Understanding anxiety — and when it’s more than worry

Anxiety is one of the most common reasons people reach out to us, and it is highly treatable. Almost everyone feels anxious sometimes; the question we help you answer is whether what you’re experiencing is ordinary worry or an anxiety disorder that’s worth treating. This page explains what anxiety disorders are, how we evaluate them at OhanaPsych, how we treat them — and where we stand on benzodiazepines and telehealth.

What anxiety disorders actually are

Worry is a normal, even useful, response to real stress. An anxiety disorder is different: the worry or fear is persistent, out of proportion to the situation, hard to control, and it gets in the way of your life. The American Psychiatric Association’s DSM-5-TR describes several related conditions — generalized anxiety disorder (chronic, hard-to-control worry across many areas), panic disorder (sudden surges of intense fear with physical symptoms), and social anxiety disorder (intense fear of being judged in social situations), among others. They overlap, and many people have more than one.

What distinguishes a disorder from ordinary nervousness is the pattern: it’s persistent, it shows up even when there’s no real threat, and it costs you something — sleep, focus, relationships, or the ability to do things you want to do. Diagnosis is something we work through together, not a checklist you score on yourself.

Signs and symptoms

Anxiety shows up in the mind and the body. Common signs include constant or excessive worry, restlessness or feeling on edge, trouble concentrating, irritability, muscle tension, and disrupted sleep. Physically, it can bring a racing heart, shortness of breath, chest tightness, stomach upset, sweating, or dizziness — symptoms that are real and sometimes frightening enough that people fear something is medically wrong. Panic attacks can feel like a heart attack. Over time, many people start avoiding the places or situations that trigger the anxiety, which can quietly shrink their world.

A picture of what this can look like

Consider someone who has always been a “worrier” but finds that, over a stressful year, the worry takes over — they lie awake running through everything that could go wrong, feel keyed up and exhausted at the same time, and start declining invitations because being around people feels like too much. (This is a fictitious, illustrative composite, not a real patient.) They’re often relieved to learn this has a name, that it’s common, and that it responds well to treatment.

How we understand and evaluate anxiety

A good evaluation does two things: it clarifies what kind of anxiety you’re dealing with, and it rules out other things that can look like or fuel anxiety — thyroid problems, sleep disorders, the effects of caffeine, alcohol, or other substances, depression, trauma, and certain medical conditions. We take a full history and use validated screening tools. The goal is an accurate, whole-person picture so the plan actually fits you.

How anxiety is treated — and our approach

The good news is that anxiety disorders are among the most treatable conditions in psychiatry. The strongest evidence supports psychotherapy — particularly cognitive behavioral therapy (CBT) — and medication, used alone or, often most effectively, together. For medication, SSRIs and SNRIs (antidepressants that also treat anxiety) are the first-line choice, with strong evidence and a good long-term safety profile. They take a few weeks to work, and we’ll talk through what to expect.

We start from lōkahi — balance across the connected parts of your life — and treat anxiety in the context of your ‘ohana (family) and daily life, not as a symptom to be silenced. Care is collaborative: we build a plan you actually agree with, and we pay attention to sleep, substances, and stress, which all feed anxiety.

On benzodiazepines (medications such as alprazolam, lorazepam, and clonazepam): they can relieve acute anxiety quickly, but they are not a first-line, long-term solution, and they carry real risks — tolerance, dependence, and problems when combined with alcohol or opioids. We follow the American Psychiatric Association’s guidance on benzodiazepine use, reserving them for carefully selected, usually short-term or adjunctive situations rather than as the foundation of treatment, and prescribing them responsibly when they’re appropriate. Like all controlled substances at OhanaPsych, we do not start them in a one-off or crisis visit; appropriate use requires an established, ongoing relationship with your provider so we can monitor benefit, side effects, and safety — and, when it’s time, taper them carefully rather than stopping abruptly. Decisions are made case by case, at provider discretion. If you are prescribed a controlled medication, you’ll complete our Controlled Substance Agreement; and if we later need to reduce or stop a controlled medication, we use our Controlled Substance Taper Agreement.

Why we don’t combine stimulants with benzodiazepines

One position we hold firmly and want to be upfront about: we do not provide long-term treatment that combines a stimulant with a benzodiazepine. This isn’t red tape — it’s pharmacology and neuroscience. The two drug classes work directly against each other in the brain. Stimulants increase activity in the dopamine and norepinephrine systems to raise arousal and sharpen attention; benzodiazepines do the opposite, boosting the inhibitory neurotransmitter GABA to slow the brain down. Taking both long-term is like pressing the accelerator and the brake at the same time: each masks the other’s effects, which tends to push doses higher, worsen rebound and tolerance, and increase the risk of serious harm. Research on adults prescribed stimulants shows this opposing-mechanism combination is both common and risky.

With a bit of dark humor: clinicians sometimes call this the “uppers-and-downers” mix — yes, the Elvis Presley combination — and it is simply not one we are willing to recreate.

So our position is straightforward, and we believe kinder in the long run: in general, you choose one path. When a benzodiazepine is truly warranted, it is for short-term, time-limited use; stimulant treatment for ADHD is long-term. We are glad to treat ADHD effectively with a stimulant and to manage anxiety with options that pair safely alongside it — therapy, SSRIs or SNRIs, and other non-controlled medications — but we will not maintain anyone on chronic stimulant-plus-benzodiazepine therapy. We say this with empathy, especially if you have been prescribed both in the past: our goal is your long-term safety and clear thinking, not to make your life harder.

If you are over 65: we follow the geriatric guidelines

If you are 65 or older, our position on benzodiazepines is firmer still, and we want to be honest about why. In older adults the risks change the math: the American Geriatrics Society’s Beers Criteria recommend avoiding benzodiazepines after 65 because they increase the risk of falls and hip fractures and of confusion and delirium, and longer-term use has been associated with an increased risk of dementia, including Alzheimer’s disease. For that reason we apply the same standards described in our care of kūpuna: for patients over 65 we strongly recommend coming off benzodiazepines, and we will walk with you through a slow, individualized taper at a pace you can manage. We understand this may be unwelcome if you have relied on this medicine for a long time — we offer it with aloha and genuine compassion, and we will never leave you without support or safer alternatives for anxiety and sleep. What we cannot do is continue chronic, long-term benzodiazepine prescribing in older adults that the evidence shows is unsafe.

Working with your primary care team — and why we do the right thing

You may have been referred to us by your primary care team, and we are grateful for that trust. We keep strong, ongoing relationships with primary care providers across our community for a simple reason: we do the right thing. We render honest clinical opinions, we practice evidence-based care, and we report our findings and recommendations back to your primary care team so everyone caring for you is working from the same page. Those referral relationships exist precisely because we have honest conversations — not because we tell people only what they want to hear.

We will be candid: if you are hoping to continue a treatment that the evidence does not support, we have real empathy for how hard that can be — but this practice will not provide non-evidence-based care. And with a wink to the occasional keyboard warrior who promises us a one-star review across every platform after not hearing what they wanted: we have come to wear that as a badge of honor. Our providers are encouraged to have the difficult, honest conversations. We will not make everyone in our community happy, but we will do the right thing — 100% of the time — and we will do it with aloha.

One more honest point, offered with respect. Many people arrive already carrying a psychiatric diagnosis made in primary care. That is no knock on primary care: because of a real and worsening shortage of mental health specialists, primary care now delivers most of the mental health treatment in this country — in our experience, well over half of it here at home — and those clinicians work hard under enormous constraints. But you are now being seen by a specialist. A brief primary-care visit is not the same as a full psychiatric evaluation, and conditions such as bipolar disorder are frequently misdiagnosed as ordinary depression when they are not assessed by someone who does this every day. So we do not automatically inherit a diagnosis made elsewhere; we conduct our own evaluation and reach our own conclusions — which is exactly what a specialist consultation is for, and exactly why your primary care team sent you to us.

At the same time, we want to be honest about who we are. The clinicians in this practice group practice alike and hold to the same evidence-based standards, so moving from one of our providers to another simply because you didn’t like what you heard is not how we work. We have firm, caring conversations and keep proper boundaries because that is part of good, safe care — always offered with aloha. If you are looking for a practice that won’t have those conversations, we may not be the right fit, and we say that with respect and genuine goodwill.

Brief screening (96127)

As part of getting started — and to track your progress over time — we use brief, validated questionnaires that are administered, auto-scored, and documented on the CNS Vital Signs platform and billed under code 96127 (brief emotional/behavioral assessment). For anxiety, that includes the GAD-7 (Generalized Anxiety Disorder scale), the DASS (Depression, Anxiety and Stress Scale), and the Zung Self-Rating Anxiety Scale; and, for children and teens, the SCARED and the Social Anxiety Scale for Children and Adolescents (CNS Vital Signs, n.d.). Each takes only a few minutes and gives your provider objective information to guide care.

Getting care by telehealth

About 85% of our care is delivered by telehealth, and anxiety treatment works very well remotely — evaluation, therapy, and ongoing medication management can all happen by secure video. SSRIs and SNRIs are not controlled substances and can be managed entirely by telehealth. These are video visits; phone-only visits have additional requirements under Hawaii law — see our telehealth page. Benzodiazepines are controlled substances, so prescribing them remotely is governed by federal DEA/Ryan Haight rules; as of this writing, the DEA and HHS have extended the telemedicine prescribing flexibilities through December 31, 2026, and depending on your situation an in-person visit may still be needed. We provide care to patients located in Hawaiʻi, and language assistance is available.

One more note on access: as we complete the final stages of becoming a Rural Health Clinic (RHC), telehealth for mental-health care is here to stay with us. Under Medicare’s rural-health rules, RHCs are permanently authorized to provide behavioral and mental-health care by telehealth — including into your home, anywhere in Hawaiʻi — not under the temporary flexibilities that expire and must be renewed. (Prescribing of controlled medications still follows the separate Ryan Haight Act and DEA rules.) For our patients, that means dependable, lasting telehealth access to the care you need.

Wherever you live, OhanaPsych is your statewide practice. We provide care across the entire state of Hawaiʻi by telehealth, reaching every island — Hawaiʻi Island, Maui, Oʻahu, Kauaʻi, Molokaʻi, Lānaʻi, and Niʻihau. If you would rather be seen in person, you have that option at our offices in Hilo and Honolulu.

When to reach out — and when it’s an emergency

If anxiety is interfering with your sleep, work, relationships, or your ability to do the things you want to do, that’s a good reason to reach out — you don’t have to be in crisis to deserve help.

If you or someone you love is thinking about suicide or self-harm, please get help right away: call or text the 988 Suicide & Crisis Lifeline (call or text 988, or chat at 988lifeline.org). In Hawaiʻi, Hawaiʻi CARES is available by calling or texting 988, or at 808-832-3100 / 800-753-6879. In a life-threatening emergency, call 911.

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Medically reviewed by George Mackel, MSN, APRN, NP-C, PMHNP-BC, CARN-AP — President & Owner, OhanaPsych / Ohana Care Clinic.
Last reviewed: June 28, 2026. Citations verified: June 28, 2026.

This page is general health education from OhanaPsych. It is not a substitute for a personal evaluation by a qualified clinician who knows your situation, and reading it does not create a provider–patient relationship. If you think you may have an anxiety disorder or another condition, reach out to us or another licensed provider. In an emergency, call 911.

References

CNS Vital Signs. (n.d.). CNS Vital Signs computerized rating instruments. https://www.cnsvs.com/WhitePapers/CNSVS-RatingInstruments.pdf

American Geriatrics Society 2023 Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052–2081. https://doi.org/10.1111/jgs.18372

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Billioti de Gage, S., Moride, Y., Ducruet, T., Kurth, T., Verdoux, H., Tournier, M., Pariente, A., & Bégaud, B. (2014). Benzodiazepine use and risk of Alzheimer’s disease: Case-control study. BMJ, 349, g5205. https://doi.org/10.1136/bmj.g5205

Brunner, E., Chen, C.-Y. A., Klein, T., Andrews, C. M., Ashworth, H., Crystal, S., Dziura, J., Fiellin, D. A., Galuska, M., Heyward, J., Kraemer, K. L., Larkin, K., Olfson, M., Rana, A., Smith, K. D., & Tilstra, S. A. (2025). Joint clinical practice guideline on benzodiazepine tapering: Considerations when risks outweigh benefits. Journal of General Internal Medicine, 40, 2814–2859. https://doi.org/10.1007/s11606-025-09499-2

Culpepper, L. (2014). Misdiagnosis of bipolar depression in primary care practices. The Journal of Clinical Psychiatry, 75(3), e05. https://www.psychiatrist.com/jcp/misdiagnosis-bipolar-depression-primary-care-practices/

Donnelly, K., Bracchi, R., Hewitt, J., Routledge, P. A., & Carter, B. (2017). Benzodiazepines, Z-drugs and the risk of hip fracture: A systematic review and meta-analysis. PLOS ONE, 12(4), e0174730. https://doi.org/10.1371/journal.pone.0174730

Hughes, P. M., Annis, I. E., McGrath, R. E., & Thomas, K. C. (2024). Psychotropic medication prescribing across medical providers, 2016–2019. Psychiatric Services, 75(5), 477–480. https://doi.org/10.1176/appi.ps.20230156

Melaragno, A. J. (2021). Pharmacotherapy for anxiety disorders: From first-line options to treatment resistance. Focus, 19(2), 145–160. https://doi.org/10.1176/appi.focus.20200048

Moore, T. J., Wirtz, P. W., Curran, J. N., & Alexander, G. C. (2023). Medical use and combination drug therapy among US adult users of central nervous system stimulants: A cross-sectional analysis. BMJ Open, 13(4), e069668. https://doi.org/10.1136/bmjopen-2022-069668

U.S. Department of Health and Human Services. (2026). Telehealth policy updates. Telehealth.HHS.gov. https://telehealth.hhs.gov/providers/telehealth-policy/telehealth-policy-updates

U.S. Department of Health and Human Services & Drug Enforcement Administration. (2025). Third temporary extension of COVID-19 telemedicine flexibilities for prescription of controlled medications.