• Pounding heart
• Chest Pains
• Light-headedness or dizziness
• Nausea or stomach problems
• Flushes or chills
• Shortness of breath or a feeling of smothering or choking
• Tingling or numbness
• Shaking or trembling
• Feelings of unreality
• Terror
• A feeling of being out of control or going crazy
• Fear of dying
• Sweating

You may genuinely believe you're having a heart attack,
stroke, losing your mind, or on the verge of death.
Attacks can occur any time, even during non-dream sleep.

Panic disorder strikes up to 1 in 73 people and is reported to be twice as common in women as in men. It can appear at any age - in children or in the elderly - but most often it begins in young adults. Not everyone who experiences panic attacks will develop panic disorder - for example, many people have one attack but never have another. For those who do have panic disorder, it's important to seek treatment. Untreated, the disorder can become very disabling.

Panic disorder is often accompanied by other conditions such as depression or alcoholism, and may spawn phobias, which can develop in places or situations where panic attacks have occurred. For example, if a panic attack strikes while you're riding and elevator, you may develop a fear of elevators and perhaps start avoiding them.

Some people's lives become greatly restricted - they avoid normal, everyday activities such as grocery shopping, driving, or in some cases even leaving the house. Or, they may be able to confront a feared situation only if accompanied by a spouse or other trusted person.

Basically, they avoid any situation they fear would make them feel helpless if a panic attack occurs. When people's lives become restricted by the disorder, as happens in about one-third of all people with panic disorder, the condition is call agoraphobia. A tendency toward panic disorder and agoraphobia runs in families. Nevertheless, early treatment of panic disorder can often stop the progression to agoraphobia.

Studies have shown that proper treatment - a type of psychotherapy called cognitive-behavioural therapy, medications, or possibly a combination of the two - helps 70 - 90 percent of people with panic disorder. Significant improvement is usually seen within 6 to 8 weeks.

Cognitive-behavioural approaches teach patients how to view the panic situations differently and demonstrate ways to reduce anxiety, using breathing exercises or techniques to refocus attention. For example, another technique used in cognitive-behavioural therapy, called exposure therapy, can often help alleviate the phobias that may result from panic disorder. In exposure therapy, people are very slowly exposed to the fearful situation until they become desensitised to it.

Some people find the greatest relief from panic disorder symptoms when they take certain prescription medications. Such medications, like cognitive-behavioural therapy, can help to prevent panic attacks or reduce their frequency and severity. Two types of medications that have shown to be safe and effective in the treatment of panic disorders are anti-depressants, which could be SSRI's, tricyclics or MAO inhibitors, and benzodiazepines.

Phobias

Phobias occur in several forms. A specific phobia is a fear of a particular object or situation. Social phobia is a fear of being painfully embarrassed in a social setting. And agoraphobia, which often accompanies panic disorder, is a fear of being in any situation that might provoke a panic attack, or from which escape might be difficult if one occurred.

Specific Phobias

I'm scared to death of flying, and I never do it anymore. It's awful when the aeroplane door closes and I feel trapped. My heart pounds and I sweat bullets. If somebody starts talking to me, I get very stiff and preoccupied. When the aeroplane starts to ascend, it just reinforces the feeling that I can't get out. I picture myself losing control, freaking out, climbing the walls, but of course I never do. I'm not afraid of crashing or hitting turbulence. It's just that feeling of being trapped. Whenever I've thought about changing jobs, I've had to think, “Would I be under pressure to fly?”. These days I only go places where I can drive or take a train. My friends always point out that I couldn't get off a train travelling at high speeds either, so why don't trains bother me? I just tell them it isn't a rational fear.

Phobias aren't just extreme fear; they are irrational fear. You may be able to ski the world's tallest mountains with ease but will start panicking just going above the 10th floor of an office building.

Many people experience specific phobias, intense, irrational fears of certain things or situations - dogs, closed-in places, heights, escalators, tunnels, highway driving, water, flying, and injuries involving blood are a few of the more common ones. Phobias aren't just extreme fear; they are irrational fear. You may be able to ski the world's tallest mountain with ease but will start panicking just going above the 10th floor of an office building. Adults with phobias realise their fears are irrational, but often facing, or even thinking about facing the feared object or situation brings on a panic attack or severe anxiety.

Phobias aren't just extreme fear; they are irrational fear. You may be able to ski the world's tallest mountains with ease but will start panicking just going above the 10th floor of an office building. Adults with phobias realise their fears are irrational, but often facing, or even thinking about facing the feared object or situation brings on a panic attack or severe anxiety.

Specific phobias strike more than 1 in 10 people. No one knows just what causes them, though they seem to run in families and are a little more prevalent in women. Phobias usually first appear in adolescence or adulthood. They start suddenly and tend to be more persistent than childhood phobias; only about 10 percent of adult phobias vanish on their own. When children have specific phobias - for example, a fear of animals - those fears usually disappear over time, though they may continue into adulthood. No one knows why they hang on in some people and disappear in others.

If the object of the fear is easy to avoid, people with phobias may not feel the need to seek treatment. Sometimes thought, they may make important career or personal decisions to avoid a phobic situation.

When phobias interfere with a person's life, treatment can help. Successful treatment usually involves a king of cognitive-behavioural therapy called desensitisation or exposure therapy, in which patients are gradually exposed to what frightens them until the fear begins to fade. Three-fourths of patients benefit significantly from this type of treatment. Relaxation and breathing exercise also help reduce anxiety symptoms.

There is currently no proven drug treatment for specific phobias, but sometimes medications may be prescribed to help reduce anxiety symptoms before someone faces a phobic situation.

Social Phobia

I couldn't go on dates or to parties. For a while, I couldn't even go to class. My sophomore year of college I had to come home for a semester.

My fear would happen in any social situation. I would be anxious before I even left the house, and it would escalate as I got closer to class, a party, or whatever. I would feel sick to my stomach - it almost felt like I had the flu. My heart would pound, my palms would get sweaty, and I would get this feeling of being removed from myself and from everybody else.

When I would walk into a room full of people, I'd turn red and it would feel like everybody's eyes were on me. I was embarrassed to stand off in a corner by myself but I couldn't think of anything to say to anybody. I felt so clumsy, I couldn't wait to get out.

Social phobia is an intense fear of becoming humiliated in social situations, specifically of embarrassing yourself in front of other people. It often runs in families and may be accompanied by depression or alcoholism. Social phobia often begins around early adolescence or even younger.

If you suffer from social phobia, you tend to think that other people are very competent in public and that you are not. Small mistakes you make may seem to you much more exaggerated than they really are. Blushing itself may seem painfully embarrassing, and you feel as though all eyes are focused on you. You may be afraid of being with people other than those closest to you. Or your fear may be more specific, such as feeling anxious about giving a speech, talking to a boss or other authority figure, or dating. The most common social phobia is a fear of public speaking. Sometimes social phobia involves a fear of using a public restroom, eating out, talking on the phone, or writing in the presence of other people, such as when signing a cheque.

People with social phobia aren't necessarily shy at all.
They can be completely at ease with people most of the
time, but in particular situations, they feel intense anxiety.

Although this disorder is often thought of as shyness, the two are not the same. Shy people can be very uneasy around others, but they don't experience the extreme anxiety in anticipating a social situation, and they don't necessarily avoid circumstances that make them feel self-conscious. In contrast, people with social phobia aren't necessarily shy at all. They can be completely at ease with people most of the time, but particular situations, such as walking down an aisle in public or making a speech, can give them intense anxiety. Social phobia disrupts normal life, interfering with career or social relationships. For example, a worker may turn down a job promotion because he can't give public presentations. The dread of a social event can begin weeks in advance, and symptoms can be quite debilitating.

People with social phobia aren't necessarily shy at all. They can be completely at ease with people most of the time, but in particular situations, they feel intense anxiety.

People with social phobia are aware that their feelings are irrational. Still, they experience a great deal of dread before facing the feared situation, and they may go out of their way to avoid it. Even if they manage to confront what they fear, they usually feel very anxious beforehand and are intensely uncomfortable throughout. Afterward, the unpleasant feelings may linger, as they worry about how they may have been judged or what others may have thought or observed about them.

About 80 percent of people who suffer from social phobia find relief from their symptoms when treated with cognitive-behavioural therapy or medications or a combination of the two. Therapy may involve learning to view social events differently; being exposed to a seemingly threatening social situation in such a way that it becomes easier to face; and learning anxiety-reducing techniques, social skills, and relaxation techniques.

The medications that have proven effective include antidepressants such as SSRI's tricyclics and MAO inhibitors. People with very specific forms of social phobia called performance phobia have been helped by drugs called beta-blockers. For example, musicians or others with this anxiety may be prescribed a beta-blocker for use on the day of a performance.

Treatment for Anxiety Disorders

Many people with anxiety disorders can be helped with treatment. Therapy for anxiety disorders often involves medication or specific forms of psychotherapy.

Medications, although not cures, can be very effective at relieving anxiety symptoms. Today, thanks to research, there are more medications available, than ever before to treat anxiety disorders. So if one drug is not successful, there are usually others to try. In addition, new medications to treat anxiety symptoms are under development.

For most of the medications that are prescribed to treat anxiety disorders, the doctor usually starts the patient on a low dose and gradually increases it to the full dose. Every medication has side effects, but they usually become tolerated or diminish with time. If side effects become a problem, the doctor may advise the patient to stop taking the medication and to wait a week - or longer for certain drugs - before trying another one. When treatment is near an end, the doctor will taper the dosage gradually.

Research has also shown that behavioural therapy and cognitive-behavioural therapy can be effective for treating several of the anxiety disorders.

Behavioural therapy focuses on changing specific actions and uses several techniques to decrease or stop unwanted behaviour. For example, one technique trains patients in diaphragmatic breathing, a special breathing exercise involving slow, deep breaths to reduce anxiety. This is necessary because people who are anxious often hyperventilate, taking rapid shallow breaths that can trigger rapid heartbeat, lightheadedness, and other symptoms. Another technique - exposure therapy - gradually exposes patients to what frightens them and helps them cope with their fears.

Like behavioural therapy, cognitive-behavioural therapy teaches patients to react differently to the situations and bodily sensations that trigger panic attacks and other anxiety symptoms. However, patients also learn to understand how their thinking patterns contribute to their symptoms and how to change their thoughts so that symptoms are less likely to occur. This awareness of thinking patterns is combined with exposure and other behavioural techniques to help people confront their feared situations. For example, someone who becomes lightheaded during a panic attack and fears he is going to die can be helped with the following approach used in cognitive-behavioural therapy. The therapist asks his to spin in a circle until he becomes dizzy. When he becomes alarmed and starts thinking, "I'm going to die", he learns to replace that thought with a more appropriate one, such as, "It's just a little dizziness - I can handle it."

Obsessive - Compulsive Disorder

I couldn't do anything without rituals. They transcended every aspect of my life. Counting was big for me. When I set my alarm at night, I had to sit it to a number that wouldn't add up to a “bad” number. If my sister was 33 and I was 24, I couldn't leave the TV on Channel 33 or 24. I would wash my hair three times as opposite to once because three was a good luck number and one wasn't. It took me longer to read because I'd count the lines in a paragraph. If I was writing a term paper, I couldn't have a certain number of words on a line if it added up to a bad number. I was always worried that if I didn't do something, my parents die. Or I would worry about harming my parents, which was completely irrational. I couldn't wear anything that said Boston because my parents were from Boston. I couldn't write the word “death” because I was worried that something bad would happen.

Getting dressed in the morning was tough because I had a routine, and if I deviated from that routine, I'd have to get dressed again.

I knew the rituals didn't make sense, but I couldn't seem to overcome them until I had therapy.

Obsessive-compulsive disorder is characterised by anxious thoughts or rituals you feel you can't control. If you have OCD, as it's called, you may be plagued by persistent, unwelcome thoughts or images, or by the urgent need to engage in certain rituals.

You may be obsessed with germs or dirt, so you wash your hands over and over. You may be filled with doubt and feel the need to check things repeatedly. You might be preoccupied by thoughts of violence and fear that you will harm people close to you. You may spend long periods of time touching things or counting; you may be preoccupied by order of symmetry; you may have persistent thoughts of performing sexual acts that are repugnant to you; or you may be troubled by thoughts that are against your religious beliefs.

The disturbing thoughts or images are called obsessions, and the rituals that are performed to try to prevent or dispel them are called compulsions. There is no pleasure in carrying out the rituals you are drawn to, only temporary relief from the discomfort caused by the obsession.

A lot of healthy people can identify with having some of the symptoms of OCD, such as checking the stove several times before leaving the house. But the disorder is diagnosed only when such activities consume at least an hour a day, are very distressing, and interfere with daily life.

Most adults with this condition recognise that what they're doing is senseless, but they can't stop it. Some people, though, particularly children with OCD, may not realise that their behaviour is out of the ordinary.

OCD strikes men and women in approximately equal numbers and afflicts roughly 1 in 50 people. It can appear in childhood, adolescence, or adulthood, but on the average it first shows up in the teens or early adulthood. A third of adults with OCD experienced their first symptoms as children. The course of the disease is variable - symptoms may come and go, they may ease over time, or they can grow progressively worse. Evidence suggests that OCD might run in families.

The disturbing thoughts or images are called
obsessions, and the rituals that are performed to try to
prevent or dispel them are called compulsions. There is
no pleasure in carrying out the rituals you are drawn
to, only temporary relief from the discomfort caused by
the obsession.

Depression or other anxiety disorders may accompany OCD. And some people with OCD have eating disorders. In addition, they may avoid situations in which they might have to confront their obsessions. Or they try unsuccessfully to use alcohol or drugs to calm themselves. If OCD grows severe enough, it can keep someone from holding down a job or from carrying out normal responsibilities at home, but more often it doesn't develop to those extremes.

Research and other investigations has led to the development of medications and behavioural treatments that can benefit people with OCD. A combination of the two treatments is often helpful for most patients. Some individuals respond best to one therapy, some to another. Antidepressants, especially SSRI's, have been found effective in treating OCD.

A number of others are showing promise, however, and may soon be available.

Behavioural therapy, specifically a type called exposure and response prevention, has also proven useful for treating OCD. It involves exposing the person to whatever triggers the problem and then helping him of her forego the usual ritual - for instance, having the patient touch something dirty and then wash his hands. This therapy is often successful in patients who complete a behavioural therapy programme, though results have been less favourable in some people who have both OCD and depression.

Post-Traumatic Stress Disorder

I was raped when I was 25 years old. For a long time, I spoke about the rape on an intellectual level, al though it was something that happened to someone else. I was very aware that it had happened to me, but there just was no feeling. I kind of skidded along for a while.

I started having flashbacks. They kind of came over me like a splash of water. I would be terrified. Suddenly I was reliving the rape. Every instant was startling. I felt like my entire head was moving a bit, shaking, but that wasn't so at all. I would get very flushed or a very dry mouth and my breathing changed. I was held in suspension. I wasn't aware of the cushion on the chair that I was sitting on or that my arm was touching a piece of furniture. I was in a bubble, just kind of floating. And it was scary. Having a flashback can wring you out. You're really shaken.

The rape happened the week before Christmas, and I feel like a werewolf around the anniversary date. I can't believe the transformation into anxiety and fear.

Post-Traumatic Stress Disorder (PTSD) is a debilitating condition that follows a terrifying event. Often, people with PTSD have persistent frightening thoughts and memories of their ordeal and feel emotionally numb, especially with people they were once close to. PTSD, once referred to as shell shock or battle fatigue, was first brought to public attention by war veterans, but it can result from any number of traumatic incidents. These include kidnapping, serious accidents such as car or train wrecks, natural disasters such as floods or earthquakes, violent attacks such as a mugging, rape, or torture, or being held captive. The event that triggers it may be something that threatened the person's life or the life of someone close to him or her. Or it could be something witnessed, such as mass destruction after a plane crash.

Whatever the source of the problem, some people with PTSD repeatedly relive the trauma in the form of nightmares and disturbing recollections during the day. They may also experience sleep problems, depression, feeling detached or numb, or being easily startled. They may lose interest in things they used to enjoy and have trouble feeling affectionate. They may feel irritable, more aggressive than before, or even violent. Seeing things that remind them of the incident may be very distressing, which could lead them to avoid certain places or situations that bring back the memories.

Ordinary events can serve as reminders of the trauma

and trigger flashbacks or intrusive images.

Anniversaries of the event are often very difficult.

Anniversaries of the event are often very difficult.

PTSD can occur at any age, including childhood. The disorder can be accompanied by depression, substance abuse, or anxiety. Symptoms may be mild or severe - people may become easily irritated or have violent outbursts. In severe cases they may have trouble working or socialising. In general, the symptoms seem to be worse if the event that triggered them was initiated by the person - such as rape, as opposed to a flood.

Ordinary events can serve as reminders of the trauma and trigger flashbacks or intrusive images. A flashback may make the person lose touch with reality and re-enact the event for a period of seconds or hours or, very rarely, days. A person having a flashback, which can come in the form of images, sounds, smells, or feelings, usually believes that the traumatic event is happening all over again.

Not every traumatise person gets full-blown PTSD, or experiences PTSD at all. PTSD is diagnosed only if the symptoms last more than a month. In those who do have PTSD, symptoms usually begin within 3 months of the trauma, and the course of the illness varies. In some cases, the condition may be chronic. Occasionally, the illness doesn't show up until years after the traumatic event.

Antidepressants and anxiety-reducing medications can ease the symptoms of depression and sleep problems, and psychotherapy, including cognitive-behavioural therapy, in an integral part of treatment. Being exposed to a reminder of the trauma as part of the therapy - such as returning to the scene of a rape - sometimes helps. And, support from family and friends can help speed recovery.

How to get help for Anxiety Disorders

If you, or someone you know, has symptoms of anxiety, a visit to a general practitioner is usually the best place to start. A doctor can help you determine if the symptoms are due to an anxiety disorder, some other medical condition, or both. Most often, the next step to getting treatment for an anxiety disorder is referral to a psychiatrist or psychologist.

Among the professional who can help are psychiatrists, psychologist, social workers, and counsellors. However, it's best to look for a professional who has experience in cognitive-behavioural therapy and who is open to the use of medications, should they be needed.

Psychologist, social workers, and counsellors sometimes work closely with a psychiatrist or other doctor, who will prescribe medications when they are required. For some people, group therapy or self-help group are a helpful part of treatment. Many people do best with combination of these therapies.

When you're looking for a GP, psychiatrist or psychologist, it important to inquire about what kinds of therapy he or she generally uses or whether medications are available. It's important that you feel comfortable with the therapy. If this is not the case, seek help elsewhere. However, if you've been taking medication, it's important not to quit certain drugs abruptly, but to taper them off under the supervision of your physician. Be sure to ask your physician about how to stop a medication.

Remember, though, that when you find a health-care professional you're satisfied with, the two of you are working as a team. Together you will be able to develop a plan to threat your anxiety disorder that may involve medication, behavioural therapy, or cognitive-behavioural therapy, as appropriate. Treatments for anxiety disorders, however, may not start working instantly. Your doctor or therapist may ask you to follow a specific treatment plan for several weeks to determine whether it's working.

Co-Existing Conditions

Many people have a single anxiety disorder and nothing else, but it isn't unusual for an anxiety disorder to be accompanied by another illness, such as depression, and eating disorder, alcoholism, drug abuse, or another anxiety disorder. Often people who have panic disorder or social phobia, for example, also experience the intense sadness and hopelessness associated with depression or become dependent on alcohol. In such cases, these problems will need to be treated as well.

Find a doctor who treats you with respect and empathy and who answers all your questions to your satisfaction.Don't settle for anything less.

- Marianne J. Legato, M.D., director of

Partnership for Women's Health at Columbia University.

SmithKline Beecham
Pharmaceuticals
The view in this booklet reflect the experience of the authors, and are not necessarily those of SmithKline Beecham Pharmaceuticals. Drugs referred to by the authors should be used only as recommended in the manufacturer's local data sheets.


NATIONAL INSTITUTES OF HEALTH
National Institute of Mental Health