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How To Deal With Anxiety: Hierarchy Of Treatments

Anxiety is characterized by feelings of fear and nervousness and can significantly affect a person’s overall functioning and wellbeing. When we develop anxiety, our sympathetic nervous system becomes engaged, arousal increases, brain waves speed up, and we may experience physical symptoms such as an increased heart rate. People tend to have varying degrees of anxiety as well as different types of anxiety.

One individual may suffer from panic attacks, while another may have generalized anxiety disorder. In some cases, anxiety can have a genetic basis and we can be predisposed to having social anxiety from various traits we inherit such as introversion and avoidant tendencies. In other cases, significant stress from work, lack of exercise, and emotional events such as a relationship break-up can trigger significant anxiety.

Regardless of how little or how much anxiety you have, the article below will attempt to offer some perspective on how you can effectively deal with it. As a fellow anxiety sufferer, I’ve attempted to come up with a hierarchy of anxiety treatments that can be pursued if you feel anxious.

How To Deal With Anxiety: Hierarchy of Treatments

When it comes to developing a hierarchy of how to deal with anxiety, exploring natural treatments is always initially recommended. These tend to be the safest, but tend to require more work than simply popping a pill once per day. Following these natural treatments come the safest anxiolytic medications, followed by first-line anxiolytics, then benzodiazepines, and finally if those don’t work, exploring counterintuitive pharmacology.

1. Natural treatments

Many people will be surprised at how effective some natural treatments for anxiety can be if they give them a legitimate trial. These days everyone wants a quick and easy fix for their anxiety (i.e. medication), when in reality, properly dealing with it can take some work. It is always recommended to pursue various natural cures for anxiety before trying medications. If you give these a try and they don’t work (or aren’t quite effective enough), at least you’ll know.

  • Aromatherapy: This is an alternative type of medicine that treats anxiety by using oils extracted from various plants. Certain extracts are thought to create a sense of physical and mental relaxation when inhaled as an “aroma.” You could visit a licensed aromatherapist and give it a shot, or you could try some recommended essential oils for anxiety on your own to determine if they have an effect.  Using aromatherapy for anxiety and stress can be an effective way to unwind and mellow out from a stressful workweek or feeling tense.
  • Avoid alcohol / illicit drugs / stimulants: Many people fail to recognize the fact that something in their life could be contributing to feelings of anxiety. For example, if you drink alcohol frequently, it will result in lower levels of serotonin and it will increase your chance of experiencing anxiety. Additionally if you are using various illicit drugs, many of them may provide temporary relief from anxiety, but when the “high” wears off, your anxiety may gradually worsen. If you are taking any medications with stimulating properties, this could be contributing to your anxiety.
  • Biofeedback / Neurofeedback: Lesser known, yet effective treatment options for dealing with anxiety include: biofeedback and neurofeedback. Biofeedback involves recognizing various bodily functions that are contributing to your anxiety and training your responses to those functions. For example, using a device like the Em Wave gives you biological feedback of your heart rate and attempts to help you recognize how to change it to a healthier range. Neurofeedback specifically focuses on targeting specific brain waves that may be contributing to anxiety and allows us to essentially train the brain to create more relaxing activity. Unfortunately most biofeedback and neurofeedback sessions with licensed professionals are fairly expensive and not usually covered by insurance. Additionally it can take several sessions to notice improvement in your ability to deal with anxiety.
  • Books: Many anxiety sufferers are undereducated on what could be causing their anxiety as well as various coping techniques that could be utilized to ease their symptoms. Reading educational books specifically geared towards helping someone with anxiety may be highly beneficial. The two books that come to mind are “Hope and Help for Your Nerves” by Dr. Claire Weekes as well as “Feel The Fear and Do It Anyway” by Susan Jeffers. Those are just a couple of books that come to mind, but there are many other options. In some cases, the best way to deal with anxiety is to educate yourself on what really works.
  • Brainwave Entrainment: There is some evidence to suggest that brainwave entrainment is an effective therapeutic tool for dealing with anxiety. Although it is relatively safe for those without a history of seizures, it is not well-researched. This type of therapy involves listening to various frequencies or “tones” that change your brainwaves from fast-paced beta waves to slower, relaxing alpha waves. In other cases, it involves a visual stimulus (e.g. from goggles) combined with an audio tone to help induce relaxation. It should be noted that there are some potential dangers of brainwave entrainment though.
    Source: http://www.ncbi.nlm.nih.gov/pubmed/18780583
  • CBT (Cognitive Behavioral Therapy): This is a type of psychotherapy that involves addressing irrational thoughts, behaviors, and emotions. CBT has been found highly effective in treating people of all ages (including adults) with all types of anxiety. For many types of anxiety, it is found to be equally effective as using a medication. It may take a few different therapist visits before you find one that you feel good about. Once you experience a few sessions of CBT and address your maladaptive unrealistic thoughts, you may feel a lot better. Read the article “What to look for in a therapist” for more information. Source: http://www.ncbi.nlm.nih.gov/pubmed/23988455
  • Diet: It is important to mention the fact that if you consume caffeine, this could significantly contribute to your feelings of anxiety. Caffeine tends to stimulate brain activity and basically serves as fuel to a fire when it comes to anxiety. Additionally, research shows that diets high in refined sugars and carbohydrates are worse for overall mental health than diets including fish, meats, vegetables, fruits, and whole grains.
  • Exposure Therapy: This is a specific type of behavioral therapy in which a person exposes themselves to the stimulus that is causing them to feel anxious. In the event that a person has a specific phobia, they would gradually expose themselves to small degrees of the anxiety-inducing stimulus. Over time, the goal is to eventually escalate to being fully exposed to the stimulus and thus alleviating symptoms of anxiety. It is very helpful specifically in the case of PTSD, phobias, and OCD.
  • Hypnosis: When most people think of hypnotism, they think of a hypnotist taking out a pocket watch, dangling it back and forth, and controlling a person’s actions. This definition is largely a misconception created by uninformed mainstream society. Using hypnosis involves listening to a hypnotherapist who will guide you into a state of deep physical and mental relaxation. From this place of relaxation, you will attempt to address and alleviate your feelings of anxiety. If you don’t want to seek out a licensed hypnotherapist, you can always engage in self-hypnosis (with audio recordings).
  • Meditation: Many types of meditation are thought to reduce stress and have a positive effect on mood. Although many types of meditation may be effective at promoting relaxation and reducing anxiety, one specific type called “Mindfulness Meditation” was found clinically effective at treating anxiety. This type of meditation involves accepting, non-judgment of how you are feeling, what you are thinking, and sensations in the present moment. Essentially you become a non-judgmental observer of your anxiety and it reduces. Source: http://www.ncbi.nlm.nih.gov/pubmed/23615765
  • Physical Exercise: It should be known that there are many psychological benefits of exercise, one of which tends to be reductions in anxiety and cortisol (a “stress” hormone). Getting adequate exercise on a daily basis helps burn off excess energy that could be contributing to your anxiety. If you hit the gym for a good workout, whether you are doing cardio or strength training, you will tire the body out and gradually reduce both physical and mental arousal.
  • Reflexology: This involves applying a massage or pressure in certain areas of the body called “reflex points” to release tension and to reduce anxiety. This is a non-mainstream way of dealing with anxiety that is supported by some professional research. To experience reflexology, consult a licensed reflexologist and give it a try.  Many individuals have found reflexology for anxiety disorders to be very helpful in managing symptoms.
  • Relaxation Techniques: Learning a helpful relaxation technique can go a long way towards dealing with anxiety. One common technique that people preach is that of deep breathing. This involves taking a deep, controlled inhale through the nose, and a slow, controlled exhale from the mouth. Other effective relaxation techniques include: guided imagery and progressive relaxation.
  • Supplements: There are a variety of natural, herbal remedies for anxiety that can be pursued prior to trying a medication. Although these options are not free of side effects, many agree that their side effects and discontinuation is much easier than those associated with anxioltic and antidepressant medications. Examples of common supplements that have some evidence supporting their usage include: German Chamomile, Kava Kava, Lemon Balm, Melatonin, and Passionflower.
  • Yoga: If you need another way to deal with anxiety, there is an array of evidence suggesting you turn to yoga. Yoga involves holding a variety of (uncomfortable) physical poses for the purpose of flexibility, stress relief, and health. Yoga has been associated with reductions in performance anxiety, general anxiety, and other forms of stress. If you want to do yoga with a professional, you could enroll in a yoga class, but if you don’t feel comfortable, you can always buy a yoga mat (and a yoga DVD) and do it at home.  It should also be noted that there is a specific type of yoga combined with cognitive behavioral therapy called Y-CBT that has also been found helpful.

2. Non-Benzodiazepine Anxiolytics

Assuming you’ve given all of the natural treatment options a legitimate chance to work, it is likely that you found something to help reduce your anxiety. However, for certain individuals with more severe forms of anxiety, natural treatments may not be effective enough for the individual to properly function in society. If anxiety is genetically-based and you’ve given natural options a shot, it’s time to explore medication.

Before hopping on an antidepressant and/or a benzodiazepine, why not try a safe, effective anxiolytic? The reason I recommend trying an anxiolytic for those with pure anxiety is because they will help treat the problem without affecting your mood. Antidepressants can really put people through an emotional rollercoaster (especially if they don’t work), while benzodiazepines are associated with easily developed tolerance and linked to dementia.

  • Buspar (Buspirone): This is an anxiolytic drug that targets the 5-HT1A receptor as a partial agonist. It has been FDA approved to treat anxiety disorders and is also documented as having slight antidepressant effects. It is considered to have mild-sedating effects and is slow acting – meaning it can take weeks before you’ll feel an effect. The nice thing about Buspar is that if it works, you won’t have to worry about becoming addicted, feeling sedated, memory problems, and/or a severe withdrawal upon discontinuation. The only downfall to this medication is that many don’t notice any effect. Still, it should be considered safer than an SSRI for targeting anxiety.
  • Clonidine: This is a commonly prescribed drug that’s primary use is to treat high blood pressure. It is also prescribed as an off-label treatment for anxiety, and one that I have personally used. The nice thing about Clonidine is that it isn’t associated with dementia like benzodiazepines and is also FDA approved for treating ADHD. If you want to maintain focus, while feeling relaxed, your psychiatrist may want to consider prescribing Clonidine for anxiety.

3. Antidepressants (SSRIs)

Assuming you’ve explored all natural options and you’ve tried nonbenzodiazepine anxiolytics without any benefit, you may need to try antidepressants. Using antidepressants for anxiety can work extremely well, and for certain individuals, this class of drugs can be the single most effective for addressing mental components of anxiety. These drugs work by inhibiting reuptake of serotonin in the brain, allowing synapses more time to “soak” in serotonin.

Although these are clinically effective and non-addictive medications, they are associated with unwanted side effects such as: sexual dysfunction and weight gain. Additionally, many of the best SSRIs for anxiety are also associated with very difficult withdrawal symptoms and hellacious discontinuations. Due to the side effects and withdrawal symptoms, they cannot be recommended ahead of medications such as Buspar.

It is also important to note that if you don’t react well to antidepressants, you may actually experience heightened anxiety. Some of these drugs simply won’t work for specific types of anxiety. Additionally, it is thought that antidepressants cause a chemical imbalance when used over time, making it extremely difficult to function for a period of time following discontinuation.

  • Paxil (Paroxetine): This is an SSRI that is geared primarily towards treating symptoms of anxiety.  It has been approved to treat social phobia, panic disorder, generalized anxiety, OCD, and PTSD.  Although this drug has developed a bad reputation as a result of the withdrawal symptoms and side effects, it is considered very effective for anxiety.
  • Lexapro (Escitalopram): This SSRI is approved for the treatment of generalized anxiety disorder.  Some people experience anxiolytic effects from this drug within one week after starting treatment and most respond to it within 8 weeks.  It is also regarded as an effective drug over the long-term for preventing anxiety relapse.
  • Zoloft (Sertraline): This drug has been approved to treat social anxiety disorder, PTSD, and OCD.  Many people have found this medication helpful for reducing their anxiety.
  • Effexor (Venlafaxine): This is the only SNRI that is used to treat social anxiety, panic disorder, and generalized anxiety disorder.  If a person doesn’t respond to common SSRIs, a doctor may prescribe this medication to determine if it helps.
  • Luvox (Fluvoxamine): If your anxiety is rooted in OCD, this may be a medication that works well to address symptoms.  It is only medically approved to treat OCD, but many doctors prescribe it for various types of anxiety too.
  • Celexa (Citalopram): In European countries this drug is approved to treat panic disorder.  Additionally it contains the same active ingredient as the drug Lexapro, therefore is likely to exhibit anxiolytic effects.

Note: Anytime you are trying an antidepressant, it is recommended to start at the lowest possible dose, give it a chance, and if you aren’t getting the anxiolytic effect, titrate the dosage upwards. The goal is to maintain the lowest dose that allows you to deal with your anxiety.  Going on a high dose will have a greater effect on physical and mental functioning as well as be more likely to cause side effects.

4. Benzodiazepines

Benzodiazepines are the single most effective drugs to treat anxiety on the market. Although they are highly effective, they are generally considered a second or third-line treatment option for numerous reasons. They are less safe than antidepressants, it is easy to become tolerant to their effects, and consistent usage is associated with permanent memory impairment and development of dementia.

Additionally these medications work by enhancing activity of GABA in the brain. Unfortunately benzodiazepines are not sustainable long-term treatment options and withdrawal from these drugs is thought to be as intense (or more intense) than any drug. As long as you understand the seriousness of benzodiazepines and have pursued other options, it is regarded as the most effective treatment for anxiety on the market.

  • Ativan (Lorazepam): This is regarded as one of the most potent anxiolytic drugs that exists. It was specifically approved to treat severe, short-term anxiety and should not be used longer than several weeks.
  • Klonopin (Clonazepam): This is a drug that is approved to treat epilepsy and panic disorders. It decreases activity in the central nervous system by acting on GABA receptors in the brain.
  • Valium (Diazepam): This drug is used to treat anxiety disorders, insomnia, as well as dealing with alcohol withdrawal. This is a longer-lasting, older benzodiazepine that is sometimes prescribed.
  • Xanax (Alprazolam): This is considered perhaps the most common anxiolytic medications on the market. It is used to treat panic disorder, generalized anxiety disorder, as well as social anxiety.

5. Beta Blockers

Although beta blockers have never been approved by the FDA to treat anxiety disorders, they are very effective at reducing physical symptoms associated with anxiety. For example if you have a fast heart rate, clammy hands, and are shaking because you are so anxious, a beta blocker will significantly reduce these symptoms.  Beta blockers may not address anxiety from a mental perspective, but they can be of benefit to individuals with significant physical symptoms.

Additionally, they are thought to be of significant benefit for performers, and are often used by speakers, actors, and other professionals to eliminate stage fright.  Despite the fact that beta blockers for anxiety can work great at addressing the physical symptoms such as blushing, palpitations, sweating, muscle tension, and shaking, they are not without risk.  This class of drugs carries the risk of causing Type 2 diabetes in certain individuals.  Therefore, it should be a mutual decision from patient and doctor as to whether a beta blocker such as Propranolol (Inderal) should be utilized.

6. Anxiolytic Augmentation Strategies

Assuming that you have gone through an array of natural treatments, you’ve given non-benzodiazepines a shot, you’ve tried some antidepressants, and finally explored the benzodiazepines, you may want to consider augmentation strategies. Although you may have found benzos to be helpful, long-term treatment with them is typically not sustainable. Therefore a psychiatrist may look to target your anxiety with a combination of medications and therapies.

The most common strategy for treating anxiety is utilizing CBT with an SSRI antidepressant. Assuming both the CBT and the medication help, some people experience full recoveries in their anxiety. The combination of CBT plus an anxiolytic is regarded as being more effective than monotherapy with one or the other.

Examples of anxiolytic augmentation strategies: There are many possible combinations of medications that a psychiatrist may test out if you aren’t finding any relief in your symptoms of anxiety.  Assuming you are already pursuing CBT and utilizing natural treatments to manage anxiety to the best of your ability, there are some additional options that may help.  Several examples are listed below…

  • SSRI + Buspar
  • SSRI + Clonidine
  • SSRI + Benzodiazepine

Additionally a psychiatrist may experiment by prescribing an array of medications to take at the same time. Essentially you may be put on an anxiolytic cocktail of drugs to help reduce symptoms. I wouldn’t ever recommend going on more than 2 psychiatric medications at the same time due to the fact that the more drugs you are on, the more difficult it is to track which drugs are actually working.

Also, the more medications you take, the greater your chances of unwanted side effects. Augmentation options should only be utilized if a medication plus natural methods were tried and none were found to be very effective.

7. Counterintuitive Treatments (Stimulants)

You may reach a point in your quest to treat anxiety and hit a brick wall. None of the traditional anxiolytic medications may be effective, no natural options work, and no matter what you do, you cannot find relief. Usually this happens after you’ve already been put through the ringer of medications and your brain chemistry has been through alterations. At this point you may feel highly anxious that nothing works and not know what to do.

Once all logical treatment options have been pursued, a psychiatrist may be puzzled. If no depressants seem to work for “anxiety” which is usually caused by higher than average arousal, something may not seem right. If you experience slowed cognition (as verified by psychological testing) and your anxiety is more associated with a lack of thought and low arousal, a psychiatrist may give you a low dose of a stimulant to try.

Although people with traditional types of anxiety may not benefit from a stimulant, some hypothesize that using something like Adderall for anxiety helps because it increases dopamine. Some people believe that elevating dopamine levels with a stimulant can have a positive effect on mood and ease anxiety in social situations because the drug essentially has “primed” your brain with ability to socialize and focus.

Final thoughts on how to deal with anxiety

It is important to realize that not everyone with anxiety will have the same way of dealing with it. For one person, the best way to deal with anxiety may be practicing daily meditation for 20 minutes. For another person, the best way to deal with anxiety may be putting on boxing gloves and smacking up a punching bag until they have no more energy to feel anxious. For others, the best way to deal with anxiety may be a combination of techniques listed above.

The whole idea is to experiment with a variety of coping mechanisms to find what works best for you. It can be very difficult to deal with anxiety if it is chronic, has a genetic basis, and/or has been a lifelong problem. However, the longer you let anxiety influence your life, the more difficult it becomes to overcome the feelings of dread, panic, nervousness, and unwanted thoughts.

You should also understand that there may not be a “cure” for your anxiety, but you can always choose to put forth enough effort to properly manage it. There may be times when you find anxiety especially difficult to deal with and you can’t think of any ways to cope. Feel free to use this article as a reference whenever you feel trapped and unable to escape your anxiety. Assuming you give the items on this list a legitimate shot, odds are favorable for finding something that helps you deal with anxiety.

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{ 5 comments… add one }
  • Meghan Guffey November 16, 2014, 3:01 pm

    Thank you for this excellent article. Very informative! :-)

  • B May 9, 2015, 5:23 pm

    Honestly, this was an absolutely fantastic read. Having done a lot of reading on this subject in the past 8 weeks or so, this was opinionated, but not pushy. And had some really really great advice, and broke down anxiety and its possible treatments in the best and most “layman’s” speak as possible. I can’t wait to come back to this! BOOKMARKED.

  • Chris Jones May 10, 2015, 4:49 am

    I agree with Meghan that this is an excellent article.

  • Marta Garbarino April 19, 2016, 11:37 pm

    One of the most well organized and easy to understand articles I’ve read on the subject. Could have done a little more on the side effects but I guess I can look those up individually.

  • bobbie barton October 11, 2016, 10:16 pm

    Wonderful article.

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