Facing Fear and Anxiety -- Jonathan Davidson, MD -- 03/13/03

By Jonathan Davidson
WebMD Live Events Transcript

For many reasons anxiety is high across the country. How do we separate everyday unease from the kind of anxiety that needs treatment from a professional? Jonathan Davidson, MD, author of The Anxiety Book, joined us to talk about diagnosing and treating anxiety disorders.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Hello, Dr. Davidson. Welcome to WebMD Live. Can you please explain the five primary forms of anxiety?

Davidson: Yes. There are five main kinds of anxiety.

  • The most common is Social Anxiety Disorder (SAD), which affects 15% of the population. In SAD, you have an exaggerated fear of embarrassment or humiliation in front of others, so as a result you avoid situations where you are the center of attention or you endure them with a great deal distress.
  • The second most common anxiety is post-traumatic stress disorder (PTSD), affecting 8% of the population. Following exposure to life-threatening trauma, some develop the classical symptoms of PTSD and it may continue for many years.
  • The third most common anxiety is generalized anxiety disorder (GAD), affecting 6% of the population. It is characterized by uncontrollable worry, apprehension, and tension.
  • The fourth most common anxiety is panic disorder (PD), which affects about 3%.
  • The final kind of anxiety is obsessive-compulsive disorder (OCD), which affects 2%.

Of course, a person could have more than one of these disorders.

Moderator: We all experience anxiety at times. How do you know when it is unhealthy anxiety?

Davidson: Anxiety becomes unhealthy under the following circumstances:

  • It prevents you from functioning in your basic day-to-day life
  • If it persists without good reason
  • If it creates significant distress
  • If it leads into complications

Member: Are any of the anxiety disorders heredity linked?

Davidson: In all of the five disorders, there is a degree of inheritable vulnerability. What that means is that if you have a family history of anxiety disorders you have a greater risk of having it too. But simply having that risk doesn't automatically guarantee that you will develop anxiety because there are other factors, too.

Moderator: Can anxiety be a symptom of another disorder?

Davidson: Yes. Anxiety can, indeed, be a symptom of other disorders, particularly depression. But when we use the term "anxiety disorder," what we are referring to is the anxiety itself as the primary problem.

Moderator: What are the first steps you should take to get a proper diagnosis?

Davidson: A good place to start is to go to a professionally qualified person: the family doctor, a psychiatrist, or a clinical psychologist. And another good place to start might be the self-tests in The Anxiety Book. These serve as a screening tool to identify the possibility that somebody may have an anxiety disorder.

In the book there are different screening questions for generalized anxiety and these include:

  • Are you feeling tense?
  • Restless?
  • Do you tire easily?
  • Do you worry about things?
  • Is it difficult to control your worries?
  • Are you irritable or impatient?
  • Do you experience muscle tension?

For social anxiety the screening questions include:

  • Do you avoid things because of embarrassment?
  • Do you avoid being the center of attention?
  • Do you avoid speaking to other people?
  • Are you troubled by blushing, sweating, or trembling?

For panic disorder, the screening questions ask whether you have had:

  • Sudden unexpected attacks of panic?
  • Dizziness?
  • Faintness?
  • Shortness of breath?
  • Do you avoid places where you may feel panicky?

For PTSD, the questions would be:

  • How much have you been bothered by unwanted memories or nightmares or reminders of the traumatic event?
  • How much effort do you have to make to avoid thinking about the event?
  • Have you lost enjoyment for things, kept your distance from people, or found it difficult to experience feelings?
  • Have you been bothered by poor sleep, poor concentration, jumpiness, irritability, or feeling watchful around you?
  • Have these symptoms interfered with your daily life?

For OCD, do troublesome thoughts keep bothering you about...

  • Dirt or contamination?
  • Harming others?
  • Sexual urges?
  • Hoarding things?
  • Blasphemy?

Do you have to repeatedly perform actions concerned with...

  • Cleaning?
  • Tidying things?
  • Checking locks or appliances?
  • Rereading?
  • Hoarding things?

Moderator: If you say yes to these symptoms, do you seek help?

Davidson: The issue would then be if you have the symptoms a lot of the time or they are interfering with daily life then you might consider that there is a possibility of anxiety disorder and professional evaluation could be pursued. However, if the symptoms are infrequent or mild, this does not necessarily mean you suffer from an anxiety disorder.

Member: Does forcing yourself to be in uncomfortable situations when you have social anxiety cure you of it?

Davidson: Great question. By staying in the feared situation for a long enough time anxiety usually diminishes. And with repeated practice the problem should be relieved. But generally, this technique works best when provided by a professionally qualified person.

Member: Is agoraphobia a type of anxiety disorder, or is it a symptom of having an anxiety disorder with panic attacks? And how is agoraphobia treated?

Davidson: Most commonly, agoraphobia occurs with panic disorder, and is a complication of having repeated panic attacks. It is widely treated either with medications such as SSRI antidepressants like Paxil, Lexapro, or Zoloft or with antianxiety drugs such as Xanax and Klonopin. In addition, cognitive behavior therapy (CBT) is very effective for agoraphobia.

Member: Is going to the doctor a problem when you have agoraphobia?

Moderator: Sometimes because of the agoraphobia, it is very difficult to take the first step of going to the doctor. Moreover, with exposure treatment you get a bit worse, initially, before you later improve. Finding someone who will help you take that first step is important.

Member: I take Klonopin for anxiety and have for more than five years. Is there any risk in taking it for so long, and is there another medication you think I should try in its place? I have tried a number of the SSRIs without much success. Thanks

Davidson: Klonopin can be safely given for many years. I have clients who have been on the drug for over a decade. It can be safely and effectively given for an indefinite period of time, if necessary. If the drug continues to work well, I see no reason to think of switching. The main problem concerning long-term use of Klonopin is that if and when the time comes to discontinue the drug, this must be done slowly and gradually in order to lessen the chance of distressing withdrawal symptoms or relapse.

Member: After much trial and error with psychiatric professional care and prescriptions, I have found that the medicine that seems to counter my depression best is Wellbutrin. Unfortunately, it brought out my anxiety attacks. Do you have any suggestions?

Davidson: A good question. Wellbutrin is one of the few antidepressants that do not generally help anxiety disorders. Indeed, it can sometimes make them a little bit worse. However, sometimes it is useful if you have both anxiety and depression, provided there is another medicine to control the anxiety. Wellbutrin can be helpful to treat sexual side effects from the SSRI antidepressants or the antianxiety drugs, and it can be useful if you wish to quit smoking or if you have attention deficit symptoms as well as anxiety problems.

Member: Can anxiety cause heart problems?

Davidson: The answer is both yes and no. To explain what I mean, if you are having an acute panic attack this will not lead to heart problems. However, untreated chronic anxiety and worry that goes on for years, especially in the context of stress, is considered to be one risk factor for developing heart disease. For this reason, among others, it makes it important to deal with chronic anxiety.

Member: I was diagnosed with GAD and depression. I was getting a bit better but I am starting to go downhill again. I have only been on my medications (Effexor XR 75 mg) for a little over a month.

Davidson: Effexor XR should be helpful for 70% or more of people with GAD, but it may take some months before you see full benefit. While 75 mg is sufficient for some people, better effects are often found at 150 or 225 mg per day. So, it is possible that a higher dose would be more effective. I suggest you discuss this with your doctor. (GAD is short for general anxiety disorder).

Member: Have you ever encountered a patient who went from panic disorder to GAD?

Davidson: Yes you can have more than one anxiety disorder and you may begin, for example, with panic disorder and develop GAD. It could also work the other way around.

Member: Can anxiety be treated without medication?

Davidson: In The Anxiety Book, we refer to a number of non-medication approaches. In particular, cognitive therapy and exposure-based therapy, which I refer to in the book as "vaccination of the mind," are very effective treatments. In order for them to work, the client must be an active participant and carry out a fair degree of homework exercises between sessions. And, generally, after two months or so, you will see considerable improvement.

Member: My wife has extreme panic and anxiety attacks, especially at night; bad dreams, etc. Her primary physician has not suggested anything. What do you recommend for our next step?

Davidson: This description suggest two possibilities: One might be panic disorder with nocturnal panic attacks that wake you from your sleep; the second possibility might be PTSD with nightmares and panic symptoms that relate to the traumatic event. In either case, effective treatments exist and these possibilities could be discussed with your family doctor. If this does not produce a satisfactory response, then consider an appointment with a psychiatrist for further evaluation.

Member: I recently had a car accident on black ice and ever since I have a severe fear of driving in snow and ice. What do you suggest?

Davidson: This suggests a post-traumatic stress problem and treatment could be successfully given either with exposure-based therapy or possibly with meds such SSRIs. Either way, I would suggest that you seek professional help for this problem. It is more likely to go away more quickly with help of this kind.

Member: Does your book list doctors by state who follow your treatment suggestions?

Davidson: The Anxiety Book does not and probably could not give a full comprehensive list of qualified practitioners, but I would recommend contact with the following web site, www.adaa.org, for further information. That is the web site for the Anxiety Disorders Association of America.

Member: Does environment play a role with anxiety disorders?

Davidson: Environment certainly plays an important role for anxiety disorders, especially continued or severe or uncontrollable stress, as well as such influences as early abuse in childhood or ongoing abuse in adulthood. In changing your fearful beliefs, we're really addressing the important role played by our thoughts or beliefs, most of which we are aware of.

Moderator: In your book you suggest that we should "Change Your Fearful Beliefs." Can you explain this?

Davidson: With anxiety disorder these beliefs are typically of a catastrophic or doom and gloom type. For example, "I wake up regularly with a headache, therefore I must have brain tumor. However, there is no evidence for such a cause, yet I remain convinced that I have cancer and I will die." This kind of irrational or unfounded belief can be challenged and replaced by a rational response such as, "My doctor has thoroughly checked every possibility and nothing has been found; cancer usually gets worse over time, yet I am 100% healthy. Even though there is a very remote possibility of such things, this just does not seem to be a real likelihood." This might be an example of the influence that beliefs can have that maybe replaced with more reality-based beliefs.

Moderator: You also talk about "Developing Serenity Skills."

Davidson: Serenity skills include techniques such as relaxation, meditation, and visualization. All of these can help us to cultivate a greater state of physical calm and serenity and to experience more positive feelings at the expense of the older, negative feelings. Such activities help to produce a greater state of mental and physical health and the skills learned can be applied at times of stress or fear. In order for them to take effect, regular practice is necessary.

Moderator: What is the role of diet, exercise, and herbs in dealing with anxiety?

Davidson: We know that exercise is associated with well-being, less depression and anxiety. We know that it produces better physical health and can be one way of effective stress management.

Diet is important to consider because excessive intake of refined carbohydrates rich in sugar can lead to imbalance of blood glucose. A diet rich in omega-3 fatty acids may well promote good mood and well-being. Moderation in the use of caffeine, alcohol, and tobacco is also recommended.

Many people take herbs for anxiety. The evidence that they work is limited. St. John's Wort, Passion Flower, and Kava Kava have been popular, however, recently kava has been linked to severe liver damage and is not recommended. Most herbal treatments are useful in mild anxiety, but are less effective than conventional treatments for anxiety disorders.

Moderator: Should all herb use be discussed with your doctor?

Davidson: Anyone who is taking medications and considering herbal treatment should certainly discuss is with their doctor because potentially serious interactions have been known to occur with some medicines.

Member: How about SAMe?

Davidson: SAMe is a naturally occurring substance in the body and can be obtained in commercial form for depression and arthritis. It may have benefit for depression, is costly, and has few side effects. But for major depression, I would not self-treat without first having a professional evaluation.

Moderator: Dr. Davidson, we are almost out of time. Before we wrap up for today, do you have any final comments for us?

Davidson: I would first like to thank you for having me. I would also like to say that if you think anxiety is putting your life on hold, don't hesitate getting help. You should not feel ashamed if you have a problem with anxiety. There are highly effective treatments available.

Moderator: Our thanks to Jonathan Davidson, MD for joining us today. For more information, please read his book, The Anxiety Book.

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