What is Anxiety and Panic?
Key Symptoms
What Causes Anxiety and Panic?
Conventional Treatments
Medications
Tests and Procedures
Treatment and Prevention
How Supplements Can Help
Self-Care Remedies
Alternative Therapies
When to Call a Doctor
Evidence Based Rating Scale
References

What is Anxiety and Panic?

The feeling of unease, worry, foreboding and fear, commonly known as anxiety, is a normal and often useful reaction to a dangerous or stressful situation. When the brain senses a threat, it triggers the release of hormones that prepare the body to either defend itself or flee. In this "fight or flight" response, muscles become tense, heart and breathing rates quicken, pupils dilate, the mouth dries out, and the blood becomes more likely to clot if an injury is sustained.

While undoubtedly beneficial as a defense against temporary stress, anxiety becomes a health problem when it is triggered excessively or persistently; when it occurs for no obvious reason or begins to interfere with day-to-day activities; or when it causes emotional distress.

Anxiety disorders can lead to a variety of physical and psychological problems, including fatigue, headaches, stomach upsets, high blood pressure, poor concentration, sleep disturbances, a sense of detachment from reality, and depression. Left untreated, anxiety disorders can also increase the risk of substance abuse and suicide.

There are two basic types of anxiety disorders: chronic and acute.

• The chronic form, called generalized anxiety disorder (GAD), is characterized by a recurring sense of worry and foreboding, accompanied by restlessness, insomnia, low sex drive and other mild physical symptoms.
  
  
• The acute form of anxiety disorder is the panic attack, a sudden and unexpected bout of intense fear and dread accompanied by rapid heartbeat and breathing, chills, excessive perspiration and other physical symptoms so severe that they are often mistaken for a physical illness, including a heart attack.        

Anxiety disorders are very common, more so among women than among men. In fact, around 15% of Americans will experience at least one panic attack in their lifetime (and 3% have these attacks often). Fortunately, anxiety disorders are highly treatable, primarily through psychotherapy, often combined with drug therapy. Certain supplements may be as effective as prescription drugs in treating anxiety disorders without the side effects and risk of dependency of conventional medications.

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Key Symptoms 


Acute anxiety (panic attack):

• Intense fear and dread
  
  
• Rapid heartbeat and rapid or shallow breathing
  
  
• Profuse sweating, hot flashes or chills
  
  
• Dry mouth or the feeling of having a lump in the throat
  
  
• Dizziness
  
  
• Dilated pupils        

Chronic anxiety (generalized anxiety disorder):

• Recurring worry and a sense of foreboding not associated with a specific activity or event
  
• Muscle tension, headache and back pain
  
  
• Restlessness, irritability and insomnia
  
  
• Decreased sex drive
  
  
• Depression        

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What Causes Anxiety and Panic? 


The exact causes of anxiety disorders are usually unknown. Some cases may be triggered by a traumatic event, such as a death, accident, or divorce, while others have no identifiable root causes. Genetic and biochemical factors, however, are thought to play a major role in anxiety disorders. Some people's central nervous systems may be predisposed to overreact to stress and to take a longer time to calm down after a stressful event, or their brain and adrenal glands may produce an excessive amount of stress hormones.

People who experience panic attacks seem to have high blood levels of lactic acid, a chemical produced when muscles metabolize sugar without sufficient oxygen. Certain drugs and chemical substances, such as caffeine, over-the-counter decongestants and cold remedies; thyroid hormone; and inhaled asthma drugs can trigger anxiety-like symptoms. Other contributing factors include withdrawal from tobacco, alcohol, caffeine, sedatives, narcotics and other addictive substances.

Conventional Treatments

Some underlying physical conditions as well as medications used to treat various conditions may trigger anxiety, so treatment may be as simple as identifying and treating any underlying cause.

Psychotherapy, combined with prescription anti-anxiety or antidepressant drugs, can be very successful in treating anxiety disorders. Prescription drugs can be used to treat both generalized anxiety and panic attacks.

Medications

The principal class of anti-anxiety medications – benzodiazepines – produce a calming effect by depressing activity in areas of the brain that control emotions. Although such drugs--which include alprazolam (Xanax) and diazepam (Valium), and others--help ease anxiety symptoms in the majority of sufferers, they can cause drowsiness and lethargy, and their use for extended periods (usually longer than three months) can lead to psychological dependence.

A new class of antidepressant drugs called SNRIs (selective serotonin and norepinephrine reuptake inhibitors) has recently become a first-line treatment for anxiety because they have few side effects and seem to be easily tolerated. For example, the drug venlafaxine (Effexor-XR), was shown to be clinically effective for treating generalized anxiety disorder. Other antidepressant drugs – SSRIs (selective serotonin reuptake inhibitors) and tricyclics – also have been a preferred treatment for many cases of anxiety. A drug such as sertraline (Zoloft), for example, is quite effective at reducing panic attacks. Antidepressants are not habit forming and can be effective at low doses (whereas doses of benzodiazepines must often be increased). And obviously antidepressants are useful when anxiety is accompanied by depression.

Other medication options include the anti-anxiety drug buspirone (Buspar), which also has fewer side effects than benzodiazepines. Doctors additionally sometimes prescribe beta blockers—commonly prescribed for high blood pressure—which block the effects of adrenaline like substances, thus preventing some of the physical symptoms of anxiety, such as palpitations.

Tests and Procedures

A physical exam, medical history and blood tests can help to diagnose any underlying cause, e.g. medical conditions such as hyperthyroidism could cause symptoms similar to anxiety. An electrocardiogram (EKG) might be performed to rule out heart problems. A psychological evaluation may help to get to the root of anxiety and any triggers.

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Treatment and Prevention 


In some situations, anti-anxiety supplements can be as effective as prescription drugs. Similarly, mood-enhancing supplements can be tried in cases where an antidepressant medication might be recommended for treating anxiety. Unlike conventional medications, the supplements may have fewer side effects and do not lead to dependence. Interestingly, the problem of drug tolerance, where increasingly large doses of a medicine are needed to maintain a therapeutic effect, does not occur when using supplements.

Eliminating caffeine, reducing your intake of sugar, sugary food products, refined carbohydrates and foods with additives and chemicals, exercising regularly, and practicing any of a variety of relaxation techniques (meditation, yoga, tai chi, progressive relaxation) can all help relieve anxiety disorders.

A note of caution: Never make any changes in either your prescription anti-anxiety medications or your antidepressant medications without talking to your doctor first. Consult your physician before combining herbal therapies with conventional anti-anxiety medications, as many of them work on similar receptors or go through similar breakdown pathways and could interact. Also, if you have a medical or psychiatric condition, it's always wise talk to your doctor before beginning a supplement program.

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How Supplements Can Help 


Calcium and magnesium, as well as a vitamin B complex promote the health and proper functioning of the nervous system and play an important role in the production of neurotransmitters, chemicals that help relay messages between nerve cells. When depression or a panic disorder is persistent – and especially when conventional medications have limited effect – supplementing with magnesium and vitamin B₆ may provide significant relief. It may take six weeks or more of treatment for effects to be noticeable. Taking calcium along with magnesium may also lessen an overreaction to stress that some research has linked to anxiety and panic attacks. (1, 2)

The herb valerian, a natural sleep aid, if taken in low doses throughout the day can also relieve anxiety symptoms, or try valerian at night if you're having difficulty falling asleep. It works on the some of the same brain receptors as the diazepam class of drugs. German health authorities endorse the use of valerian for restlessness and sleeping disorders that are caused specifically by nervous conditions. In fact, anyone who suffers from stress, panic attacks, or other nervous conditions may benefit from valerian. However, scientific evidence regarding anxiety has been conflicting. A 2002 United Kingdom study of 54 healthy volunteers who took a stress test after taking either kava or valerian showed decreased blood pressure after an initial test, and heart rates decreased in the valerian group. (3) Conversely, small studies have found no significant difference between valerian and placebo in anxiety scores. And, a 2006 Cochrane Database review investigating the effectiveness and safety of valerian for treating anxiety disorders found limited evidence to determine its efficacy or safety compared to placebo. Further randomized, controlled trials with larger sample sizes comparing valerian to placebo or conventional medications are needed. (4-6)

Also consider either St. John's Wort or SAMe (S-adenosylmethionine) if you are experiencing the depression that sometimes accompanies anxiety. A Cochrane Database review of 27 different studies of St. John's wort including 2,291 study participants concluded that St. John's wort works better than placebo in treating mild to moderate depression. (7) Note, it may take a month before the full effects of St. John's Wort are felt.  Several small studies have shown SAMe, which contributes to the formation of mood-enhancing chemicals in the brain, also is more effective than placebo – and possibly as effective as conventional medications – in treating depression. (8-10) Unlike St. John's wort, SAMe has been shown to take effect immediately.

The mood-enhancing chemical 5-HTP (5-hydroxytryptophan) may help to improve mood in patients with anxiety or panic attacks. The chemical increases serotonin and endorphin levels. Panic attacks are more likely to occur when the availability of serotonin in the brain is low. Therefore, 5-HTP's ability to increase serotonin levels may inhibit the panic response. In a 2002 study of 48 subjects (24 with panic disorder and 24 healthy individuals), who received either 200 mg of 5-HTP or placebo before a carbon dioxide-induced panic challenge, 5-HTP compared to placebo significantly reduced panic disorder patients' reaction to the panic challenge in measures of subjective anxiety, panic symptoms score, and number of panic attacks. No similar effects were seen in healthy volunteers. (11) A 2002 Cochrane Database review of trials comparing 5-HTP or tryptophan to traditional antidepressants in alleviating symptoms of depression found only two trials (out of 108 available) were of sufficient scientific quality for inclusion in the review; however those two studies did indicate that 5-HTP was more efficacious than placebo. (12) And a 2007 study in mice showed that 5-HTP affects anxiety-related behavior through the release of stress hormones. (13) More research is needed.

A decade ago, the primary anti-anxiety supplement would have been kava, an herb long known for its calming effects. However, the FDA has issued warnings on kava due to reports of its adverse effects on the liver. Before using this herb, please read the entry on kava in the WholeHealthMD Reference Library. Kava seems to be very effective at easing the nervousness, dizziness and heart palpitations of anxiety and may even prevent panic attacks. Several studies, including a meta-analysis and a Cochrane Database Review of studies that included 645 participants, showed that kava extracts standardized to 70% kavalactones were more effective than placebo in treating symptoms of anxiety. Treatment with kava supplementation led to improved aggression, mood and tension. (14-18) In these studies kava seemed to be safe for short-term treatment up to 24 weeks, but at least eight weeks may be necessary for significant improvement. One early study had indicated that kava may be as effective as low-dose benzodiazepines. (19) Further studies are needed to confirm safety and efficacy: unfortunately, they are unlikely to be conducted in the present environment.

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Self-Care Remedies 


Avoid caffeine, alcohol and too much sugar, all of which can trigger anxiety. To minimize headaches and other withdrawal symptoms, reduce caffeine intake gradually. Instead of caffeinated beverages, try drinking tea made from chamomile (or passionflower, skullcap or lemon balm), which will relax you without causing drowsiness or addiction.

Engage in a regular program of aerobic exercises. This type of exercise burns lactic acid, produces mood-enhancing chemicals called endorphins, and causes the body to use oxygen more efficiently.

Controlled breathing techniques can help ease a panic attack. When an attack strikes, try this breathing exercise: Inhale slowly to a count of four, wait four counts, exhale slowly to a count of four, wait another four counts, then repeat the cycle until the attack passes.

Consult a mental health counselor to help you control and overcome anxiety.

Alternative Therapies

Some evidence indicates that acupuncture can help to reduce symptoms of anxiety, particularly when combined with other therapy, such as psychotherapy. This technique, which uses hair-thin needles at specific body points to prevent or treat illness, has been described as relaxing and is also meant to relieve stress. However, research is limited. A 2007 Cochrane Database review of studies found four randomized, controlled trials evaluating the use of acupuncture in treating anxiety, which were of poor quality and did not provide conclusive evidence. (20) More research is needed.

Some preliminary evidence indicates aromatherapy – the use of scents from essential oils for therapeutic purposes – may help to reduce anxiety. In particular, lavender oil has received attention in this regard. One study in gerbils made anxious by maze exercises, found that the anxiolytic profile of inhaled Lavandula angustifolia was similar to that of diazepam and became progressively more pronounced with prolonged exposure up to 14 days. (33) Along with rosemary oil, it also reduced test anxiety in graduate nursing students, and along with a relaxation audio program, reduced pre-procedure anxiety in patients undergoing gastroscopy. (34, 35). However, in another well-controlled trial, it was demonstrated that the relaxing effects of lavender have more to do with expectation than to its actual physiological effects. (36) The use of aromatherapy may be of particular use when combined with massage, particularly as an adjunct treatment for patients with cancer. A 2008 review of 10 trials evaluating the use of either aromatherapy and/or aromatherapy massage found that aromatherapy massage may reduce anxiety short-term in patients with cancer and may have a beneficial effect on symptoms of cancer, such as pain and nausea. However, the studies were of poor quality. (21)

Meditation, which has been shown to increase neural activity in the brain regions associated with positive mood states, may be effective in reducing anxiety caused by conditions such as cancer, heart disease and psychiatric illness. (22-24)

Some studies show that cognitive behavioral therapies (CBT) – which promote long-term life changes – may improve the efficacy of conventional treatments. (25) University of Washington researchers showed that of 232 patients suffering from panic disorder, those treated with CBT had 60 more anxiety-free days over the course of a year than did the study participants who were treated with medication alone. (26)

Reflexology, a technique in which pressure is applied to specific points on the feet to promote relaxation, may relieve anxiety. In a 2000 study of foot reflexology in 23 inpatients with breast or lung cancer, treatment significantly relieved anxiety (as well as one measure of pain). (27) And in a later study, self-foot reflexology by 46 middle-aged women brought significant improvements in depression, stress, systolic blood pressure, and some measures of immune function. (28)

The relaxing effects of yoga may improve symptoms of anxiety. But while patients have reported favorable results, scientific evidence is lacking. Preliminary studies have been difficult to design and inconclusive. (29, 30) However, a 2009 study in breast cancer patients undergoing conventional treatment compared the calming effects of yoga to supportive therapy. In the study, 99 patients with stage II or stage III breast cancer (and being treated with surgery followed by radiotherapy or chemotherapy) were treated with either 60-minute yoga sessions or supportive therapy daily during their hospital visits as part of routine care. The yoga treatment group showed an overall decrease in self-reported state anxiety and trait anxiety compared to controls; and a positive correlation was noted between anxiety measures and symptom severity, indicating potential efficacy of yoga to manage treatment-related symptoms and anxiety in breast cancer patients. (31) More research is needed in this area.

Some practitioners may consider individualized homeopathic remedies to treat anxiety and panic attacks, based on specific symptoms and general constitutional and personal attributes. Anecdotal evidence indicates homeopathy is often used by to treat anxiety, and one reported case series in twelve patients who had previously had partial or poor response to conventional therapies found that more than 50% improved with homeopathic treatment. (37) However, while limited studies have shown positive results, other trials have been contradictory or provided insufficient evidence. (32) More research is needed.

People suffering from anxiety also may find some relief through guided imagery, music therapy, tai chi, and other mind-body techniques designed to relieve stress and promote relaxation.

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When to Call a Doctor 
 

If anxiety symptoms or recurring panic attacks interfere with your daily activities and quality of life.

 If you experience rapid heartbeat, chest pain, shortness of breath or other anxiety symptoms—these could also be signs of a serious physical illness or be caused by certain medications. (A doctor can determine the cause of your symptoms and suggest appropriate treatments.)