Anxiety

Introduction 

Anxiety is a feeling of unease, such as worry or fear, that can be mild or severe.

Everyone has feelings of anxiety at some point in their life. For example, you may feel worried and anxious about sitting an exam or having a medical test or job interview.

Feeling anxious is sometimes perfectly normal. However, people with generalised anxiety disorder (GAD) find it hard to control their worries. Their feelings of anxiety are more constant and often affect their daily life.

Anxiety is the main symptom of several conditions, including:

• Panic disorder
• Phobias
• Post-traumatic stress disorder

The information in this section is about generalised anxiety disorder (GAD).

Generalised anxiety disorder (GAD)

GAD is a long-term condition which causes you to feel anxious about a wide range of situations and issues, rather than one specific event.

People with GAD feel anxious most days and often struggle to remember the last time they felt relaxed. GAD can cause both psychological (mental) and physical symptoms. These vary from person to person, but can include feeling irritable or worried and having trouble concentrating or sleeping.

How common is anxiety?

GAD affects about 1 in 20 adults in Britain. Slightly more women are affected than men, and the condition is most common in people in their 20s.

How is anxiety treated?

GAD can significantly affect your daily life, making it difficult to carry out everyday tasks. However, several different treatments are available to ease your psychological and physical symptoms. These include psychological therapy and medication.

There are also many things you can do to ease the symptoms of anxiety yourself.

Symptoms of generalised anxiety disorder 

The symptoms of general anxiety disorder (GAD) often develop slowly. How severe they are varies from person to person.

Some people have only one or two symptoms, while others have many more.

Anxiety can affect you physically and mentally.

Psychological symptoms of anxiety

GAD can cause a change in your behaviour and the way you think and feel about things. Psychological symptoms of GAD include:

• Restlessness
• A sense of dread
• Feeling constantly "on edge"
• Difficulty concentrating
• Irritability
• Impatience
• Being easily distracted

Your symptoms may cause you to withdraw from social contact (seeing your family and friends) to avoid feelings of worry and dread. You may also find going to work difficult and stressful and may take time off sick. These actions can make you worry even more about yourself and increase your lack of self-esteem.

Physical symptoms of anxiety

The physical symptoms of GAD can include:

• Dizziness
• Drowsiness and tiredness
• Pins and needles
• Irregular heartbeat (palpitations)
• Muscle aches and tension
• Dry mouth
• Excessive sweating
• Shortness of breath
• Stomach ache
• Nausea
• Darrhoea
• Headache
• Excessive thirst
• Frequent urinating
• Painful or missed periods
• Difficulty falling or staying asleep (insomnia)

How anxiety can intensify

If you are anxious as a result of a phobia or because of panic disorder, you will usually know what the cause is. For example, if you have claustrophobia (a fear of enclosed spaces), you know that being confined in a small space will trigger your anxiety.

However, if you have GAD, what you are feeling anxious about may not always be clear. Not knowing what triggers your anxiety can intensify your anxiety and you may start to worry that there will be no solution.

Causes of generalised anxiety disorder 

As with most conditions that affect mental health, the exact cause of generalised anxiety disorder (GAD) is not fully understood.

Some people develop the condition for no apparent reason. Others may develop GAD after a major stressful incident.

Neurotransmitters and anxiety

Research has suggested that GAD may be caused by an imbalance of certain chemicals that occur naturally in the brain. These chemicals are known as neurotransmitters.

Two neurotransmitters thought to affect anxiety are serotonin and noradrenaline. If the level of these chemicals in your brain becomes unbalanced, it can significantly affect your mood and increase your likelihood of developing anxiety-related conditions such as GAD.

However, GAD is most likely to have a complex combination of causes, rather than being triggered by just an imbalance of brain chemicals.

Combination of causes of anxiety

Researchers believe that GAD is caused by a combination of factors, including:

• Your body's biological processes
• Genetics (the genes you inherit from your parents)
• Your environment
• Your life experience

Diagnosing generalised anxiety disorder 

See Dr. B C Shah if anxiety is affecting your daily life or is causing you distress.

Generalised anxiety disorder (GAD) can be difficult to diagnose. In some cases, it can also be difficult to distinguish from other mental health conditions, such as depression.

Talking to Dr. B C Shah about anxiety

Dr. B C Shah may ask you questions about your worries, fears and emotions. They may also ask about your personal life. Tell him about all your symptoms – physical and psychological – and explain how long you have had them.

You may find it difficult to talk about your feelings, emotions and personal life. However, it is important that Dr. B C Shah understands your symptoms and circumstances so that the correct diagnosis can be made.

You are most likely to be diagnosed with GAD if you have had the symptoms for six months or more. Finding it difficult to manage your feelings of anxiety is also an indication that you may have developed the condition.

To help with the diagnosis,Dr. B C Shah may carry out a physical examination to rule out any other conditions that may be causing your symptoms.

Treating generalised anxiety disorder 

There are two main forms of treatment for generalised anxiety disorder (GAD):

• Psychological therapy 
• Medication

Depending on your circumstances, you may benefit from one of these types of treatment or a combination of the two.

Studies of different treatments for GAD have found that the benefits of psychological treatment last the longest, but no single treatment is best for everyone.

Before you begin any form of treatment, Dr. B C Shah should discuss all your treatment options with you. They should outline the pros and cons of each and make you aware of any possible risks or side effects. With Dr. B C Shah, you can make a decision on the treatment most suited to you, taking into account your personal preferences and circumstances.

Psychological treatment for anxiety

If you have been diagnosed with GAD, you will usually be advised to try psychological treatment before you are prescribed medication. The main type of psychological treatment for GAD is cognitive behavioural therapy (CBT).

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is one of the most effective types of treatment for GAD. Research suggests that around half of people who have CBT recover from GAD and many others get some benefit.

CBT works by helping you identify unhelpful and unrealistic beliefs and behavioural patterns. You and your therapist work together to change your behaviour and replace unhelpful beliefs with more realistic and balanced ones.

CBT mainly focuses on the problems you have at the moment, rather than events from the past. It teaches you new skills and helps you understand how to react more positively to situations that would usually cause you anxiety.

Applied relaxation

Applied relaxation is an alternative type of psychological treatment. It was initially used to treat phobias, but it is now also being used to treat conditions such as GAD.

Applied relaxation focuses on relaxing your muscles in a particular way during situations that usually cause anxiety. The technique will need to be taught by a trained therapist, but it involves: 

• Learning how to relax your muscles
• Learning how to relax your muscles quickly and in response to a trigger, such as the word "relax"
• Practising relaxing your muscles in situations that make you anxious

You will need 12 to 15 hour-long sessions to learn how to use applied relaxation correctly. It has been found to be as effective as CBT.

Medication for anxiety

Dr. B C Shah can prescribe a variety of different types of medication to treat GAD. Some medication is designed to be taken on a short-term basis, while other medicines are prescribed for longer periods. Depending on your symptoms, you may require medicine to treat your physical symptoms as well as your psychological ones.

If you are considering taking medication for GAD, Dr. B C Shah should discuss the different options with you in detail, including the different types of medication, length of treatment, side effects and possible interactions with other medicines before you start a course of treatment.

Long-term medication includes: 

• Selective serotonin reuptake inhibitors (SSRIs), such as sertraline, fluoxetine, citalopram or paroxetine   
• Venlafaxine
• Pregabalin

Short-term medication includes: 

• Antihistamines
• Benzodiazepines
• Buspirone

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant that increase the level of a chemical called serotonin in your brain. They can be taken on a long-term basis.

As with all antidepressants, SSRIs can take several weeks to start working. You will usually be started on a low dose which will gradually be increased as your body adjusts to the medicine.

You may be offered an SSRI called sertraline. Sertraline is not specifically licensed to treat GAD, which means that the manufacturers of the medicine have not applied for a license for it to be used to treat the condition. However, it is used to treat similar conditions, such as panic disorderand obsessive compulsive disorder (OCD). 

Citalopram, fluoxetine and paroxetine are SSRIs that are often prescribed to treat GAD.

Common side effects of SSRIs include:

• Nausea (feeling sick)
• Low sex drive 
• Blurred vision 
• Diarrhoea or constipation
• Dizziness 
• Dry mouth 
• loss of appetite 
• Sweating 
• Feeling agitated 
• Insomnia (problems sleeping)

When you start taking an SSRI, you should see Dr. B C Shah after two, four, six and 12 weeks to check your progress and to see if you are responding to the medicine. Not everyone responds well to antidepressant medicines, so it is important that your progress is carefully monitored.

If Dr. B C Shah feels it is necessary, you may require regular blood tests or blood pressure checks when taking antidepressant medication. If, after 12 weeks of taking the medication, you do not show any signs of improvement, Dr. B C Shah may prescribe an alternative SSRI to see if that has any effect.

When you and Dr. B C Shah decide that it is appropriate for you to stop taking your SSRI medication, you will gradually be weaned off the medication by slowly reducing your dose. Never stop taking your medication unless he specifically advises you to.

Venlafaxine

If SSRIs do not help ease your anxiety, you may be prescribed a different type of antidepressant known as venlafaxine.

Venlafaxine belongs to a group of medicines known as selective serotonin and noradrenaline reuptake inhibitors (SNRIs). This type of medicine increases the amount of the chemicals serotonin and noradrenaline in your brain, helping restore the chemical imbalance that sometimes causes GAD.

You cannot be prescribed venlafaxine if you: 

• Have high blood pressure that is not being treated 
• Have recently had a heart attack
• Are at risk of having irregular heartbeats (cardiac arrhythmias)

If you have any of the above conditions, you may be at risk of developing complications if you take venlafaxine.

Common side effects of venlafaxine may include: 

• Nausea 
• Headache 
• Drowsiness 
• Dizziness 
• Dry mouth 
• Constipation 
• Indigestion 
• Insomnia
• Sweating

If you are prescribed this medicine, your blood pressure will be monitored regularly.

Pregabalin

If SSRIs and SNRIs are not suitable for you, you may be offered pregabalin. This is a medication known as an anticonvulsant, which is used to treat conditions such as epilepsy (a condition that causes repeated seizures). However, it has also been found to be beneficial in treating anxiety.

The most commonly reported side effects of pregabalin include:

• Drowsiness
• Dizziness
• Headaches

Pregabalin is less likely to cause nausea or a low sex drive than SSRIs or SNRIs.

Antihistamines

Antihistamines are usually prescribed to treat allergic reactions. However, some are also used to treat anxiety on a short-term basis.

Antihistamines have a calming effect on the brain, helping you feel less anxious.

Antihistamines are only effective when used for a short period of time and will only be prescribed for a few weeks.

Hydroxyzine is the most commonly prescribed antihistamine for treating anxiety. This antihistamine can make you feel drowsy, so it is best not to drive or operate machinery when taking the medication. Other side effects of hydroxyzine include:

• Dizziness 
• Blurred vision 
• Headache 
• Dry mouth

Benzodiazepines

Benzodiazepines are a type of sedative that help ease the symptoms of anxiety within 30 to 90 minutes of taking the medication.

Although benzodiazepines are very effective in treating the symptoms of anxiety, they cannot be used for long periods of time. This is because they can become addictive if used for longer than four weeks. Benzodiazepines also start to lose their effectiveness after this time.

For these reasons, you will usually only be prescribed benzodiazepines to help you cope during a particularly severe period of anxiety. Benzodiazepines can cause side effects, including: 

• Confusion 
• Loss of balance 
• Memory loss 
• Drowsiness and light-headedness

Due to the above side effects, benzodiazepines can affect your ability to drive or operate machinery. Therefore, avoid these activities when taking the medication.

Speak to Dr. B C Shah if you experience any of the side effects listed above. They may be able to adjust your dose of medication or prescribe an alternative.

Buspirone

Buspirone is a medicine that can help ease the psychological symptoms of anxiety. It belongs to a group of medicines known as anxiolytics.

You will usually have to take buspirone for two weeks before you notice an improvement. It will be up to Dr. B C Shah how long you continue to take the medicine after this.

Buspirone works in a similar way to benzodiazepines, but does not become addictive. However, it is only recommended as a short-term form of medication.

Referral for anxiety

If you have tried any two treatments (out of medication, CBT and self-help with guidance from Dr. B C Shah) and you still have significant symptoms of GAD, you may want to discuss with Dr. B C Shah whether you should be referred to a mental health specialist.

An appropriate mental health specialist from your local team will carry out an overall reassessment of your condition. They will ask you about your previous treatment and how effective you found it. They may also ask about things in your life that may be affecting your condition, or how much support you get from family and friends. Your specialist will then be able to devise a treatment plan for you, which will aim to effectively treat your symptoms. This may include any of the following:

• psychological therapies such as CBT 
• appropriate treatment of other diseases and conditions that may have an effect on your anxiety 
• other medication
• further referral to specialists

Self-help treatments for generalised anxiety disorder 

If you have generalised anxiety disorder (GAD), there are many ways that you can ease the symptoms of anxiety yourself.

Exercise for anxiety 

Regular exercise, particularly aerobic exercise, will help you combat stress and release tension. It also encourages your brain to release the chemical serotonin, which can improve your mood.

Aim to do a minimum of 150 minutes of moderate exercise a week. Moderate exercise should make you feel slightly out of breath and tired. Going for a brisk walk is a good example.

Relaxation

As well as getting regular exercise, learning how to relax is important. You may find relaxation and breathing exercises helpful, or you may prefer activities such as yoga or pilates to help you unwind.

Diet

Changing your diet may help ease your symptoms. Too much caffeine can make you more anxious than normal. This is because caffeine can disrupt your sleep and also speed up your heartbeat. If you are tired, you are less likely to be able to control your anxious feelings.

Smoking and drinking

Smoking and alcohol have been shown to make feelings of anxiety worse. Drink alcohol in moderation and, if you smoke, try to give up. 

The Department of Health recommends that men should not drink more than three to four units of alcohol a day and women no more than two to three units.

Support groups for anxiety

Support groups can give you useful advice about how to effectively manage your anxiety. They are also a good way to meet other people with similar experiences.

Support groups often involve face-to-face meetings where you can talk about your difficulties and problems with other people. Many support groups also provide support and guidance over the phone or in writing. 

Understanding your anxiety

Some people find that reading about anxiety can help them deal with their condition. There are many books based on the principles of cognitive behavioural therapy (CBT). These may help you understand your psychological problems better and learn ways to overcome them by changing your behaviour.