Anxiety: Definitions, Medication & Counseling

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Host: Dr. Pamela B. Morris – Cardiologist

Guest: Dr. Linda Austin - Associate Dean for Communication Development, Professor of Psychiatry.

Dr. Pamela B. Morris: Hi! I am Dr. Pam Morris and I am talking today with Dr. Linda Austin. Dr. Austin today we are talking about anxiety. Define anxiety for me.

Dr. Linda Austin: Oh! Boy people have been trying to define that for years, decades actually. First it’s important to say that there are a number of different kinds of anxiety. Probably, what you and I might call anxiety would be generalized anxiety disorder, which is a state in which a person just feels tense and irritable and uptight a lot of the time and waxes and wanes throughout the day and lots of days are filled with anxiety, that’s generalized anxiety disorder. There is an entity called social anxiety disorder and people with this will say, ?Oh you know I hate going to parties or I hate going to the Wal-Mart,? that’s the ultimate test of social anxiety, it’s Wal-Mart. Some people have trouble even with the telephone, public speaking. Anxiety is so common you could hardly even classify it as a disorder, but technically it would be considered as social anxiety disorder. There is an entity called panic attacks with panic disorder and these are acute, severe, but really heart-pumping episodes of anxiety that are really quite overwhelming at the time and then there are several other forms of anxiety disorders as well.

Dr. Pamela B. Morris: Do the treatments for these types of disorders differ?

Dr. Linda Austin: I would say, yes and no. From a medication point of view, there are two major classes of medicines that we use for all these. The first class are the anti-depressants, some of the old standbys are Prozac, Paxil, Zoloft, Effexor; all antidepressants with the possible exception of Wellbutrin, although some people have had some success with Wellbutrin for anxiety, can be helpful. The downside of antidepressants for anxiety is that they may take 4, 6, 8, 10, 12 weeks to really see the full affect; it takes a long time. The second class is the so-called anti-anxiety or minor tranquilizers, medications like Klonopin and Xanax; those kick in right away. You can feel them within half an hour or an hour. So, we often use both simultaneously. We use the short-term ones to just take the edge off and offer the person some really quick relief and then use the anti-depressants to get a more long lasting 24-hour a day, 7-day a week relief from the anxiety.

Dr. Pamela B. Morris: You know, it’s confusing. I often times hear the medications that are termed the antidepressants are used for so many different problems.

Dr. Linda Austin: That’s very true. It’s almost like aspirin. Aspirin can be used for muscle aches or headaches or to take down a fever and it’s the same with the antidepressants. Yes they are for depression, but they are also good for anxiety. In high doses, they are good for another anxiety disorder, obsessive compulsive disorder. They can be used premenstrually. So they really do have a number of different activities.

Dr. Pamela B. Morris: Linda, one of my concerns with anxiety is the disability associated with these disorders.

Dr. Linda Austin: And the disability can be a really extreme. Depression over the last 10 or 15 years has gotten a lot of press, and I think people understand that depression can be a really disabling disorder. Anxiety in my experience can be equally, sometimes even more disabling than depression and sometimes it is more difficult to treat, sometimes not, but for example, if you have panic attacks on a daily basis where all of a sudden out of the blue, you feel as terrified as if somebody came into the room and put a machine gun to your head, that’s what a panic attack feels like and people with recurrent panic attacks often can't leave their house. It may start off that they can’t drive over the bridge, then they can’t go to elevators, and they can’t go to Wal-Mart, and then after a while, they can’t even leave their homes. Social anxiety disorders are often a very common cause of alcohol abuse because people can't go out in social situations without getting drunk first. We have all seen that. I mean, it’s very, very common I think, especially for young people or can’t go to interviews or can’t talk on the phone, and it really does limit their lives enormously.

Dr. Pamela B. Morris: One thing I have also heard from patients is they are very clearly aware that there isn’t anything genuinely threatening them, but in spite of that they can’t control their fear and anxiety. They are very rational about it, and they realize that fear is irrational.

Dr. Linda Austin: And that’s why I think in some ways it is more debilitating than depression. There is a certain shame that often goes along with anxiety disorders. People feel very embarrassed about them and sometimes don’t even tell family members that they are having these anxiety disorders. There is just something in the nature of it, feeling that people are looking at you or feeling that people are critical of you or they become very critical of themselves, so it does become a very isolating kind of problem to have.

Dr. Pamela B. Morris: We have talked some about medication that are used for this. Is there a role for counseling or talk therapy in the management of anxiety disorders?

Dr. Linda Austin: Well, absolutely and again it depends a little bit on the nature of the anxiety disorder. For example, posttraumatic stress disorder is a form of an anxiety disorder and it is important to be able to talk about the trauma. With obsessive compulsive disorder, another anxiety disorder, you have to do a very specific form of behavioral therapy in which you have the person do the thing that they hate to do the most. For example, if their obsession is about having dirty hands, you have to get their hands dirty. You know, touch the bottom of their shoes, touch the inside of the toilet bowl, and then not wash their hands and believe it or not if you do that for several hours a day for several weeks, your OCD will get markedly better, but that’s a different kind of -- I mean it’s not talking about your mother, you know, it’s really a very structured kind of behavioral therapy for that particular anxiety disorder.

Dr. Pamela B. Morris: Dr. Austin what about the term that we hear called performance anxiety? I know many of us have to give lectures or speak in public or read the scripture at church. How do you manage and treat that?

Dr. Linda Austin: Well, there are a couple of different ways. Sometimes the benzodiazepines like Klonopin, Xanax, and so forth can be useful. Oftentimes, actually especially for musicians I have found and other people who perform where they need a high level of either voice control or fine motor control, a group of medications called beta-blockers can be very useful. The beta-blockers have block with the so-called beta-adrenergic nervous system, which is another way of saying the butterflies in your stomach kind of feeling. When your hand is shaking and your voice sort of tightens up and you feel like an idiot and you have butterflies in your stomach and you can't think straight. The beta-blockers interestingly enough block the affect of adrenaline on the body so that cognitively you may experience some anxiety leading up to the event, but you don’t get into that cycle of shaking hands and feeling idiotic. So for example, performers, let’s say musicians, pianists, violinists who have been in jury to trials actually perform better with beta-blockers than without because they have much better fine motor control. In fact, surgeons who have to do microsurgery, now this is not due to anxiety, but because beta-blockers block tremor, may be able to operate more smoothly. So, the beta-blockers really get rid of the handshaking component of anxiety that’s so embarrassing and sometimes it’s a debilitating part of the disorder.

Dr. Pamela B. Morris: This may sound like a bit of a silly question, but we see it on TV and in movies so often, what is the role of the brown paper bag?

Dr. Linda Austin: Well, sometimes when people become very anxious, they hyperventilate and when you hyperventilate, you breathe very, very fast and you are exchanging your oxygen and carbon dioxide too quickly and your oxygen is going up and your carbon dioxide in your body is going down and that can make you very dizzy, so you get it into a vicious cycle that of breathing really hard and then getting to see and thinking you are having heart attack and so cycles like that. So, if you are one who hyperventilates and you grab a brown paper bag, you are rebreathing your own air and you are reversing the balance to what it should be and it helps with that dizzy feeling. There is nothing more magical than that and may be part of this just is having something dramatic to do at the moment.

Dr. Pamela B. Morris: Well, this has been a very interesting discussion and I feel so much more relaxed after having gone through these diagnoses. Thank you so much Dr. Austin.

Dr. Linda Austin: Thank you very much.

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