My Doctor Online The Permanente Medical Group

Symptoms

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There are several different types of anxiety disorders. Although anxiety is common to all anxiety disorders, each one has different symptoms. Symptoms can include overwhelming feelings of tension, worry, or panic or obsessions that do not go away. You may also have other symptoms that could include the following:

• Restlessness 
• Fatigue 
• Irritability or edginess 
• Muscle tension 
• Sleep problems 
• Shortness of breath 
• Stomachaches 
• Diarrhea 
• Dizziness 
• Difficulty controlling the worry 
• Compulsive behaviors 
• Using alcohol or other drugs to manage these symptoms

You may even have feelings of wanting to harm yourself or others. If anxiety often disrupts your home or work life, you should seek help.

Anxiety disorders often make people vulnerable to alcohol and other substances in a belief that turning to them will relieve your symptoms. Unfortunately, the alcohol and substances themselves will make the anxiety symptoms worse, have harmful effects on a person's physical health, and cause significant disruption in your work and relationships. One goal of treatment may include reducing use of alcohol or any substance that may be worsening your symptoms.

Types

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Anxiety disorders are the most common mental health issue in the U.S. They will affect about one-third of all U.S. residents at some point during their lives. Social anxiety disorder alone may affect as many as 13 percent over their lifespan. Types of anxiety disorders include the following:

Generalized anxiety disorder (GAD)

Generalized anxiety disorder consists of overwhelming worry that occurs on most days and that lasts 6 months or more. Although the worry is focused on everyday aspects of life such as health, finances, family, work, or school, for those with GAD the worry is excessive in intensity and experienced as hard to control. It may be accompanied by physical symptoms such as restlessness, muscle tension, stomachaches, dizziness, sleep problems, or other physical aches and pains.

Social anxiety disorder (SAD)

Social anxiety disorder manifests as a pronounced fear of being negatively judged in a variety of social situations. You may fear being embarrassed or ridiculed by others, which causes you to avoid social activities. As a result of this social anxiety, you may also have physical symptoms such as blushing, sweating, rapid heartbeat, or feeling faint.

Post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder can be the result of a traumatic experience that happens to you or someone else. Witnessing or being a victim of a traumatic event such as a physical or sexual assault, violence, or death can have serious effects. People with PTSD can develop the following:

• Repeating or "re-experiencing" the trauma in flashbacks or dreams 
• Feeling emotionally numb 
• Having difficulty relating to other people 
• Avoiding the place or places where the traumatic event took place 
• Having difficulty sleeping or concentrating 
• Feeling irritable

Panic disorder

Panic disorder involves the experience of recurring, unexpected panic attacks.  A person with panic disorder will often have persistent concern about having additional attacks, worry about the implications of the attack (for example, think they will lose control or are “going crazy”), or experience a significant change in behavior related to the attacks.

Panic attacks involve a sudden intense feeling of fear accompanied by physical symptoms such as chest pains, the feeling that you cannot breathe, smothering, sweating, trembling, tingling of the hands or feet, dizziness, or nausea. These symptoms can be so severe that some people mistake them for a heart attack. A panic attack can happen at any time – it can even wake you from sleep. The symptoms usually peak within 10 minutes, but it may take much longer for all the symptoms to go away.

Obsessive-compulsive disorder (OCD)

Obsessive-compulsive disorder leads people to feel very anxious or fearful. It is driven by repetitive disturbing thoughts or impulses (obsessions) that cause people to repeat certain behaviors (compulsions) in order to quiet the thoughts. For instance, you might feel that you are contaminated by germs, and this may lead you to wash your hands over and over again. You may worry that objects are not placed quite right and that something bad might happen if you do not spend excessive time arranging things to be "just right." If you feel that you spend more than an hour a day having seemingly unreasonable and intrusive thoughts, and/or performing unneeded repetitive actions, you may benefit from an evaluation for OCD.     

Specific phobia

Specific phobia (also known as simple phobia) consists of unreasonable, excessive fears of specific objects or situations, such as driving a car over a bridge, using an elevator, or flying in a plane. You may have difficulties in confined spaces or feel claustrophobic. Just thinking about or approaching the feared situation or object can trigger anxiety. In this disorder, the person’s anxiety or avoidance of the feared situation or object has a significant impact on their normal routine, relationships, or general functioning.

Causes

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Anxiety disorders result from complex interactions between life experiences and biology. People may find ways to limit the anxiety while not learning to confront the fear underlying it, thus creating a cycle of fear and avoidance. This cycle causes the anxiety disorder to continue. Various factors may contribute to anxiety disorders.

• Genetic. Anxiety disorders seem to run in families, so genes may play some part in whether a person develops an anxiety disorder.
• Life experiences. Children who experience traumatic events may have more risk of developing anxiety disorders when they get older. Adults who experience stressful life situations such as divorce, death, illness, or financial pressures feel tension and worry, which can spark an anxiety disorder.
• Neurological development. The parts of the nerves and brain involved in the fear response are more active in people with anxiety disorders. This enhanced activity is probably due both to genes and behavior.

Screening and Diagnosis

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Tell us if you are feeling more than the usual amount of anxiety. We will ask you questions about your anxieties and worries, how long you have been experiencing them, and what physical symptoms you might have. We will also ask about your medical history to make sure that your symptoms are not the result of a physical illness. A diagnosis of anxiety disorder includes the following:

• Overwhelming anxiety or worry every day for at least 6 months
• Difficulty managing your anxiety
• Other symptoms such as difficulty concentrating, sleeping, or making decisions; restlessness; or stomach pains

Lifestyle Management

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Learning to successfully manage your anxiety takes practice. Anxiety can affect many parts of your life including relationships with friends and family and how you perform at work or school. There are actions you can take to reduce your anxiety: 

• Exercise. Physical activity is calming. When you begin to feel anxious, take a walk around the block or do another activity that you enjoy.
• Make healthy lifestyle choices. Get enough rest, eat a healthy balanced diet, participate in activities that you enjoy, and reduce or eliminate caffeine, nicotine, and alcohol.
• Be consistent with the recommended treatment plan.
• Socialize with close family and friends. They can be a source of support and encouragement. Avoid isolating yourself from others.
• Learn relaxation techniques. Deep relaxation exercises, yoga, or meditation can help reduce your anxiety.

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Treatments

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There are effective treatments for anxiety. We recommend either medication, therapy, or both. People with generalized anxiety disorder, social anxiety, panic disorder, PTSD, obsessive-compulsive disorder, and other anxiety disorders can benefit from one of several types of therapy, medication, or both.

People with generalized anxiety disorder (GAD), panic disorder, or social anxiety disorder usually benefit from one of several types of therapy, including:

• Cognitive-behavioral therapy (CBT) helps you recognize and change your negative thought patterns into healthy thought patterns. Discouraging or irrational automatic thoughts can cause you to feel bad. When you replace negative thoughts with healthy positive ones, you become calmer and can also change the way you react to situations that cause anxiety.
• Relaxation techniques help you become aware of tension in your body. You learn how to relax, which reduces your feelings of anxiety. Techniques such as those used in yoga and other relaxation practices include deep breathing exercises and methods to relax specific muscles. 
• Guided imagery is a technique in which you learn how to use your imagination to reduce anxiety and stress. 
• Exposure response prevention therapy (ERP) involves systematic and controlled exposure to the situations or objects that are causing panic attacks or other anxiety symptoms. Initially, this exposure is through visualization, but, frequently, the treatment involves actual exposure to the anxiety-provoking stimulus. This type of therapy is excellent for specific phobias (i.e., a fear of spiders), panic disorder, and obsessive-compulsive disorder.

There are many medication options for treating anxiety. We will work with you to decide which options are right for you, including: 

• Benzodiazepines help reduce anxiety. However, this kind of medication can be addictive, so we prescribe it only for short periods of time. Benzodiazepines are commonly known as Xanax, Librium, Ativan, and Serax.
• Antidepressants are approved by the Food and Drug Administration (FDA) to treat depression and/or anxiety. Some antidepressants we may prescribe for general anxiety disorder are Prozac (fluoxetine), Celexa (citalopram), Zoloft (Sertraline), Paxil (paroxetine), and Effexor (venlafaxine). Antidepressant medication takes 2 to 6 weeks to be fully felt. You may need to try different medications before you find the one that works best for you.
• Buspirone (BuSpar). This medication can take up to 2 weeks before you feel its full effect.

Medications during pregnancy and breastfeeding

Many anxiety medications can be used safely in pregnancy and while breastfeeding. If you are considering getting pregnant and are already on anxiety medications we can review whether you should stay on this medication, switch to another medication, or stop your current therapy. Although there may be some risk to the baby associated with these medications, the risks are minimal and should be weighed against the risks of stopping treatment.

Your Care with Me

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If you have symptoms of anxiety or have other behavioral health concerns, you can contact the Psychiatry or Health Education Departments directly, without a referral from me. They will be able to help you find the resources that best fit your needs. The Health Education Department can help connect you with a wide variety of related classes. You can also find classes in the Tools and Classes section on this site.

You can also contact me. Depending on the situation and what is most convenient for you at the time, you can connect with me in a variety of ways. I am available online, by telephone, or in person.

• For nonurgent questions or concerns, you can e-mail me using this site. You can also book an appointment online to see me in person.
• If your concerns are immediate, or you simply prefer to use the telephone, please call our Appointment and Advice line, which is available 24 hours a day, 7 days a week. Our advice nurses can give you immediate advice, and our telephone staff can send me a message or book an appointment with me or one of my colleagues, if I am not available.

You may also contact the Chemical Dependency Recovery Program if you have concerns about your use of alcohol or other substances.

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How We Coordinate Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system which allows all of the doctors and clinicians involved in your care to stay current on your health status and to collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization.  We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the “After Visit Summary” that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed, or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments as needed. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you and I will send the prescription electronically in advance of your arrival at the pharmacy.

If refills are needed in the future, you can:

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures we will schedule an appointment with the radiology department. When the results are ready I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to a specialist

My specialty colleagues are readily available to assist me if I need additional advice about your condition. In some cases, I may contact them during your visit, so we can discuss your care together. If we decide you need a specialty appointment after that discussion, we can often schedule it the same day or soon thereafter.

If you are due for preventive screenings or tests

As part of our commitment to prevention, additional members of our health care team may contact you to come in for a visit or test.  We will contact you if you are overdue for cancer screenings or conditions which may require monitoring.

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Convenient Resources for You

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My goal is to provide high quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available 24/7 so that you can access and manage your care where and when it is most convenient. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions and schedule appointments.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at our medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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