiazepines include less sedation and effects on coordination, and less memory impairment. Withdrawal effects with azapirones are minimal compared to benzodiazepines. Buspirone (Buspar®) is the only azapirone approved for medical use.

Side effects may include nausea, headaches, dizziness, drowsiness, upset stomach, constipation, diarrhea, and dry mouth. Azapirones are not to be taken with monoamine oxidase inhibitors (MAOIs, a type of antidepressant) due to the increase risk of life-threatening high blood pressure.

Antidepressant medications :

Selective serotonin reuptake inhibitors (SSRIs): SSRIs are antidepressants that alter the levels of the neurotransmitter serotonin in the brain. SSRIs have been used to treat panic disorder, obsessive-compulsive disorder (OCD), and generalized anxiety disorder (GAD). They are often prescribed because they have less severe side effects than the older antidepressants.

Some SSRIs used in anxiety disorders include fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and citalopram (Celexa®) which are commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. SSRIs generally are started at low doses and gradually increased until they have a beneficial effect.

Tricyclic antidepressants (TCAs): TCAs are older antidepressants that may be prescribed for panic disorder, obsessive-compulsive disorder (OCD), and generalized anxiety disorder (GAD). Tricyclics can also be prescribed for anxiety disorders co-occurring with depression. The tricyclics typically take around two weeks to provide symptom relief.

Tricyclics include imipramine (Tofranil®), which is prescribed for panic disorder and GAD, and clomipramine (Anafranil®), which is the only tricyclic antidepressant useful for treating OCD.

Monoamine oxidase inhibitors (MAOIs): MAOIs are the oldest class of antidepressant medications.

The MAOIs most commonly prescribed for anxiety disorders are phenelzine (Nardil®), followed by tranylcypromine (Parnate®), and isocarboxazid (Marplan®), which are useful in treating panic disorder and social phobia.

Atypical antidepressants :

There are several newer atypical antidepressants which target other neurotransmitters either alone or in addition to serotonin. Some of the brain chemicals they affect include norepinephine and dopamine.

Venlafaxine (Effexor®), an atypical antidepressant, is used to treat GAD.

Antidepressants take up to four to six weeks to begin relieving symptoms, so they aren't helpful if first taken during a panic attack.

Antidepressants are often prescribed instead of benzodiazepines because the risk for dependency and the abuse is less.

Antidepressant can cause loss of sexual desire, nausea, insomnia, sweating, nervousness, dizziness, weight gain or weight loss, dry mouth, constipation, and blurred vision. MAOIs also have severe interactions with certain foods, drinks, and medications. When an individual takes an MAOI, he or she must carefully monitor what is eaten and what drugs are taken. Items that are restricted include many cheeses, chocolate, wine, and beer.

Beta-blockers :

Beta blockers are type of drug used to treat high blood pressure and heart problems. In anxiety, beta blockers can help control physical symptoms such as nervousness, rapid heart rate, trembling voice, sweating, dizziness, and shaky hands. Beta blockers are prescribed off label for anxiety.

Because they don't affect the emotional symptoms of anxiety such as worry, beta blockers are most helpful for phobias, particularly social phobia and performance anxiety (such as a speech or being in front of an audience).

Examples of beta blockers include propranolol (Inderal®), metoprolol (Lopressor®) and atenolol (Tenormin®).

Side effects include light-headedness, sleepiness, short-term memory loss, unusually slow pulse, fatigue, insomnia, diarrhea, cold hands and feet, and sexual side effects.

Strong scientific evidence :

Kava: Kava kava (Piper methysticum) is a shrub from the South Pacific islands that has been used for centuries to produce calming effects in humans. Studies have found moderate benefit of kava in the treatment of anxiety, and preliminary evidence suggests that kava may be equivalent to benzodiazepine drugs such as diazepam (Valium®). In one human study, kava's effects were reported to be similar to the prescription drug buspirone (Buspar®) used for generalized anxiety disorder (GAD). However, a recent study found no effect in generalized anxiety disorder. The kava supplement should be standardized for best results.

There is concern regarding kava's potential toxicity, based on multiple reports of liver damage in Europe and a number of cases in the United States, including hepatitis, cirrhosis, and liver failure. The U.S. Food and Drug Administration (FDA) has issued warnings to consumers and physicians. Kava should not be used in individuals with pre-existing liver conditions or a history of alcohol or drug abuse. Caution is advised when taking kava as numerous adverse effects including sedation and drug interactions are possible. Kava should not be used if pregnant or breastfeeding.

Music therapy: Music is an ancient tool of healing. Many different forms of music intervention have been used to reduce anxiety in a variety of medical conditions and medical procedures. Most studies have positive findings, although not all do. There is evidence that music interventions help reduce anxiety related to cataract surgery, sigmoidoscopy, bronchoscopy, breast biopsy, cesarean delivery, colonoscopy, esophagogastroduodenoscopy, cardiac catheterization, hospitalized asthmatic patients, psychotherapy, general medical procedures, radiation therapy, treatment for acute myocardial infarction, preparation for surgery, total knee arthroplasty, ventilator-dependence and transurethral resection of the prostate (TURP). Many of these studies have found reduced blood pressure and heart rate as well. A minority of studies found no benefit including studies related to mammogram, ischemic heart disease, pediatric outpatient surgery, and cardiac catheterization. The choice of music may be a factor in outcomes: listening to music of one's preference has been found to be an important consideration. Overall, the evidence favors use of music interventions for anxiety, although more studies are needed to determine what forms work best.

Good scientific evidence :

Aromatherapy: Fragrant oils have been used for thousands of years. Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. Several small studies report that lavender essential oil aromatherapy is able to cause reductions in anxiety levels. Additionally, rosemary (Rosmarinus officinalis) essential oil is frequently used in aromatherapy for treatment of a variety of conditions, including anxiety. Early study has shown benefit in reducing stress levels and increasing alertness. More study is needed to draw a firm recommendation. The use of aromatherapy for anxiety disorders needs more research.

Art therapy: Art therapy may enable the expression of inner thoughts or feelings when verbalization is difficult or not possible. Some evidence suggests that creative expression programs in schools involving art therapy may help alleviate problems of self-esteem and can improve social functioning in school age children. However, there is some evidence suggesting that art therapy may not benefit children with PTSD symptoms. Limited evidence suggests that art therapy, in the context of group psychotherapy, may contribute to reduction of symptoms of emotional distress in military personnel receiving mental health treatment.

Hypnosis: Hypnosis is associated with a deep state of relaxation. Several studies support the use of hypnosis to reduce anxiety, particularly prior to dental or medical procedures, or in the management of phobias. Early evidence suggests that these effects may last for up to three years with benefits reported in children and adults.

Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional (psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner). Psychotherapy, especially cognitive behavioral therapy, may help decrease the symptoms of anxiety disorders when used along with medications, including GAD, OCD, panic disorder, and PTSD.

Relaxation therapy: Clinical studies suggest that relaxation techniques may be beneficial in patients with anxiety, although these approaches do not appear to be as effective as psychotherapy. Numerous human studies report that relaxation techniques (for example using audio tapes or group therapy) may moderately reduce anxiety, particularly in individuals without significant mental illness. Relaxation may be beneficial for phobias such as agoraphobia (fear of crowds), panic disorder, work-related stress, and anxiety due to serious illnesses, prior to medical procedures, or during pregnancy. However, there are many types of relaxation techniques used in studies, and many trials do not clearly describe design or results.

Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Yoga may reduce daily stress and anxiety in healthy people when practiced several times weekly. Several human studies support the use of yoga therapy in the treatment of clinical anxiety disorders, including generalized anxiety and OCD. Available data remains inconclusive, yet thousands of years of effectiveness in India for stress and anxiety must be appreciated.

Unclear or conflicting scientific evidence :

Acupressure: Acupressure, or shiatsu, has been used in China for thousands of years for health and healing. Preliminary clinical trials suggest that acupressure may significantly reduce general and pre-operative anxiety. However, these studies have been small and poorly designed, warranting better-quality research.

Acupuncture: Acupuncture, or the use of needles to manipulate the "chi" or body energy, originated in China over 5,000 years ago. Several studies have reported benefits in anxiety disorders, but the studies have been small and poorly designed, leaving the scientific evidence on acupuncture use in anxiety inconclusive.

Bacopa: Bacopa (Bacopa monnieri) is commonly called "brahmi" and is used in the Ayurvedic system of medicine in India. Although bacopa is traditionally used for anxiety, high-quality clinical trials are lacking. The one weak study below found some evidence that bacopa reduces clinical anxiety. However, more independent research is needed. Caution is advised when taking bacopa supplements as numerous adverse effects including heart palpitations are possible.

Gotu kola: In the traditional Indian system of Ayurvedic medicine, gotu kola is said to develop the crown chakra, the energy center at the top of the head, and to balance the right and left hemispheres of the brain. It has traditionally been used by yogis as a food for meditation. Animal research has demonstrated anxiolytic (anxiety reducing) properties of gotu kola, but human studies are lacking. A single randomized trial assessing the effects of gotu kola on startle responses in healthy (non-anxious) individuals has reported some benefits. These preliminary findings are promising, although further research should be performed. Gotu kola is not related to the cola nut, and does not contain caffeine. Gotu kola is generally reported as safe when used in humans for short term use.

Guided imagery: Guided imagery may include a number of techniques, such as metaphor, story telling, fantasy, game playing, dream interpretation, drawing, visualization, active imagination, or direct suggestion using imagery. Therapeutic guided imagery may be used to help patients relax and focus on images associated with personal issues they are confronting. Initial evidence suggests that guided imagery relaxation audiotapes may reduce anxiety after surgeries, and may improve healing. More studies are needed.

Healing touch (HT): Preliminary data from an uncontrolled trial suggests HT may help reduce symptoms of PTSD in women. More studies are needed.

Lemon balm: Preliminary human evidence has been published that supports the use of lemon balm (Melissa officinalis) for anxiety. In a large case series that included 1,599 patients with symptoms of anxiety, a combination of lemon balm and valerian (Valeriana officinalis) was found to improve symptoms of anxiety, including nervousness, fatigue, and sleep disturbances in over 90% of the patients. Although only mild side effects were reported, caution is advised when taking lemon balm supplements as numerous adverse effects including drowsiness and drug interactions are possible.

Massage: Various forms of therapeutic superficial tissue manipulation have been practiced for thousands of years across cultures. Several human trials have assessed the effects of massage in patients with anxiety, including those with cancer or chronic illnesses, hospitalized for psychiatric disorders, pre-operative anxiety (anxious about themselves or for family members having surgery), dementia, multiple sclerosis, before/during medical procedures, depressed adolescent mothers, women with premenstrual syndrome, patients with fibromyalgia and in elderly institutionalized patients. Additional research is necessary in order to form a scientifically based recommendation.

Meditation: Various forms of meditation, including mindfulness, transcendental meditation®, and "meditation-based stress reduction programs" have been studied for their effects on anxiety. Better studies are needed.

Qi gong: Qi gong is a type of Traditional Chinese Medicine (TCM) that is thought to be at least 4,000 years old. Preliminary study shows that Qi gong may be beneficial for relieving stress. Available data remains inconclusive, yet thousands of years of effectiveness in China for stress and anxiety must be appreciated.

Reflexology: Reflexology involves the application of manual pressure to specific points or areas of the feet that are believed to correspond to other parts of the body. There is preliminary evidence that reflexology may be useful for relaxation and to decrease anxiety. However, it is not clear that reflexology is equivalent or superior to massage or other types of physical manipulation. Better research is needed in this area.

Therapeutic touch: Results of different studies do not agree with each other, and therefore it is currently unclear if therapeutic touch is a useful anxiety treatment. Some trials report benefits, while others find no effects. Also, there is early evidence that therapeutic touch may reduce anxiety in children with life-threatening illnesses, reduce stress in teenagers with psychiatric disease, and help relax premature infants. Most studies have not been well designed, and better research is necessary in order to draw firm conclusions.

Valerian: Valerian (Valeriana officinalis) has traditionally been used for sleep improvement and for stress and anxiety. Studies have generally been of poor methodological quality, and several have used valerian in combination with other herbs, such as passion flower (Passiflora incarnata), lemon balm (Melissa officinalis), and St. John's wort (Hypericum perforatum). Studies report that valerian is generally well tolerated for up to four to six weeks in recommended doses. Caution is advised when taking valerian supplements as numerous adverse effects including drowsiness, sedation, and drug interactions are possible. Do not use valerian if pregnant or breastfeeding.