How Do Psychiatrists Treat Anxiety Disorders?

Aditi is a brilliant 20-year-old student at a top engineering school in India. She has always excelled in her studies and has supportive friends. However, she has struggled with feelings of excessive worry for most of her life. 

At times she would not be able to sleep or eat properly due to her fears. More often than not, her worries seem unreasonable to people around her. These feelings have sometimes made her feel stuck, like a deer in headlights. 

Lately, her worries have been leaving her irritable, restless and fatigued. She spoke to her mentor about it and he recommended seeing a doctor. Her General practitioner has referred her to a psychiatrist.

What is Anxiety?

Worry is a normal part of the human experience. We worry about our family, career, future, health and more. What happens when rather than facilitating our lives, this worry pulls us back? Far from enabling us to plan our future better, it leaves us feeling debilitated and helpless.

This marked distress in the day-to-day functioning of an individual is what separates everyday worries and fears from anxiety. Understanding this can help one in the right direction and seek professional help. 

Anxiety as Generalised Anxiety Disorder (GAD):

When your worries become chronic, excessive and irrational, it may be suggestive of anxiety. When this chronic feeling is accompanied by at least three physical symptoms such as restlessness, fatigue, difficulty in concentration, irritability, sleep disturbance or muscle tension, a conclusive diagnosis of Generalized Anxiety disorder may be made by your doctor. In some cases, a therapist may also make the diagnosis. In any case, a self-diagnosis should not be made especially for mental health issues. 

Irrational fears can also manifest as disorders other than generalised anxiety disorder. These are:

1. Social anxiety disorder (social phobia)
2. Specific phobias
3. Agoraphobia
4. Panic disorder
5. Separation anxiety disorder
6. Selective mutism
7. Unspecified anxiety disorder

Social anxiety

Social anxiety is an irrational fear of scrutiny and negative appraisal by others while performing any activity in public. This could range from a common fear of public speaking to a fear of eating in public. The intensity of this fear is so distressing that the person skips these situations altogether and if not, endure it with great pain.

Specific phobia

If fear is triggered by a specific object or situation and  causes significant distress, it can be categorised as a specific phobia. An encounter with this object/situation can induce a panic attack.  Hence the object/situation is avoided, even at great personal cost. For instance, an individual with claustrophobia (fear of closed spaces) joins a new company. 

They like the work but avoid taking the elevator due to their claustrophobia. Instead, they take the stairs to the 15th floor every day. Eventually, this takes a toll on them and they decide not to continue with the company anymore. This maladaptive avoidance with a personal cost is a distinctive feature of any phobia.

Agoraphobia

In this anxiety disorder, an individual has a critical fear of being stuck in a place they may not be able to get out of. This may include public transportation, parking lots, malls, theatres, being in a crowd or even waiting in a queue. The underlying fear is that they may not be able to get out of the area in case they start to experience panic-like symptoms.

Panic disorder 

Panic disorder is characterised by recurrent panic attacks which often seem unexpected. A panic attack can be understood as a sudden burst of intense fright and discomfort, peaking within minutes. The accompanying physical symptoms may include sweating, trembling, accelerated heartbeat, chest pain, shortness of breath, nausea, dizziness, fear of losing control and in extreme cases, fear of dying. 

Separation anxiety disorder

Separation anxiety refers to an irrational and debilitating fear of separation from a loved one or an attachment figure. Even though it is more common in children, adults can experience it too. It can manifest as reluctance to leave the attachment figure, excessive worry about separation from them and intense fear of altogether losing them. Physical symptoms of anxiety may also arise during real or anticipated separation. 

Selective mutism

Selective mutism is a specific anxiety disorder of fear of speaking. This involves being able to speak in almost all situations except in a specific, fear-inducing social situation. For example, a child might speak everywhere else but not in class. Even though it is a childhood anxiety disorder, adolescents and adults can experience it too. However, it is rarer than other anxiety disorders.

When to See a Psychiatrist for Anxiety Disorders

If you feel that you are experiencing any of the above symptoms, it can be helpful to seek psychiatric help. Even if it's been a short while since you started experiencing these symptoms, a psychiatric visit still helps gain more insight and treatment. The stigma attached to mental health issues deters a significant population from seeking help. Do not let the fear of judgement stop you from getting better.

What to Expect During Your First Visit to a Psychiatrist for Anxiety

The psychiatrist would usually ask you to tell them about your symptoms, how you have been feeling and how long you've been experiencing the symptoms. Additionally, they may ask you about any family history and any recent experience(s) that might have triggered or worsened your symptoms.

Lifestyle-related questions such as alcohol and other substance use may be asked. It is advisable to provide the required information as accurately as possible as it allows the professionals to help you better.

In some cases, a verbal test may be used to assess the severity of your symptoms. In any case, try to discuss your symptoms as accurately and extensively as possible, without any fear of judgement.

How Can Psychiatrists Help in Treating Anxiety Disorders?

1.Diagnosis formulation 

The foremost duty of a psychiatrist is to thoroughly examine your symptoms. They might even take an extensive medical case study to see where your symptoms are stemming from and take into consideration any other situation/ condition. If your symptoms are indeed an indication of anxiety, they would use that knowledge to plan a suitable course of treatment. 

2.Psychoeducation

The next step is informing you about the conclusion, whatever that may be. Just the knowledge that your symptoms are recognizable and treatable can have a therapeutic effect on the person. Next, they will inform you about the available and advisable treatment plan. 

They may also tell you the lifestyle changes you may need to make to facilitate the treatment plan. In case you have someone accompanying you, they might speak to them too for relevant information and reassurance about your symptoms and treatment plan, provided you consent to it. 

3.Using tDCS for anxiety

Transcranial direct current stimulation (tDCS) is a non-invasive neurostimulation technique gaining a lot of traction. Imagine a device the size of your headphones which can stimulate your brain through a low, consistent current. The electrodes are attached to your scalp through a wearable device to pass the current. 

This low, consistent current enhances the signalling between the neurons in your brain. Neuromodulation allows for a decrease in the excitability in brain regions in case of an anxiety disorder. Arc, India's first non-invasive brain stimulation wearable from Mave.

It safely treats anxiety at home without any side effects. Mave is launching a 12 week long personalised treatment program, centred around Arc to treat and manage anxiety effectively. 

4.Pharmacological treatment 

The psychiatric treatment route for anxiety is indeed pharmacological. This includes taking prescription medicines which can regulate the levels of serotonin, norepinephrine and most importantly gamma-aminobutyric acid (GABA). The choice of medication and duration is decided by the psychiatrist.  

A.Selective Serotonin Reuptake Inhibitors (SSRIs):

SSRIs are usually the first line of treatment for most anxiety disorders. This medication elevates the level of the neurotransmitter serotonin in your brain by inhibiting its reuptake. Owing to its effectiveness, it easies the experienced anxiety and alleviates mood too. Common SSRIs are: Sertraline, Fluoxetine, Escitalopram 

B.Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs):

When SSRIs alone do not show significant improvement or are not fully effective, SNRIs are used.

Apart from increasing serotonin, they increase the levels of norepinephrine through the same mechanism of reuptake inhibition. Common SNRIs are: Duloxetine, Venlafaxine

C.Tricyclic Antidepressants (TCAs) or Monoamine Oxidase Inhibitors (MAOIs):

This category of drugs is reserved for when both SSRIs and SNRIs do not show significant improvement.  

This may be due to the nature of anxiety, lack of tolerance, side effect profiles or dietary restrictions.

Tricyclic antidepressants inhibit the serotonin and norepinephrine reuptake just like the drugs discussed above. Monoamine Oxidase Inhibitors, on the other hand, help reduce the breakdown of these neurotransmitters.

Common TCA: Amitriptyline, common MAOI: Phenelzine 

D.Benzodiazepines

Benzodiazepines are a special category of drugs which increase the effect of gamma-aminobutyric acid (GABA) in the brain. GABA is a calming neurotransmitter and the use of benzodiazepine produces a sedative effect. The most important thing to note about benzodiazepines is that they run a high risk of dependence and tolerance. This means more and more of the same drug is required to create the same level of calming effect. Long-term use is avoided. Only short-term and closely monitored use is recommended, especially for acute anxiety symptoms. Common benzodiazepines: Lorazepam, Alprazolam, Diazepam 

E.Beta-Blockers:

These types of drugs control the adrenaline effects in your body. They do so by blocking the effect of epinephrine just like norepinephrine. This helps control the physical symptoms of anxiety such as sweating, trembling, accelerated heartbeat and hypervigilance.

Common beta-blockers: Propanol 

Note: Pharmacological treatment requires regular monitoring. If you notice an elevation in your symptoms or if you experience noticeable side effects, do inform your doctor. Many medications above can produce withdrawal symptoms and should not be discontinued abruptly. Talk to your doctor if you want to get off the medication. All the drugs mentioned above are not to be bought/sold without a legitimate prescription. 

5.Relaxation and grounding techniques for anxiety 

Relaxation techniques include breathing or somatic techniques which can help one regulate physical symptoms of anxiety. One or more of the techniques listed below can be used to regulate  symptoms of anxiety:

A. 4-7-8 breathing: 

in this technique, one needs to inhale through one's nose till the count of 4, hold your breath for the next 7 seconds and lastly exhale through your mouth slowly over 8 seconds. You can repeat this process a couple of times to release acute physical symptoms.

B. Diaphragmatic breathing: 

Another breathing technique that involves the use of the abdomen and not just the chest. One has to inhale very slowly, let your abdomen rise and the abdomen slowly falls as you slowly exhale through your mouth. Deep breathing slowly helps regulate somatic symptoms.

C. Progressive muscle relaxation: 

This technique involves bringing your body from tension to relaxation. One starts by tensing your toes, legs, arms and moving up to your head. Hold the tension for a few seconds and then slowly release the tension. Physically feeling the difference between this tension and relaxation state helps regulate the physical symptoms

D. Visualisation and Guided imagery: 

Either through self-imagination (visualisation) or using a recording (guided imagery), one imagines subjective situations which can make you feel calm. E.g. imagining an open field. One can visualise the smell, sound or sensations related to the imagination theme. 

E. 3 3 3 Rule for Anxiety: 

The 333 rule is a grounding technique which directs an individual to identify three objects they can see, three they can hear and three they can touch. This technique helps bring back an individual’s thoughts to their physical surroundings.

F. 54321 Technique: 

5 4 3 2 1 grounding technique or the five-senses meditation caters to all five senses of the body. Much like the 333 rule, it calls upon the individual to use their physical environment to rid the racing thoughts.

It includes naming five things you can see, four things you can touch, three things you can hear, two things you can smell and one thing you can taste. 

All these techniques are known to be effective in helping regulate somatic symptoms of anxiety. Practising them can help facilitate your healing journey. One can practise these techniques even while not actively experiencing the symptoms. This can help you build strength against acute stress or anxiety symptoms.

6.Psychotherapy for anxiety

Psychotherapy is another therapeutic avenue which can significantly help with anxiety disorders. It can be used as an adjunct to pharmacological treatment or even as a standalone treatment. Professionals like Clinical psychologists and counselling psychologists are trained to impart therapy. 

The average course is six to eight weeks with 1-2 sessions with your psychologist per week. Common therapies for anxiety include:

A.Cognitive Behavioral Therapy (CBT): 

CBT boasts great empirical evidence as an effective therapy for the management of anxiety. It includes changing the thought patterns which are constantly leading to anxiety-inducing thoughts. This is called cognitive reconstructing and helps in challenging irrational thoughts. Actively restructuring these negative thought patterns and challenging anxiety-provoking thoughts. 

B.Acceptance commitment therapy (ACT): 

This form of therapy relies on cognitive diffusion which means detaching oneself from their thoughts. Conversely, the therapy also allows for the acceptance of thoughts related to things which can't be changed. This acceptance thus offers some relief from anxiety-inducing thoughts. The second part of it is committing oneself to actions that align with the values of the individuals and help them keep anxiety at bay. 

C.Interpersonal therapy (IPT): 

IPT helps individuals address deficits in their interpersonal relationships. This may include conflict, unhealthy communication and response patterns. The psychologist works with the client to address these issues, bring them to the forefront and mutually explore ways to adopt healthy interpersonal patterns.

Note: the choice of therapy usually depends on symptoms, need of the hour, individual differences and the professional expertise of the psychologist. 

7.Lifestyle changes for anxiety

Apart from actively incorporating treatment in your healing journey, you can also make healthy lifestyle changes. These changes significantly improve the effectiveness of your treatment and prevent relapses. Some commonly suggested changes include:

1. Cutting down your caffeine intake which can help bring down the jittery effect of this stimulant
2. Aiming for a balanced diet rich in green leafy vegetables, seasonal fruits, proteins and healthy fats
3. Monitoring your vitamin levels and taking supplements for the same
4. Incorporating exercise in your daily routine, especially those involving low-intensity body movement. 
5. Maintaining sleep hygiene by prioritising adequate sleep. Go to bed and wake up around the same time every day and make sure to get 7-9 hours of sleep. 
6. One can also effectively incorporate yoga and or meditation into their routine.

Say no to social isolation and remember to reach out for help from your friends, family, doctors and therapists. 

Conclusion

Help is available and you are not alone. Anxiety is a part of life, and even when it becomes severe and qualifies for a diagnosis, it can be managed.  Whether you take tDCS, medicines or therapy, you will always be the biggest player in your healing journey. Seek help today if you or anyone around you is experiencing symptoms of anxiety.

FAQ of Anxiety

Can a psychiatrist diagnose Anxiety?

Yes, a psychiatrist is well-qualified to diagnose an anxiety disorder.

Do I Have to See a Psychologist or Psychiatrist for Anxiety?

The difference between a psychiatrist and a psychologist majorly includes the different treatment options. It is better to consult both a psychiatrist and a psychologist for diagnosis and treatment 

What Other Types of Doctors Treat Anxiety Disorders?

Psychiatrists and general practitioners are qualified to prescribe anti-anxiety medications. Other mental health professionals like clinical psychologists, counsellors, psychiatric nurses and psychiatric social workers also play an important role in management of anxiety.

Citations

1. American Psychiatric Association. Anxiety Disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Text Revision. American Psychiatric Association; 2022: pp. 215-231.
2. Anxiety disorders - Diagnosis and treatment - Mayo Clinic
3. Anxiety Treatment Options From a Psychiatrist
4. Generalized anxiety disorder - Diagnosis and treatment - Mayo Clinic 
5. TThe Role of a Psychiatrist in Anxiety Management | Grouport Journal 
6. Psychiatry.org - What are Anxiety Disorders? 

Full article: Treatment of anxiety disorders