All Questions

How can I overcome my fear of driving on highways and bridges or when I don’t know the exact route? Why am I afraid of driving in high places and on roads with vast open areas, even though I’m a rock climber?

Response from Patrick B. McGrath, PhD:

Patrick McGrath, PhD

A fear of driving may come about for many reasons.

Fear Factors

Some people who have been in an accident fear that they will be in another one. Even if they have driven for 20 years without incident, it’s easy to wipe out the safe memories of driving and replace them all with one bad experience. When this happens, even thinking about getting in a car cues the accident memories, and it may lead to thoughts of driving becoming almost as frightening as driving itself.

Others fear that they will have a panic attack or other panic symptoms while driving. With that often comes the erroneous belief that a panic attack is dangerous and that it will cause you to either lose control, go “crazy,” or pass out. If this were to happen, the consequences could be severe, so the typical thought is that it is best not to drive so that this will not happen.

People may also fear harming others, and they will avoid driving so that they will not be the cause of someone being hurt. And some people may have a significant fear of getting lost, so they stop driving because they don’t want to get themselves or their passengers lost. Even if it is just in their neighborhood, over a route they’ve traveled hundreds of times while someone else was driving, they may fear that they might forget where to go.

When it comes to a specific phobia, like open spaces or heights, it doesn’t matter what you do not fear. You may be a mountain climber who fears driving in vast areas. You may be a pilot who fears driving over bridges. Reasons for having phobias often don’t make logical sense, even though they appear to make a great deal of emotional sense to the person experiencing the fear.

Getting Treatment

Good treatment is available for phobias, and it’s called exposure and response prevention (ERP) therapy. In ERP, a fear hierarchy is created – a list that ranks feared situations from least to most feared.

A therapist works with the patient on slowly doing the tasks (exposures) on the list, while also encouraging the patient to not engage in coping strategies (avoidance or seeking reassurance). Some of the tasks were easier than others.

A hierarchy that I have used with a patient who had been in a car accident looked like this:

  • Stand five feet from the car and stare at it.
  • Walk over to the car.
  • Touch the car.
  • Touch the door handle.
  • Open the door.
  • Sit in the car.
  • Put the key in the ignition.
  • Start the car.
  • Put the car in drive.
  • Start to drive around the parking lot at 5 mph.
  • Pull out onto a side street and drive.
  • Drive on a main street.
  • Drive on the highway for one exit.
  • Drive on the highway for two exits.
  • Drive on the highway for unspecified times.

Accomplishing Your Goal

Ultimately, it was important to accomplish the following:

  1. Do the task.
  2. Stay in the task until your anxiety has gone down on its own to at least half of what it was when the exposure started.
  3. Repeat the task until it becomes a routine.

You may learn your fear after just one experience, but it will usually take numerous experiences to replace your fear with adaptive coping behaviors.

Patrick B. McGrath, PhD, is Director, Center for Anxiety and Obsessive Compulsive Disorders, Alexian Brothers Behavioral Health Hospital, Hoffman Estates, Illinois, and author of The OCD Answer Book (Sourcebooks, Inc.; December 1, 2007).

 

I’m always worried that I have a serious disease. My doctor says there’s nothing wrong with me, but I still have symptoms. What can I do?

Response from Jonathan Abramowitz, PhD:

This appears to be hypochondriasis, which is a preoccupation with the belief that you have or are in danger of developing a serious illness. Many people focus on bodily functions or sensations, or they worry about a specific organ or fear getting cancer or another disease.

Severe Health Anxiety

When they have hypochondriasis, people often believe that any discomfort whatsoever means bad health. They misinterpret normal bodily sensations (breathing, heartbeat), minor physical abnormalities (skin blemishes), or physical sensations (headaches, stomachaches) as dangerous.

But our “noisy” bodies create all kinds of sensations that aren’t dangerous. Think of the human body as a complex machine like a computer or automobile that produces clicking, whirring, and other noises even when it’s working properly.

A healthy body also produces normal physical symptoms that might be uncomfortable, painful, unexpected, and unwanted. It might also include changes in vision, heart rate and blood pressure, breathing, balance, or muscle tone. When you misinterpret these as symptoms of a terrible disease, it makes you worry. This explains why medical tests come out negative: The sensations are real, but they’re not symptoms of a disease.

Why Reassurance Doesn’t Help

People with hypochondriasis are often reluctant to seek mental health evaluations because they believe very strongly they have unexplained medical illnesses. And the urge to call the doctor grows intensely. 

Reassurance from doctors doesn’t help, though. Why not? When you become anxious, you may experience a rapid heart rate, difficulty catching your breath, dizziness, the sweats, or seeing spots. Although these sensations are not dangerous, if they occur right when you’re anxious about your health—wham! It adds fuel to the worry fire.

Seeking reassurance from a doctor and checking your body may actually prevent you from realizing that you are not sick. But you become preoccupied and more likely to notice subtle sensations that most people ignore. A vicious cycle develops of noticing a sensation, misinterpreting it as threatening, becoming anxious, and seeking reassurance—which leads to further preoccupation and worry with the essentially harmless sensation.

Treatment

Under a skilled therapist’s assistance, you will learn the role that your thoughts and behaviors play in generating health anxiety.

Effective treatment requires that you correct your threatening interpretations of certain body sensations and eliminate compulsive checking and seeking reassurance. This treatment approach is called cognitive-behavioral therapy, or CBT, and it involves the following.

Medical Evaluation
A thorough physical exam will rule out actual medical problems. You will review this information (one time only) and then accept it as evidence of good health.

Education
Education about bodily symptoms is a vital. You will be provided with nonthreatening explanations for the bodily sensations that you frequently misinterpret as threatening symptoms of underlying diseases.

This is not the same as providing reassurance. You must use this knowledge yourself, rather than asking the doctor for the same information many times.

Cognitive Therapy
Cognitive therapy techniques help modify unrealistic interpretations of harmless physical sensations. A therapist helps you explore the evidence for and against the threatening misinterpretation.

Exposure Therapy and Response Prevention

  • Exposure therapy helps correct mistaken beliefs. During exposure, you will gradually confront the situations and bodily sensations that you avoid because of your fear of illness. You also learn to tolerate uncertainty about whether a sensation is really a symptom. At first you might become anxious, but your distress will subside as you get used to it. As a result, you learn not to fear these situations and sensations because your distress does not go on forever.
  • Response prevention is used in tandem with exposure. It involves resisting the urge to seek reassurance about your health and illness. Once exposed to the feared sensations, you are taught to use healthy coping strategies (such as examining the evidence) rather than calling doctors.

Jonathan Abramowitz, PhD, is a licensed clinical psychologist and leading authority who specializes in the treatment of obsessive-compulsive disorder and other anxiety disorders. He is also a professor of psychology and the director of the Anxiety and Stress Disorders Clinic at the University of North Carolina at Chapel Hill.

Resources

Listen to a podcast on health anxiety.

Psychological Treatment of Health Anxiety and Hypochondriasis: A Biopsychosocial Approach, by Jonathan S. Abramowitz  and Autumn E. Braddock (Hogrefe Publishing, 2008)

It’s Not All in Your Head: How Worrying About Your Health Could Be Making You Sick, by Gordon J.G. Asmundson and Steven Taylor (Guilford Press, 2005)


What medications are used to treat anxiety disorders?

Response from Peter Roy-Byrne, MD:

Medication treatment of anxiety is generally safe and effective. But it often takes time and patience to find the drug that works best for you.

The first line of treatment for an anxiety disorder is often cognitive-behavioral therapy, or CBT. This is a well-established, highly effective, and lasting treatment. Some people find that excessively high levels of anxiety make them unable to get the most out of such treatment, however. In this case, medication may allow full participation in CBT. Those without access to CBT or those who have not had a satisfactory response to it may benefit from medication treatment, too.

Listen to Dr. Roy-Byrne's podcast on medications.

Things to Consider

Have a discussion with your doctor about medication if you are suffering from significant insomnia, which is frequently associated with generalized anxiety disorder, or GAD. Distressed by repetitive and excessive worry, people with GAD usually focus on the day’s activities, such as what was left undone, what went wrong, what needs to be done tomorrow, and the like. People with this condition describe it as a difficulty turning their mind off, and they often have difficulty falling asleep. Improving sleep has been shown to reduce anxiety and depressive symptoms, and it can often be achieved with medication treatment.

Depression often complicates chronic anxiety. Don’t ignore a sad mood, bouts of tearfulness, low self-esteem, feelings of guilt or hopelessness, and other depressive symptoms. Medication is often helpful in reducing symptoms of anxiety and alleviating those of depression. Most drugs used to treat anxiety come from the antidepressant class of medication, so they can be used to treat both conditions effectively.

Variety of Medications

Four major classes of medications are used to treat anxiety disorders.

Medication class Generic names How it works
SSRI (selective serotonin reuptake inhibitor)  citalopram, escitalopram, fluoxetine, paroxetine, sertraline  Relieves symptoms by blocking the reabsorption, or reuptake, of serotonin by certain nerve cells in the brain. This leaves more serotonin available, which enhances neurotransmission—the sending of nerve impulses—and improves mood. SSRIs are “selective” because they affect only serotonin and not other neurotransmitters.
SNRI (serotonin-norepinephrine reuptake inhibitor)  venlafaxine, duloxetine  Increases the levels of the neurotransmitters serotonin and norepinephrine by inhibiting their reabsorption into cells in the brain.
Tricyclic antidepressant  amitriptyline, imipramine, nortriptyline  Inhibits the reabsorption of the neurotransmitters serotonin and norepinephrine. (Has been increasingly replaced by SSRIs.)
Benzodiazepine  alprazolam, clonazepam, diazepam, lorazepam  Promotes relaxation and reducing muscular tension and other physical symptoms of anxiety. Frequently used for short-term management of anxiety, such as for minor medical procedures.

Other medications may also be used to treat anxiety disorders, including MAOI's (monoamine oxidase inhibitors), anticonvulsants, beta blockers, and atypical antipsychotics (also known as second-generation antipsychotics).

If you experience a side effect of any medication, contact your physician. Do not stop taking a medication abruptly because it may create other health risks.

Making a Decision

If you and your doctor have decided on medication as a treatment option, you have many choices. Work with your doctor to find the medication that’s right for you. With patience and persistence, you will find a treatment that will help alleviate your anxiety symptoms.

Peter Roy-Byrne, MD
Chief of Psychiatry, Harborview Medical Center
Professor and Vice Chair, Department of Psychiatry and Behavioral Sciences, University of Washington at Harborview Medical Center
Director, Center for Healthcare Improvement for Addictions, Mental Illness and Medically Vulnerable Populations (CHAMMP)

 

How can I tell if I’m having a panic attack or a heart attack?

Response from Reid Wilson, PhD, and Mark H. Pollack, MD:

Panic attacks and heart attacks can feel frighteningly similar: shortness of breath, palpitations, chest pain, dizziness, vertigo, feelings of unreality, numbness of hands and feet, sweating, fainting, and trembling. Some people describe this experience as feeling as if they’re losing control or going to die.

A panic attack occurs spontaneously or a stressful event can trigger it, but it poses no immediate danger. A heart attack is dangerous, and it requires prompt medical attention. In women, though, heart disease symptoms are sometimes mistaken for a panic attack.

Panic disorder is diagnosed in people who experience panic attacks and are preoccupied with the fear of a recurring attack. Like all anxiety disorders, this one is treatable.

Reid Wilson, PhD (at right), offers this advice:

For someone who has had a heart attack and also has panic attacks, together we identify, along with their physician, the symptoms that should trigger an immediate trip to the emergency room. Whether it turns out to be another panic attack or not, this person should treat those symptoms as a possible heart attack. He or she is to treat all other symptoms as signs of anxiety or a panic attack, even though they may feel like a heart attack.

Those who have never had a heart attack—but have been diagnosed with panic disorder and are fearful of a heart attack—should get a thorough physical evaluation to determine their heart health. If they are not at risk of a heart attack, then we begin the psychological work: They must be willing to be uncertain whether they are having a panic attack or a heart attack.

Their first goal is to respond to their typical anxiety or panic symptoms as anxiety or panic. Their position should be to say, ‘I want to recover from panic disorder strongly enough that I am willing to have a heart attack and miss it.’ That is how they will confront their need to be 100 percent certain.

Recent research suggests that people who have received a diagnosis of panic attacks or panic disorder under age 50 have an increased risk of developing heart disease or suffering a heart attack. The conclusions in this study are not definitive, and reasons for the increase in heart disease and heart attack were not established. More studies must be conducted to find out whether panic disorder is a risk factor for developing heart disease.

Mark PollackMark Pollack, MD (at left), says the findings of this research offer some value. He adds, “The study does suggest the possibility that, like other modifiable cardiac risk factors such as poor diet, sedentary lifestyle, or hypertension, treatment of panic and anxiety may have a beneficial effect on reducing the likelihood of developing heart disease.”
 
Whenever you’re in doubt about your symptoms, seek care without delay. Only medical tests can rule out the possibility of a heart attack. Once a heart attack is ruled out, seek effective treatment such as talk therapy and medication.

Find a therapist with experience treating panic disorder to learn how to manage panic attacks in the future.

Learn seven steps to break the cycle of panic in Facing Panic, Self-Help for People with Panic Attacks.

Reid Wilson, PhD, is the Director of the Anxiety Disorders Treatment Center, Chapel Hill, North Carolina, and the Associate Clinical Professor of Psychiatry at the University of North Carolina School of Medicine .

Mark H. Pollack, MD, is the Chairman of the Psychiatry Department at Rush University Medical Center in Chicago, Illinois. He is a member of the ADAA Board of Directors.

When asked out on a date, or talking to someone you’re interested in, when is the right time to explain your GAD or other disorder? What tips do you have to explain it in ways someone will understand and respect?

Response from Debra Kissen, PhD:

Debra Kissen, PhDWhen it comes to divulging personal information when you’re dating, there’s no need to rush. Like all other processes, dating takes time. So take your time in sharing any details, whether they're about your medical or mental health history, finances, or political views.

Timing

There is no perfect timing for sharing information about your mental health. But if you have a history of your GAD or other disorder affecting relationships, or you can predict ways that it might get in the way of your new relationship, it might be helpful to explain. You might say something like this: “I have a tendency to get caught up in my worries. It’s something I’m actively trying to work on, but there are some moments when I may lose perspective and worry more than the average person.”

Conversations

Communication is an ongoing process, so you’ll most likely have several small conversations instead of one big all-encompassing conversation about your GAD, other anxiety disorders, depression, or any mental health concern. The most important thing is to just to try to be yourself and have fun!

Debra Kissen, PhD, a licensed clinical psychologist, is the Clinical Director of the Light on Anxiety Treatment Center in Chicago. She has a special interest in mindfulness-based treatment for anxiety disorders.

In her practice, she provides cognitive-behavioral therapy (CBT) to children, adolescents and adults with a focus on anxiety and stress-related disorders, including OCD, PTSD, panic disorder, agoraphobia, social anxiety disorder, generalized anxiety disorder, specific phobias, separation anxiety disorder, compulsive skin picking, and trichotillomania. 

I am too shy to even to make small talk with my coworkers. Will I always be this way?

Response from Jennifer Shannon, LMFT:

Jennifer ShannonFirst of all, you are not alone! It may seem like everyone else is comfortable in social situations, but this is not true. In one study of 1,000 people, 40 percent said they were shy to the point of it being a problem.

Social anxiety disorder is the fourth most common mental health disorder after depression, alcohol abuse, and specific phobias.

The Difference Between Shyness and Social Anxiety Disorder

The hallmark of shyness is the fear of being scrutinized or negatively judged by others in social situations. Shy people are afraid of saying or doing something that will embarrass or humiliate them. Anticipating these feared situations provokes anxiety in the shy person, and how you handle this anxiety is how we determine if you are simply shy or if you have social anxiety disorder.

If you are avoiding social situations to the point where it is interfering significantly with your work, school, social activities, or relationships you are likely suffering from social anxiety disorder.

Causes of Social Anxiety

Genetics play a big role in both shyness and social anxiety disorder. You are two to three times more likely to have social anxiety disorder if you have a parent or sibling with it. The disorder affects males and females equally, and it is very unusual to develop it in adulthood; the typical age of onset is between 11and 19 years old.

Effective Treatment

Cognitive-behavioral therapy, or CBT, is an effective treatment for social anxiety disorder. CBT is based on the relationship between thoughts, feelings, and behaviors. Let’s take a typical situation, where you’d like to engage in conversation with a coworker but you find yourself avoiding situations where a conversation might happen. It’s true that by avoiding you may feel less anxious, but you do not get to test if your anxious thoughts are accurate, and you don’t get to practice small talk. So avoidance works in the short run, but not in the long run. (See diagram below.)

social-avoidance cycleAs with all anxiety disorders, people overestimate the threat—and social anxiety disorder is no exception. A CBT therapist will usually begin by helping you identify of the threatening thought you are having. “I won’t know what to say. There will be awkward silences and my coworker will think I am boring and stupid.”

How accurate is that thought? While it’s true that if you engage in a conversation with your co-worker, there may be an awkward silence. But everyone experiences this at times, and it does not usually lead to rejection.

The “B” in CBT stands for behavioral change—helping people to face their fears. We call this exposure therapy, which is done in small and manageable steps, like climbing a ladder. A typical first exposure might be simply to smile and say hi to a coworker. Subsequent exposures may be asking a question, sharing one thing about your weekend, and eventually, having a three-minute conversation.

Shyness: Not a Bad Thing

Shyness itself is not bad. In fact, shy people are often sensitive, thoughtful, and good at understanding others. It is important not to let your shyness stop you from doing what you want to do, like meeting people, making friends, dating, and speaking in front of groups.

People who have social anxiety have an underlying belief that they need to be socially perfect: no awkward silences, no signs of anxiety, and never tripping over their words, forgetting names, and always sounding smart and interesting. I call this social perfectionism, and no one can meet this standard. This is what I tell my clients all the time:
•    Lower the bar for yourself.
•    Be willing to make mistakes because everyone else does.
Once you develop more realistic expectations for yourself, it becomes a little easier to face your fears and live the life you want.

Ms. Shannon, a licensed marriage and family therapist, is the cofounder and clinical director of the Santa Rosa Center for Cognitive-Behavioral Therapy. 

Resources

The Shyness and Social Anxiety Workbook for Teens: CBT and ACT Skills to Help Build Social Confidence, by Jennifer Shannon, LMFT (Instant Help Books, New Harbinger, 2012)

Podcast: Teen Social Anxiety Disorder: Cognitive-Behavioral Interventions That Work

Video: Ms. Shannon's daughter, Rose, speaks about her social anxiety as a teen and how cognitive-behavioral therapy (CBT) helped her.

How can I overcome my fear of flying?

Response from Martin N. Seif, PhD, ABPP:

Dr. Martin SeifOvercoming a fear of flying takes a lot of courage and practice. But it is possible with appropriate treatment. I never flew until I was almost 30 years old, and getting over my own fear of flying was one of the most difficult achievements of my life.

If you can successfully identify the triggers that produce your anxiety, you've taken the first step. It's important to note that fear of flying is not a single phobia. Most people who fear flying are claustrophobic, or frightened of being locked in the plane and unable to choose when to get off.

A phobia is an intense fear that is out of proportion to the danger, which is particularly relevant to fears of flying. Most “flight phobics” agree that flying is safe, yet frightening. They have a hard time reconciling their fear with safety statistics. Although we know our phobias are not logical, we cannot reason ourselves out of one.

Understanding Triggers

Our fears of flying have triggers, which are thoughts, images, sensations, and memories to which we have become sensitized. A person who is sensitized to certain bodily feelings might fear turbulence or normal take-off and landing. And someone who fears heights might become terrified thinking about flying many miles above the ground.

The list of triggers is long: turbulence, take-off, landings, terrorism, crashes, social anxieties, or being too far from home. Some people fear fire, illness spread through the air system, using the toilets, or violence on a plane. Others have a “bad feeling” about their flight, afraid that their anxieties will somehow predict a catastrophe.

Behind the Phobias and Fear

The common denominator for more than 90 percent of flight phobics is the fear that they will become overwhelmed with anxiety during the flight.

Usually people experience an unexpected panic while flying, and then they fear the terrifying symptoms will return during their next flight. These panics typically emerge between the ages of 17 to 34, around the time of a significant life change such as a birth, death, marriage, divorce, or graduation. That is why people with flying phobias often wonder why they had once been able to fly so comfortably. Very few fears of flying originate with a traumatic flight.

Fear of flying is quite common, but almost 20 percent of the population report that their fear interferes with their work and social lives. It’s not uncommon for fearful fliers to avoid vacations and job promotions. Experts divide fear of flying into three main groups; which one do you belong to?

  1. Those who don’t fly or haven’t flown for more than five years despite the opportunity to do so.
  2. Those who fly only when absolutely necessary with extreme terror.
  3. Those who fly when required, but with anxiety. 

Elements of Successful Treatment

The “active ingredient” for overcoming phobias is exposure to feared triggers. It’s important to note that avoidance keeps your phobia alive and intense.

With fear of flying, there is a huge component of anticipatory anxiety, or the fear experienced in anticipation of taking a flight. Any successful treatment will help fearful fliers manage anticipatory anxiety (because many people avoid planning flights, or they just cancel them) as well as during a flight.

Newer treatments for fear of flying involve traditional methods of cognitive-behavioral therapy, or CBT, tailored to flying. Therapy includes techniques for managing anxiety, such as diaphragmatic breathing, to use while on the flight. People who are sensitized to bodily sensations during take-off, landing, or turbulence are desensitized to these triggers.

Education helps calm anxiety, too: how a plane flies, facts about turbulence, and the meaning of the various sounds and bumps during a normal flight. Virtual reality programs, during which fearful fliers are exposed to computer simulations of flight triggers, are also helpful. So, too, are flight simulators that are ordinarily used to teach private pilots how to fly small planes. (These are sometimes located near airports.)

Group therapy programs that meet at airports and culminate in a graduation flight with the therapist are a
vailable in many parts of country, including New York, Chicago, Los Angeles, Denver, and Minneapolis. They are particularly helpful in overcoming anticipatory anxiety and extending the treatment to the flight itself.

Medical treatment offers no perfect solution. Anti-anxiety medication (usually an SSRI or an SRNI) is helpful to some people who experience panic while flying, but they must be willing to take the drugs every day for a prolonged period of time. And they have little effect on anticipatory anxiety. The benzodiazepines can reduce anticipatory anxiety, but they also interfere with the therapeutic effects of exposure.

Having once been flight phobic myself, now I am constantly rewarded by the pleasure of being able to jump on a plane and fly anywhere in the world.


Martin N. Seif, PhD, ABPP, is a master clinician who has spent the last thirty years developing treatment methods for anxiety disorders. He has also experienced first-hand the crippling effects of anxiety. His path to recovery led him to develop the Anxiety Disorder Treatment Program.

Find Fear of Flying Workshops in your area and other resources. 

Can antibiotics increase anxiety symptoms?

Response from Mary E. (Beth) Salcedo, MD:

Antibiotics are among the most widely prescribed drugs in the United States, and they can cause many side effects. But when they are used properly, they’re considered quite safe. Most of their side effects are physical; one of the most common is an allergic reaction.

Anxiety symptoms are one of the lesser-known side effects. In certain people, antibiotics can cause symptoms that may mimic anxiety, such as dizziness or gastrointestinal side effects. In these cases, anxiety may be secondary to other side effects, instead of being a side effect on its own.

Although relatively infrequent, psychiatric symptoms have been reported as a side effect of most antibiotics. The class of antibiotics known as fluoroquinolones (Cipro is a well-known example) are probably most likely to cause anxiety. These side effects can vary among people, and they often get better as an individual adapts to the medication. Fortunately for most people, the symptoms should fully abate once they stop taking the drug.

It is unusual for anxiety to be so distressing that an antibiotic must be discontinued, but this has been reported. Most likely in these cases, however, is the risk factor of a pre-existing anxiety disorder.

Mary E. (Beth) Salcedo, MD, the Medical Director of The Ross Center for Anxiety and Related Disorders in Washington, D.C.

My SSRI antidepressant doesn’t work for me anymore. Why not?

Response from Mark Pollack, MD:

Your doctor has prescribed an SSRI (serotonin selective reuptake inhibitor) for your anxiety disorder or depression (or both), but you feel you aren’t responding adequately to your treatment.

Mark Pollack, MDConsider these issues: 
•    Your prescribed dose may be too low.
•    You may not have been taking it long enough to achieve a full response.
•    Side effects may prevent you from taking adequate doses.



SSRIs (Selective Serotonin Reuptake Inhibitors)

Generic names How they work
citalopram, escitalopram, fluoxetine, paroxetine, sertraline
Relieves symptoms by blocking the reabsorption, or reuptake, of serotonin by certain nerve cells in the brain. This leaves more serotonin available, which enhances neurotransmission—the sending of nerve impulses—and improves mood. SSRIs are “selective” because they affect only serotonin and not other neurotransmitters.

While the SSRIs work in similar ways, they’re not identical because they differ in their chemical structure and in their potency. And for reasons we do not yet fully understand, some patients may respond better to one SSRI than another.

Another Issue

Now some intriguing research suggests another potential cause for why SSRIs may not be effective in some cases. Recent evidence suggests that nonsteroidal anti-inflammatory agents (NSAIDs) taken with SSRIs may reduce their effectiveness.

NSAIDs (Nonsteroidal Anti-Inflammatory Drugs)

Generic names How they work
aspirin, celecoxib, diclofenac, diflunisal, etodolac, ibuprofen, indomethacin, ketoprofen,  ketorolac,  nabumetone, naproxen, oxaprozin, piroxicam, salsalate, sulindac, tolmetin Used primarily to treat inflammation, mild to moderate pain, and fever, NSAIDs block the enzymes and reduce prostaglandins throughout the body that promote these symptoms.

According to one theory, depression may be related to the body’s inflammatory responses. Called the cytokine hypothesis, this theory is based on observations that some cytokines, or the chemicals released as part of inflammation, help regulate serotonin and other neurotransmitters. Reducing inflammation, the NSAIDs negate the effects of the SSRIs, which increase levels of these chemicals.

Talk to your doctor if you take SSRIs and NSAIDs, and do not stop taking either medication. Learn about discontinuing medications. Ask if your use of NSAIDs — long-term or occasional — might be affecting your response to your SSRI antidepressant.

Mark Pollack, MD, is the Grainger Professor and Chairman, Department of Psychiatry, Rush University Medical Center

I am African American, and I think I may have an anxiety disorder. I worry that a therapist who is not African American might not be able to help me with my issues. How can I make sure my therapist understands what is wrong with me?

Response from Angela Neal-Barnett, PhD:

You are not alone. More than 40 million adults in the United States suffer from some form of anxiety. Sadly, only one-third recognize what may be happening and talk to their doctor. Congratulations on taking the first step in reclaiming your life and asking for help.

When talking to your doctor, make sure you do the following:

  • Use your own words to describe your feelings, symptoms, and experiences.
  • Give an example such as, “Lately, rather than driving over a bridge, I will take the long way around.” or “At night for no reason at all I wake up with my heart pounding and feeling very, very scared.”
  • Describe your physical symptoms.
  • Tell your doctor how these experiences make you feel.

Once you explain what you are experiencing, your doctor will refer you to a psychologist, psychiatrist, or social worker who has expertise in treating anxiety disorders. At the first meeting, this person will gather more information about your symptoms and explain how the therapy process works.

Most will use some form of cognitive-behavioral therapy (CBT) to help you overcome and manage the disorder. CBT is a form of therapy that helps you understand how thoughts and feelings influence behaviors.

As an African American psychologist who specializes in anxiety among African Americans, I frequently receive calls and e-mails from people who are concerned because their physician has referred them to a non-African American therapist. They want to know if this therapist will understand “their issues.” It’s an excellent and important question.

Whereas it would be wonderful if everyone who contacts me could be referred to an African American therapist, the reality is that the number of African American therapists is extremely small: Only about 1.8 percent of licensed psychologists are African Americans, 2.3 percent of all psychiatrists are African Americans, and 7 percent of licensed social workers are African American.

Fortunately, to be a licensed mental health professional in most states, you must receive training in multicultural issues. This means you must be trained to deliver treatment to African Americans, Latinos and Latinas, Asian Americans, and American Indians and Alaska Natives. As someone who provides that training, I know firsthand the care and commitment that goes into insuring that trainees are culturally competent.

If you are concerned about your therapist’s ability to understand African American issues, the best course of action is to simply ask. Here are three important questions:

  • Have you ever treated an African American with an anxiety disorder?
  • I’m concerned that you may not understand my issues, concerning being an African American female or male and being anxious. Do you feel you can?
  • Have you been trained in multicultural issues?

Anxiety is treatable, and with the help of a therapist who has been trained in multicultural issues, regardless of race or ethnicity, you can reclaim your life.

Angela Neal-Barnett, PhD, an associate professor of psychology at Kent State University, is a leading expert on anxiety disorders among African Americans. She is the CEO of Soothe Your Nerves, Inc., and the author of Soothe Your Nerves: The Black Woman’s Guide to Understanding and Overcoming Anxiety, Panic, and Fear (Fireside/Simon and Schuster, 2003). 

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