Most people feel anxious from time to time. However, anxiety can become abnormal if it interferes with your day-to-day activities. Anxiety is a symptom of various anxiety disorders which are discussed below. They can often be treated. Treatments include various talking treatments, and medication.
What is anxiety?
When you are anxious you feel fearful and tense. In addition you may also have one or more unpleasant physical symptoms. For example, you might have a fast heart rate, a thumping heart (palpitations), feeling sick, shaking (tremor), sweating, dry mouth, chest pain, headaches, fast breathing.
The physical symptoms are partly caused by the brain which sends lots of messages down nerves to various parts of the body when you are anxious. The nerve messages tend to make the heart, lungs, and other parts of the body work faster. In addition, you release stress hormones (such as adrenaline) into the bloodstream when you are anxious. These can also act on the heart, muscles and other parts of the body to cause symptoms.
Anxiety is normal in stressful situations, and can even be helpful. For example, most people will be anxious when threatened by an aggressive person, or before an important race. The burst of adrenaline and nerve impulses which we have in response to stressful situations can encourage a 'fight or flight' response.
Anxiety is abnormal if it:
- Is out of proportion to the stressful situation; or
- Persists when a stressful situation has gone, or the stress is minor; or
- Appears for no apparent reason when there is no stressful situation.
What are anxiety disorders?
There are various conditions (disorders) where anxiety is a main symptom. You may have an anxiety disorder if anxiety symptoms interfere with your normal day-to-day activities, or if worry about developing anxiety symptoms affects your life. About 1 in 20 people have an anxiety disorder at any one time. The following is a brief overview of the main anxiety disorders. Some people have features of more than one type of disorder.
Reactions to stress
Anxiety can be one of a number of symptoms as a reaction to stressful situations. There are three common types of reaction disorders:
Acute reaction to stress (sometimes called acute stress reaction)
Acute means the symptoms develop quickly, over minutes or hours, reacting to the stressful event. Acute reactions to stress typically occur after an unexpected life crisis such as an accident, bereavement, family problem, bad news, etc. Sometimes symptoms occur before a known situation which is difficult. This is called situational anxiety. This may occur, for example, before an examination, an important race, a concert performance, etc.
Symptoms usually settle fairly quickly, but can sometimes last for several days or weeks. Apart from anxiety, other symptoms include low mood, irritability, emotional ups and downs, poor sleep, poor concentration, wanting to be alone.
See separate leaflet called Acute Stress Disorder for more details.
This is similar to the above, but symptoms develop days or weeks after a stressful situation, as a reaction or adjustment to the problem. For example, as a reaction to a divorce or house move. Symptoms are similar to acute reaction to stress but may include depression. The symptoms tend to improve over a few weeks or so.
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) may follow a severe trauma such as a serious assault or life-threatening accident. Symptoms last at least one month, often much longer. Anxiety is only one symptom which may come and go. The main symptoms of PTSD are:
- Recurring thoughts, memories, images, dreams, or flashbacks of the trauma, which are distressing.
- You try to avoid thoughts, feelings, conversations, places, people, activities or anything else which may trigger memories or thoughts of the trauma.
- Feeling emotionally numb and detached from others. You may find it difficult to have loving feelings.
- Your outlook for the future is often pessimistic. You may lose interest in activities which you used to enjoy.
- Increased arousal which you did not have before the trauma. This may include difficulty sleeping, being irritable, difficulty concentrating, and increased vigilance.
See separate leaflet called Post-traumatic Stress Disorder for more details.
Phobic anxiety disorders
A phobia is strong fear or dread of a thing or event. The fear is out of proportion to the reality of the situation. Coming near or into contact with the feared situation causes anxiety. Sometimes even thinking of the feared situation causes anxiety. Therefore, you end up avoiding the feared situation, which can restrict your life and may cause suffering.
Social anxiety disorder
Social anxiety disorder (also known as social phobia) is possibly the most common phobia. With social anxiety disorder you become very anxious about what other people may think of you, or how they may judge you. Therefore, you fear meeting people, or 'performing' in front of other people, especially strangers. You fear that you will act in an embarrassing way, and that other people will think that you are stupid, inadequate, weak, foolish, crazy, etc. You avoid such situations as much as possible. If you go to the feared situation you become very anxious and distressed.
See separate leaflet called Social Anxiety Disorder for more details.
This too is common. Many people think that agoraphobia means a fear of public places and open spaces. But this is just part of it. If you have agoraphobia you tend to have a number of fears of various places and situations. So, for example, you may have a fear of:
- Entering shops, crowds, and public places.
- Travelling in trains, buses, or planes.
- Being on a bridge or in a lift.
- Being in a cinema, restaurant, etc where there is no easy exit.
But they all stem from one underlying fear. That is, a fear of being in a place where help will not be available, or where you feel it may be difficult to escape to a safe place (usually to your home). When you are in a feared place you become very anxious and distressed, and have an intense desire to get out. To avoid this anxiety many people with agoraphobia stay inside their home for most or all of the time.
See separate leaflet called Agoraphobia for more details.
Other specific phobias
There are many other phobias of a specific thing or situation. For example:
- Fear of confined spaces or of being trapped (claustrophobia).
- Fear of certain animals.
- Fear of injections.
- Fear of vomiting.
- Fear of being alone.
- Fear of choking.
But there are many more.
Other anxiety disorders
Panic disorder means that you get recurring panic attacks. A panic attack is a severe attack of anxiety and fear which occurs suddenly, often without warning, and for no apparent reason. The physical symptoms of anxiety during a panic attack can be severe and include a thumping heart (palpitations), trembling, feeling short of breath, chest pains, feeling faint, numbness, or pins and needles. Each panic attack usually lasts 5-10 minutes, but sometimes they come in waves for up to two hours.
See separate leaflet called Panic Disorder for more details.
Generalised anxiety disorder
If you have generalised anxiety disorder (GAD) you have a lot of anxiety (feeling fearful, worried and tense) on most days. The condition persists long-term. Some of the physical symptoms of anxiety (detailed above) may come and go. Your anxiety tends to be about various stresses at home or work, often about quite minor things. Sometimes you do not know why you are anxious. In addition, you will usually have three or more of the following symptoms:
- Feeling restless, on edge, or 'keyed up' a lot of the time.
- Tiring easily.
- Difficulty concentrating and your mind going blank quite often.
- Being irritable a lot of the time.
- Muscle tension.
- Poor sleep (insomnia). Usually it is difficulty in getting off to sleep, or difficulty in staying asleep.
See separate leaflet called Generalised Anxiety Disorder for more details.
Mixed anxiety and depressive disorder
In some people, anxiety can be a symptom when you have depression. Other symptoms of depression include low mood, feelings of sadness, sleep problems, poor appetite, irritability, poor concentration, decreased sex drive, loss of energy, guilt feelings, headaches, aches, pains, and palpitations. Treatment tends to be aimed mainly at easing depression, and the anxiety symptoms often then ease too.
See separate leaflet called Depression for more details about depression.
Obsessive-compulsive disorder (OCD) consists of recurring obsessions, compulsions, or both.
- Obsessions are recurring thoughts, images, or urges that cause you anxiety or disgust. Common obsessions are fears about dirt, contamination, germs, disasters, violence, etc.
- Compulsions are thoughts or actions that you feel you must do or repeat. Usually a compulsion is a response to ease the anxiety caused by an obsession. A common example is repeated hand washing in response to the obsessional fear about dirt or germs. Other examples of compulsions include repeated cleaning, checking, counting, touching, and hoarding of objects.
See separate leaflet called Obsessive-compulsive Disorder for more details.
What is the treatment for anxiety disorders and phobias?
The main aim of treatment is to help you to reduce symptoms so that anxiety no longer affects your day-to-day life.
The treatment options depend on what condition you have, and how severely you are affected. They may include one or more of the following:
Understanding the cause of symptoms, and talking things over with a friend, family member or health professional may help. In particular, some people worry that the physical symptoms of anxiety, such as a thumping heart (palpitations), are due to a physical illness. This can make anxiety worse. Understanding that you have an anxiety disorder is unlikely to cure it, but it often helps.
This may help some people with certain conditions. For example, counselling which focuses on problem-solving skills may help if you have GAD.
Anxiety management courses
These may be an option for some conditions, if courses are available in your area. The courses may include: learning how to relax, problem-solving skills, coping strategies, and group support.
Cognitive and behavioural therapy
These therapies, if available in your area, can work well for persisting anxiety disorders and phobias:
- Cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as anxiety and depression. The therapist helps you to understand your current thought patterns - in particular, to identify any harmful, unhelpful, and false ideas or thoughts which you have that can make you anxious (or depressed). The aim is then to change your ways of thinking to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful. Therapy is usually done in weekly sessions of about 50 minutes each, for several weeks. You have to take an active part, and are given homework between sessions. For example, you may be asked to keep a diary of your thoughts which occur when you become anxious or develop physical symptoms of anxiety.
- Behavioural therapy aims to change any behaviours which are harmful or not helpful. For example, with phobias your behaviour or response to the feared object is harmful, and the therapist aims to help you to change this. Various techniques are used, depending on the condition and circumstances. As with cognitive therapy, several sessions are needed for a course of therapy.
- Cognitive behavioural therapy (CBT) is a mixture of the two where you may benefit from changing both thoughts and behaviours. (Note: cognitive and behavioural therapies do not look into the events of the past. They deal with, and aim to change, your current thought processes and/or behaviours.) See separate leaflet called Cognitive Behavioural Therapy (CBT) for more details.
There are various national groups which can help by giving information, advice and support (see below). They, or your doctor or practice nurse, may also be able to put you in touch with a local group for face-to-face support.
You can also get leaflets, books, tapes, videos, etc, on relaxation and combating stress. They teach simple deep-breathing techniques and other measures to relieve stress, help you to relax, and possibly ease anxiety symptoms. See separate leaflet in this series, called Stress and Tips on How to Avoid It.
These are commonly used to treat depression, but also help to reduce the symptoms of anxiety even if you are not depressed. They work by interfering with brain chemicals (neurotransmitters) such as serotonin which may be involved in causing anxiety symptoms.
- Antidepressants do not work straightaway. It takes 2-4 weeks before their effect builds up and the anxiety symptoms are helped. A common problem is that some people stop the medicine after a week or so, as they feel that it is doing no good. This is often too soon to know if the medication will work.
- Antidepressants are not tranquillisers, and are not usually addictive.
- There are several types of antidepressants, each with various pros and cons. They may differ in their possible side-effects. However, selective serotonin reuptake inhibitor (SSRI) antidepressants are the ones most commonly used for anxiety disorders. Two examples of SSRIs are escitalopram and sertraline.
- Note: after first starting an antidepressant, in some people the anxiety symptoms become worse for a few days before they start to improve. Your doctor or practice nurse will want to keep a check on you in the first few weeks of treatment to see if you have any problems.
Benzodiazepines such as diazepam used to be the most commonly prescribed medicines for anxiety. They were known as the minor tranquilisers but they do have some serious known side-effects. They often work well to ease symptoms. The problem is they are addictive and can lose their effect if you take them for more than a few weeks. They may also make you drowsy. Now they are not used much for persistent anxiety conditions. A short course of up to two weeks may be an option for anxiety which is very severe and short-term, or now and then to help you over a bad spell if you have persistent anxiety symptoms.
Buspirone is sometimes prescribed to treat GAD. It is an anti-anxiety medicine, but different to the benzodiazepines and is not thought to be addictive. It is not clear how it works. It is thought to affect serotonin, a brain chemical which may be involved in causing anxiety symptoms.
A beta-blocker, for example propranolol, can ease some of the physical symptoms such as trembling and a thumping heart (palpitations). They do not directly affect the mental symptoms such as worry. However, some people relax more easily if their physical symptoms are eased. These tend to work best in short-lived (acute) anxiety. For example, if you become more anxious before performing in a concert then a beta-blocker may help to ease 'the shakes'.
In some cases a combination of treatments such as cognitive therapy and an antidepressant may work better than either treatment alone.
Alcohol and anxiety
Although alcohol may ease symptoms in the short term, don't be fooled that drinking helps to cure anxiety. In the long run, it does not. Drinking alcohol to 'calm nerves' can lead to problem drinking and may make problems with anxiety and depression worse in the long term. See a doctor if you are drinking alcohol (or taking street drugs) to ease anxiety.
Dr Tim Kenny
Dr Euan Lawson
Dr John Cox