Anxiety Treatments: Know Your Options

Anxiety disorders can have multiple potential causes and co-existing conditions, so there is no single remedy that works for all of them. Anxiety treatment must be tailored specifically for each individual; what works well for one person may not work for another.  Understand your options - and then work with your doctor or therapist to determine the course of action that is best for you. 

Professional Therapy

The treatment options listed below require the assistance of mental health or medical providers or other licensed professionals.

• Cognitive behavioral therapy: CBT focuses on identifying, understanding, and changing thinking and behavior patterns related to anxiety in regular meetings with a licensed, CBT-trained therapist. Therapists who practice CBT may use interpersonal therapy (IPT) to help their clients develop coping skills, encourage them to record their thoughts throughout the week as they occur, and attempt exposure therapy if appropriate for their disorder (read more below).
• Dialectical behavioral therapy: DBT is a specific type of CBT. The term "dialectics" refers to a philosophical practice of examining multiple or often contradictory ideas, combining acceptance and change simultaneously. For example, a patient can accept where she is in her life and also feel motivated to improve it. DBT places an emphasis on mindfulness, enabling people to recognize and attempt to understand thoughts as they occur.
• Exposure Therapy: As this term suggests, exposure therapy gradually exposes an individual to the feared situation in a safe, controlled environment. Eliminating the actual fear is the ultimate goal. Practitioners begin by having the patient repeatedly imagine the feared situation or object and potential responses to it. Often used in treating OCD, phobias, and PTSD, this therapy may incorporate virtual reality or computer simulations to create a more realistic yet completely safe method of exposure.
• Group Therapy: The phrase "group therapy" describes a few therapeutic environments⁶ with participants beyond a single patient and provider. In addition to normalizing an individual's experience by relating to others, group therapy may offer an alternative for those who are unable to afford one-on-one therapy.  Peer support groups offer an opportunity to share experiences and offer advice. In addition to fostering relationships between people with similar struggles, participating in a support group validates the shared experience of anxiety.  A process group may be a good fit for people with social anxiety or generalized anxiety disorder (GAD). The theory behind these groups is that, as you develop friendships with others in the group, over time the sources of anxiety will emerge and can be addressed.
• Hypnosis: Hypnotherapists may be doctors, therapists, psychologists, social workers, nurses, or other licensed professionals. Hypnosis ⁷ helps people achieve a very relaxed state through breathing, guided imagery, or muscle-relaxing techniques and make them more amenable to suggestions. The hypnotherapist may use imagery or simple verbal suggestions to reduce the severity of anxiety symptoms. Some people may see positive results after one or two sessions. If hypnosis shows promising results, a hypnotherapist may also teach ways to practice self-hypnosis.

Prescription Medications

The medications described below can be obtained only with a prescription. Primary care physicians can diagnose and treat anxiety, but they may recommend that you consult a psychiatrist for severe or treatment-resistant anxiety disorders.

What is most commonly prescribed for anxiety?

• SSRIs and SNRIs: These two classes were initially prescribed as antidepressants but, more recently, research has found that they might help with anxiety as well. They were named based on how they work in the brain: selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). To understand these, some terms need to be defined. First, a neurotransmitter is like a messenger or a runner in a relay race; when an impulse affects a nerve fiber, that fiber then releases a substance (i.e., the neurotransmitter) that will transfer the message to the next stop along the path, which ultimately leads to a muscle, gland, or other target cells.
  
  Serotonin is a chemical that acts as a neurotransmitter, carrying signals along and between nerves—and it also plays a role in mood regulation, which is helpful for someone with anxiety. SSRIs block certain nerve cells in the brain from reabsorption, or reuptake, which leaves more serotonin available. SSRIs include fluoxetine, fluvoxamine, sertraline, citalopram, paroxetine, and escitalopram. Brand names associated with SSRIs include Paxil, Prozac, and Zoloft. SSRIs may be used to treat post-traumatic stress disorder (PTSD), generalized anxiety disorder (GAD), panic disorder, social anxiety disorder (SAD), and obsessive-compulsive disorder (OCD).
  
  SNRIs increase the levels of serotonin and norepinephrine (a chemical also known as a stress hormone) by inhibiting their reabsorption into brain cells. SNRIs include venlafaxine, milnacipran, desvenlafaxine, levomilnacipran, and duloxetine. Cymbalta and Effexor are examples of SNRI brand names. A physician may prescribe SNRIs for patients with GAD, SAD, or panic disorder.
• Benzodiazepines: These drugs work on the GABA (gamma-aminobutyric acid) neurotransmitter, which plays numerous roles related to sleep, relaxation, anxiety, mood changes, and memory. Although benzodiazepines are typically fast-acting, they also tend to be habit-forming, so doctors usually try other medications first, especially in their patients with a history of addiction. Among the benzodiazepines that may be prescribed for the treatment of anxiety are lorazepam, clonazepam, and diazepam. Some of the brand names are Xanax, Librium, Valium, and Ativan. Individuals who suffer from panic disorder, SAD, or GAD may be prescribed benzodiazepines as part of their treatment plan.
• Beta Blockers: This class of drugs blocks the binding of epinephrine (also known as the hormone adrenaline) and norepinephrine to nerve receptors. Typically used to treat cardiac conditions, beta-blockers like atenolol and propranolol¹ may be prescribed to a patient with social anxiety disorder specifically in performance situations, such as speaking in public, rather than as a long-term treatment. Brand name beta-blockers include Inderal, Tenormin, and Lopressor. Beta-blockers are usually only used to treat infrequent, performance-related episodes of social anxiety.
• Off-Label and Other Drugs: A physician may prescribe other types of medications, such as a tricyclic antidepressant (imipramine); a monoamine oxidase inhibitor, or MAO inhibitor; an anxiolytic (buspirone); or others that work via different mechanisms, such as mirtazapine. Currently, ketamine² is receiving increased scholarly interest as a potential treatment for depression³ and anxiety; the FDA gave it priority status⁴ as a treatment for depression, and some physicians have been using it as an off-label⁵ treatment for anxiety.
  
  A doctor may also consider an off-label use of a drug specified by the Food and Drug Administration (FDA) as effective for a condition other than an anxiety disorder or one that is approved outside the United States.

Brain Stimulation Therapies

These procedures target the regions of the brain that influence stress, anxiety, mood, and fear response.

How do you treat anxiety without medication?

• DBS: Deep brain stimulation is a procedure⁸ that involves implanting an electrode in the brain. In the same way that a pacemaker delivers an electrical current to the heart to keep it beating as it should, the electrode helps regulate the patient's mood. Because it is an invasive procedure, DBS has typically been reserved for severe, treatment-resistant obsessive-compulsive disorder (OCD). Although still in the initial stages of research, DBS may also be an effective treatment for PTSD⁹.
• rTMS: Most researched for OCD, repetitive transcranial magnetic stimulation delivers magnetic field pulses to the brain via an electrode¹⁰ placed on the patient's scalp. rTMS is increasingly being considered and studied¹¹ as a treatment for other anxiety disorders including panic disorder, PTSD, and social anxiety disorder.
• Vagus Nerve Stimulation: Because the vagus nerve is connected to many areas of the brain, it has been studied as a way to indirectly deliver impulses to deeper areas without being as invasive as brain surgery. Although in an early stage of research, vagus nerve stimulation shows promise for refractory cases of PTSD, panic disorder, and OCD¹².
• Other Brain Stimulation Therapies: Additional therapies include transcranial direct current stimulation (tDCS), transcranial electrical stimulation (tES), and electroconvulsive therapy (ECT). Because anxiety-specific studies on these procedures are scarce, they are not considered first-line treatments for anxiety disorders; however, ongoing research suggests that these may provide further options for treating generalized anxiety disorder, OCD, PTSD, and social anxiety disorder.

Self-Help

For those who seek alternatives to traditional medicine or would like to supplement their treatment, self-help and complementary and alternative medicine (CAM) may be useful.

How can I treat anxiety naturally?

• Self-Help: Many self-help books and materials (DVDs, CDs) are available. Before investing in these, consider the background and credentials of the author or producer, as well as the credibility of the publisher. Ask your mental health care or primary care provider for recommendations, check reputable websites¹³, or consult trusted family and friends.
• Exercise: When you pick up the pace physically, your body releases endorphins, which are hormones that can improve your mood. Activities that require concentration, such as catching a ball or following an aerobics routine, also keep your brain occupied. Replacing negative thoughts with neutral or positive ones can help calm you down. And exercise may increase confidence and personal satisfaction as you begin to accomplish your goals and overcome challenges.
• Diet and Nutrition: Some research suggests an association between nutrient deficiencies and different manifestations of anxiety. For example, zinc deficiency may have a relationship to panic disorder¹⁴ and OCD. Other deficiencies that may contribute to anxiety are magnesium¹⁵ and vitamins D, B₆, and B12. Your doctor will likely order a blood test if a deficiency is suspected.
  
  The nutrients L-theanine¹⁶ and tryptophan may help decrease anxiety if added to your diet. What vitamin is good for anxiety? Ongoing research seeks to determine whether vitamin E, omega 3 polyunsaturated fatty acids, glycine, and inositol supplements could have protective or other anti-anxiety benefits.
  
  Using diet to manage anxiety may also require avoiding or moderating some foods and beverages. A study in 2005 found that the preservative sodium benzoate, found in jelly, soda, and other products, contributes to anxiety. There is also some evidence that links age and high-cholesterol to anxiety. Because of their stimulating effects — which can increase anxiety— sugar and caffeine should be consumed in moderation. In addition to all of the anxiety-exacerbating problems that can come with drinking too much, alcohol is a diuretic that can speed up the loss of valuable nutrients¹⁷.
• Meditation and Mindfulness: Although separate concepts, meditation and mindfulness are often practiced together, especially for the treatment of anxiety. Both focus on thoughts that drive anxiety for many people.  Meditation is a conscious practice of focusing your thoughts in one specific direction, redirecting them when they begin to wander. It is usually best practiced in an environment without sensory distractions such as crying babies, barking dogs, cold temperatures, pungent odors, or uncomfortable furniture.  Many consider mindfulness a subcategory of meditation. It keeps your thoughts focused on the present moment, even if they wander. For example, you might notice muscle tension in your shoulders, then the sound of the clock ticking and the pattern of your breathing. In practicing mindfulness, it's important that you recognize your own experiences without casting judgment.
• Relaxation Techniques: Many methods help people relax, including guided imagery (listening to a script to visualize calm environments) and breathing exercises for slowing the heart rate and focusing thoughts. Another method, progressive muscle relaxation, involves tensing and releasing different muscle groups throughout the body. During this process, note positive sensations and decreased stress with every release. Other relaxation techniques include massage, tai chi, yoga, reiki¹⁸ or other healing touch therapies, and music and art therapy or similar creative outlets.
• Herbal Supplements: Scientific research on herbal supplements as anxiety treatments have been limited and inconclusive. Using supplements as a complementary or alternative treatment must be done with great caution. Before taking any herbal supplement, discuss it with your doctor to minimize the chance of an adverse drug interaction or side effect. Read more about Natural supplements for anxiety.
  
  Of supplements marketed for anxiety, chamomile¹⁹ and kava²⁰ have shown some promise. Studies of passionflower²¹ have shown mixed results or were tested only in small groups of people. No studies have reported benefits of using St. John's Wort to treat anxiety. In fact, if you have been prescribed an SSRI or SNRI, adding St. John's Wort can cause a potentially life-threatening condition known as serotonin syndrome. The research on lavender oil, lemongrass, bacopa monnieri, and other herbs is ongoing; there simply is not enough information to know whether they can treat anxiety, work better than a placebo, and most importantly if they are safe to use at all.

Unless you experience adverse side effects, don't be too quick to abandon treatment because it doesn't provide instantaneous results. Weeks may pass before you detect improvement. Discuss all side effects with your mental health provider; it's often worth sticking with treatment and seeking out ways to reduce or eliminate any negative side effects. Importantly, never stop taking medication without consulting your doctor first because an abrupt stop may cause other health problems.