How can psychiatry help me with anxiety?

Anxiety is a part of the human experience. It’s a natural human response that we evolved to protect ourselves from perceived threats. Anxiety is our brain’s way of telling us to get ready to “fight or flee.” 

Since the days when our ancestors depended on this response to survive danger and stress, many of the things that cause us anxiety have changed—or at least evolved in ways that don't always protect us like it should.  

What is anxiety?

When people feel anxiety all the time or on most days, we might diagnose them as having Generalized Anxiety Disorder (GAD). The excessive worry and uneasiness that they experience can have a big effect on different parts of their everyday life, including their work, relationships, physical health, and daily routines. Anxiety causes them distress and means they can’t function at their best or live life how they want. 

Here are some of the symptoms people experience when they have an anxiety disorder—and that we look for when making a diagnosis: 

• Worrying too much: Typically persistent and uncontrollable about various aspects in life. Usually disproportionate to actual threat. 
• Having a hard time concentrating: Mental skills—such as learning, thinking, and how we reason through things—are weaker, which can greatly affect school, work, or other areas of life.  
• Feeling irritable or easily annoyed: Small things can lead to intense emotional reactions, which can sometimes lead to conflict in our relationships. 
• Restlessness: Feeling “on edge” or keyed up,” and having a hard time relaxing. Restlessness is a physical way anxiety shows up when something stimulates the brain. 
• Muscle tension: Physical symptoms can include tightening muscles and stiffness. Sometimes people notice the after-effects in their body, such as pain or discomfort, which they report instead. 
• Fatigue or tiredness: Always feeling like you need to be ready to “fight or flee” can be mentally and physically draining, which leads to feelings of fatigue and exhaustion even when you weren’t doing anything difficult with your body.
• Sleep disturbances: Difficulty falling asleep, and trying to maintain sleep can then exacerbate feelings of fatigue and impair overall well-being. 

Generalized Anxiety Disorder isn’t the only kind of anxiety someone can have. I work with clients and ask them questions to get a more accurate diagnosis of how they experience their anxiety. If I’m working together with their therapist, I also will review their notes about a client’s symptoms. 

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This is a quick rundown of how some of these anxiety disorders differ: 

Generalized anxiety disorder or GAD

GAD tends to be chronic, diffuse, and exaggerated worry about routine aspects of life. 

Panic disorder

This disorder shares some symptoms with GAD, such as excessive worry and anxiety. However, its hallmark is unexpected panic attacks. These manifest as intense episodes of fear accompanied by physical sensations such as palpitations, sweating, trembling, and shortness of breath. 

Social anxiety disorder 

People with social anxiety disorder experience intense fear and anxiety in social situations, especially if it involves scrutiny or potential embarrassment. 

Specific phobias

Phobias typically involve an irrational fear of a particular object or situation, such as heights, spiders, flying, or small enclosed spaces to name a few. 

Obsessive compulsive disorder 

OCD is characterized by intrusive and distressing thoughts or obsessions. It also includes people repeating behaviors or actions as a way to soothe or lessen anxiety, called “compulsions.” 

Post traumatic stress disorder

A key distinction of this form of anxiety results from exposure to traumatic events. Symptoms can include flashbacks, nightmares, and emotional numbing, which are not common in GAD. 

How does a psychiatrist diagnose anxiety? 

When seeing a new client, it’s important that we don’t diagnose them before meeting and to be unbiased by any previous diagnosis.  Approaching each client through a new lens helps to get a more accurate understanding of the current symptoms they’re experiencing, as this can change with time and circumstance. 

We start by ruling out different, possible reasons for why someone feels the way they do. The first step is making sure someone is feeling anxiety and not fear. As psychiatrists, knowing the difference matters for making an accurate diagnosis and figuring out the right treatment. Then I rule out medical reasons that can cause symptoms that look like anxiety.

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What’s the difference between fear and anxiety?

Anxiety and fear aren’t the same thing, especially when making a diagnosis. Fear is a response to an immediate and existing threat. It’s one of our core emotions, a reaction to feeling we are in danger. 

There are times that anxiety can cause people to feel similar physical symptoms to fear, such as nausea or shortness of breath. Anxiety, though, is a more general feeling of uneasiness about future events or what could happen. Symptoms show up in people physically but also mentally and emotionally. 

Ruling out medical causes 

Anxiety shares symptoms with other conditions, including many medical conditions. Establishing a differential diagnosis—which is identifying other possible conditions that could make you feel like you have anxiety—is important to do early. I use this to rule out any medical causes for perceived anxiety. 

These are examples of medical causes that can feel like anxiety:

• Thyroid disorders: Hyperthyroidism (an overactive thyroid that creates too many hormones) can lead to increased heart rate, palpitations, and nervousness. Hypothyroidism (an underactive thyroid that doesn’t create enough hormones) can cause fatigue, irritability, and feelings of unease. 
• Cardiovascular disorders: Conditions such as arrhythmia, angina, and heart failure can trigger anxiety-like symptoms, such as chest pain, shortness of breath, and the sensation of impending doom. Often, these symptoms feel like panic attacks. 
• Respiratory conditions: Chronic obstructive pulmonary disease or asthma can lead to breathing difficulties and feelings of panic, especially during an “attack” or when the condition flares up. 
• Neurological disorders: Conditions such as epilepsy, brain tumors, and multiple sclerosis can cause anxiety as a result of disruptions to brain functions—or fear of having an “episode” or event caused by the condition. 
• Endocrine disorders: Disruptions in the body’s hormonal balance can contribute to anxiety.
• Vitamin and mineral deficiencies: Lack of vitamins and minerals such as B12, magnesium, or iron can lead to symptoms like fatigue, irritability, and nervousness, which resemble symptoms of anxiety. 
• Chronic pain: Conditions such as fibromyalgia or migraines can be associated with anxiety due to ongoing physical and emotional burden. 
• Autoimmune diseases: Certain conditions like lupus or rheumatoid arthritis can show up in how our brain works or in our behaviors, including anxiety. 
• Medication side effects: Some medications may cause or worsen anxiety symptoms. This includes corticosteroids, stimulants—and even certain antidepressants and antipsychotics. 
• Substance use and withdrawal: Even common substances such as caffeine can trigger anxiety, as can prescriptions such as stimulants or other substances that are seen as less harmful. People can also experience rebound anxiety due to withdrawal from benzodiazepines or alcohol. 

What kind of treatment options are available for someone with anxiety? 

I believe therapy should always be a component of managing anxiety disorders. Evidence-based therapies such as Cognitive Behavioral Therapy, exposure therapy, and mindfulness-based therapies are shown to be effective for treating anxiety disorders. 

Therapy identifies and challenges negative thought patterns and cognitive distortions, which are mental shortcuts or biases that our brain forms to lighten its load. Sometimes, those shortcuts and biases can be unhelpful and even harmful. Through therapy, people can address these shortcuts and get guidance. Therapists work with clients to gradually expose them to feared situations and gain awareness about being in those moments. They build tools that people can add to their toolbox to manage their anxiety.  

Some people with anxiety disorders need tools that can’t be built in therapy alone. That’s where psychiatry and medication might help. 

What psychiatric treatments are available for anxiety? 

The first tenant in medicine is “Do No Harm.” My approach to treatment is to start with the least invasive, evidence-based option that can be effective. 

When I have clients who are already in therapy but need more care, usually the least invasive treatment or starting option is adding an SSRI. These are FDA-approved and serve as a first line treatment for most anxiety disorders.

If SSRIs are ineffective, intolerable, or the client does not want to use it as part of their treatment plan—usually due to concerns about side effects—I’ll have a discussion with them. I walk them through the risks, benefits, and potential side effects of other options. It’s important for them to have a say in their options and treatment planning. Treatment depends on what the client wants to do as well as what works for them.

There are several options for treating anxiety with medication. Here is what we might use to treat anxiety. 

• Selective Serotonin Reuptake Inhibitors (SSRIs) serve as first line medication for most anxiety disorders. They increase the availability of serotonin, which is a neurotransmitter that aids in regulating mood and emotions. 
• Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) increase the levels of serotonin and norepinephrine, a neurotransmitter that affects adrenaline and energy. SNRIs provide another option for managing symptoms. 
• Benzodiazepines provide short-term relief for acute anxiety or panic attacks. Ideally, they should be prescribed for short durations due to risk of dependence and withdrawal symptoms. 
• Buspirone is another anxiety medication that has a weaker effect compared to benzodiazepines and is preferred if dependence is a concern. 
• Beta blockers are often used to manage blood pressure and heart conditions. They can be used on an as-needed basis, such as for situational anxiety and for events such as public speaking. They help control physical symptoms of anxiety such as trembling and a rapid heart rate.
• Antihistamines can provide a calming effect. Histamine, a chemical messenger, has a role in anxiety and stimulation in addition to an immune response. Certain kinds are often used as needed for anxiety, panic attacks, or insomnia. 
• There are many other classes of medications that can be used for anxiety. Newer treatments offer promising options for treating anxiety in the future. Some of these include ketamine-assisted therapy, transcranial magnetic stimulation, deep brain stimulation, cannabinoids, and neurofeedback to name a few. 

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Why would medication be effective for treating anxiety? 

While there can be many emotional and psychological reasons that people experience anxiety, there are also many neurological reasons, too. The science of the chemicals and pathways in our brains and how our brains work can be part of an anxiety disorder, which means it’s something we can address physically through medication. 

This is a quick overview of some of the brain science behind anxiety:

• Neurotransmitters: Anxiety involves complex interactions between neurotransmitters, chemical messengers that send signals in your brain. The main neurotransmitters in anxiety disorders are serotonin, gamma-aminobutyric acid (GABA), and norepinephrine. Imbalances in these chemicals can be part of developing and continuing to feel anxiety symptoms.
• The amygdala: This almond-shaped region deep within the brain plays a crucial role in processing emotions and detecting potential threats. In people with anxiety disorders, the amygdala may be overly sensitive, leading to exaggerated fear responses even in non-threatening situations.
• Genetics: Research suggests that there is a genetic component to anxiety disorders. Certain genetics can make it more likely for some people to develop anxiety, though their environment plays a big part, as well. 
• Stress and trauma: Experiencing a lot of stress and trauma for long periods of time can shape how the brain responds to anxiety. Such events can even change how our brain is wired, so people experience strong anxiety responses even after the event. 
• Medical conditions and substance use: Anxiety can also be a symptom of certain medical conditions or a result of substance use and withdrawal. Identifying and addressing these underlying issues is essential in the therapeutic process. 

Monitoring the effects

During treatment, I continue to meet with clients to check in on the effects of the treatment—whether it’s working and to make changes if necessary. 

There are several different reasons why we may need to make changes. Over time, medications or the dosage can become less effective. People might experience side effects later on, such as changes in weight or sex drive. Clients might also have trouble with compliance—meaning they have difficulty taking medications correctly or at all. 

If it’s time to change course, we discuss adjusting the dosage, adding another medication, or changing the medication and treatment entirely to try a different path.  

Again, I tailor treatment by factoring what a client has shared about their comfort level and preferences after we’ve discussed risks, benefits and potential side effects of alternative options.  

What I check for during treatment are:

1. Safety
2. Tolerability
3. Effectiveness

Safety is first, because some medications can have concerning, unintended effects—most of which are fairly uncommon, such as suicidal ideation, severe allergic reactions, and other effects. 

Tolerability is about making sure that clients are actually able to take their medication. They may have a hard time sticking to their course and regularly taking medication if they have unpleasant side effects, such as  nausea, abdominal pain, headaches, drowsiness, sexual side effects, weight gain, etc. 

Of course, we check for effectiveness—that the treatment is working. We want to see less symptoms and improvements in a person’s daily life. I also check for improvement from the client’s feedback and from evidence-based tracking. 

How do I know if I have anxiety?

There are a few ways to find out if you’re experiencing symptoms of anxiety and could benefit from support. 

Doing an assessment like the GAD-2 can help you decide if you should see a mental health provider. You can talk with a therapist or a psychiatrist about your symptoms. While an assessment can help you sort out what you’re experiencing, only a licensed clinical provider can give you a diagnosis. 

Together, you can figure out how to manage an anxiety disorder better. A type of therapy that works for someone else’s anxiety might not be right for you. Or you might need a combination of different types of therapies, or even talk therapy together with medication management. 

As discussed earlier, your anxiety treatment depends on what you’re comfortable doing and what will actually work for you. “Every person is different” isn’t just a nice saying: It’s true scientifically with how each of our brains and bodies work. 

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