Anxiety: symptoms, panic attacks and treatment by video

Feeling anxious now and then is normal: before an exam, an interview or a big decision. According to the National Institute of Mental Health (NIMH), an anxiety disorder is different: the anxiety does not go away, shows up in many situations, can get worse over time and interferes with your routine, work, school and relationships.

The most common types are:

• Generalized anxiety disorder (GAD): you worry too much about everyday things (health, money, work, family) and find that worry hard to control on most days for at least 6 months.
• Panic disorder: sudden, repeated episodes of intense fear with no apparent danger, and fear of the next one.
• Social anxiety and phobias: intense fear of social situations or of something that poses little or no real danger.

There is no single known cause. According to MedlinePlus, genetics, brain chemistry, stress and your environment may all play a role.

Anxiety shows up in both mind and body. The most common anxiety symptoms are:

• Excessive worry that is hard to control
• Feeling restless, nervous or on edge
• Fatigue
• Trouble concentrating
• Irritability
• Muscle tension or aches
• Sleep problems
• Racing or pounding heart
• Sweating or trembling
• Avoiding places or activities out of fear

What many people call an anxiety attack is close to what doctors call a panic attack: a sudden episode of intense fear with physical symptoms such as a racing heart, shortness of breath, chest pain, dizziness, trembling, sweating, nausea, tingling hands or a feeling that you are going to die.

According to MedlinePlus, a panic attack most often peaks within 10 to 20 minutes, and some symptoms can last an hour or more. NIMH explains that panic attacks are not life-threatening, but they can feel like a heart attack.

What to do in the moment: sit somewhere safe, breathe slowly, remind yourself that the feeling will pass, and ask someone you trust to stay with you. Avoid coffee, alcohol and energy drinks.

Take chest symptoms seriously. If you have chest pain or pressure, shortness of breath or you faint, do not assume it is anxiety: call 911. A heart attack and other emergencies can feel the same, and they are ruled out in an emergency room, not by video. See when to go to the ER.

Before calling it "just anxiety", the doctor looks for physical causes with similar symptoms. MedlinePlus notes that other medical disorders must be checked for before panic disorder is diagnosed.

• Thyroid: hyperthyroidism can cause nervousness, irritability, hand tremor and a fast heartbeat.
• Coffee and caffeine: according to the FDA, too much caffeine can cause anxiety, jitters, a fast heart rate and insomnia. For most adults, the FDA cites 400 mg a day as an amount not generally linked to negative effects.
• Low blood sugar (hypoglycemia): causes shakiness, nervousness, sweating and a pounding heart, especially if you have diabetes.
• Medicines, alcohol and other substances: some medicines can cause anxiety-like symptoms. According to MedlinePlus, suddenly stopping alcohol after heavy drinking can cause anxiety, jumpiness, shakiness and sweating.

If needed, we give you a lab order for a lab near you, for example to check your thyroid or blood sugar.

You see Dr. Diana Nieves Castro, a Puerto Rico–licensed general practice physician, in English or Spanish. We evaluate, diagnose and treat. We send you a secure video link; it works on your phone, tablet or computer.

The doctor asks how long you have felt this way, what makes it worse, how you sleep, what you take (coffee, alcohol, medicines, supplements), how your mood is and what is going on in your life. She may use a short questionnaire such as the GAD-7, 7 questions and one of the most studied tools for spotting generalized anxiety.

Since 2023, the US Preventive Services Task Force (USPSTF) has recommended screening for anxiety disorders in adults 64 or younger, including pregnant and postpartum people. It is part of primary care: you do not have to wait for a crisis to bring it up.

Therapy. According to NIMH, cognitive behavioral therapy (CBT) is the gold-standard psychotherapy for anxiety: it helps you recognize and question the thoughts that feed fear and gradually face what you avoid. If it suits you, we refer you.

Habits that help: cut back on coffee and energy drinks, avoid using alcohol to calm down, move every day and protect your sleep. Anxiety and insomnia feed each other, so the doctor treats them together.

Many people improve with therapy, medicine or both. The doctor follows up to see how you are doing and adjust the plan.

There are several types of anxiety medication, and each has benefits and risks. This is general information; it does not replace an evaluation.

• SSRI antidepressants: such as sertraline, escitalopram and fluoxetine. According to NIMH, they may take several weeks to start working.
• SNRI antidepressants: another family of antidepressants also used for anxiety, such as venlafaxine or duloxetine.
• Buspirone: taken every day; it takes 3 to 4 weeks to be fully effective. It does not work when taken only as needed. More in the buspirone guide.
• Hydroxyzine: an antihistamine used to relieve anxiety and tension. It causes drowsiness: do not drive until you know how it affects you. More in the hydroxyzine guide.
• Beta blockers: propranolol is a blood pressure and heart medicine. It is sometimes used off-label for the physical symptoms of performance anxiety, such as shaking or a racing heart.
• Benzodiazepines: these are controlled medicines. In 2020 the FDA required a boxed warning on the risks of abuse, misuse, addiction, physical dependence and withdrawal reactions. The FDA warns that these risks increase when they are combined with opioids, alcohol or other drugs. Tolerance can build over time.

NIMH warns that children, teens and young adults under 25 may have more suicidal thoughts when starting an antidepressant or changing the dose, and that no one should stop a medicine suddenly without medical help.

After evaluating you, the doctor decides which treatment is appropriate and safe for you. If appropriate, the doctor prescribes and we send your prescription to your pharmacy.

Children and teens get anxiety too. Since 2022, the USPSTF has recommended screening for anxiety from ages 8 to 18.

The doctor sees patients of all ages by video. Patients under 21 need a parent or legal guardian on camera for the whole visit, with ID. If your child avoids school, is not sleeping, often complains of stomachaches or headaches, or you are worried about their mood, tell the doctor.

Book an evaluation; the doctor decides whether a treatment is right for you.

Video visits 24/7, from anywhere in Puerto Rico. See how online mental health care works.

If you have thoughts of harming yourself or ending your life, do not wait for an appointment. Call or text 988, or call ASSMCA’s Línea PAS at 1-800-981-0023: it is confidential, free and open 24 hours. In an emergency, call 911. Get help now if you have:

• Thoughts of harming yourself or ending your life
• Chest pain, fainting or shortness of breath: call 911
• Panic with confusion or not knowing where you are
• Shaking, sweating or hallucinations after stopping alcohol or other substances