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Anxiety

Introduction

We all feel anxious at certain times in our lives, perhaps before an important event such as a job interview or exam, or when we're in a difficult or dangerous situation. Although this anxiety can be unpleasant, it rarely lasts long and we usually manage to cope with it. But for some people anxiety is a much more frightening experience which becomes a real problem in their lives. Anxiety of this severe kind can mean feeling overcome with panic, experiencing restlessness, breathlessness, or sweating. It can involve excessive worrying or feeling unable to control disturbing or upsetting thoughts. It can even mean being unable to leave your home because of overwhelming fears, or being unable to keep a job because the anxiety interferes with your concentration.

If you, or someone you know, experiences this kind of severe anxiety then you are not alone. At least one person in ten will have their life disrupted by anxiety at some point in their lives. However the good news is that people with anxiety problems, even serious ones, can be helped. So if anxiety is causing you distress or preventing you from living life to the full, then this is for you. If you are worried about a friend or relative who seems to be overwhelmed by anxiety you should also find this very useful. It describes what anxiety is and how severe anxiety differs from ‘normal', everyday anxiety. It looks at how you can help yourself, where you can get help from other people, and also describes some of the different forms of treatment currently available. At the end of the you can find a list of useful organisations and addresses which can give you further help and information.

What is anxiety?

Anxiety can be described as a feeling of discomfort or unease. Anxiety which continues for a long time can have a serious effect upon your ability to cope with everyday life. You may not be able to identify a specific cause of your anxiety, although feelings of anxiety are often associated with particular places or events.

How do you know if you are anxious? The easiest signs of anxiety to recognise are physical changes, such as sweating, a racing heart, palpitations, or rapid breathing. These changes are caused by an increase in adrenaline, the substance which is released by your body to help you get ready to deal with danger or escape from something. It is quite normal to feel anxious when you are facing something dangerous or difficult, but it is not usual to feel anxious all the time or to feel that anxiety is ruling your life.

What is severe anxiety?

Severe anxiety is a bit like a ‘false alarm'. It happens when our bodies over-react, and respond with anxiety to something which is not really dangerous. This is sometimes to do with the way we think about situations; for example we may exaggerate how difficult or dangerous something is going to be. It can also happen when we are under stress, or when we start thinking about past difficulties and experiences.

Why does severe anxiety persist?

Usually if we feel a little anxious we carry on with what we are doing and the anxiety gradually goes away. However, if you have severe anxiety you may find it so unpleasant that you begin to find ways of avoiding the situation or event that makes you feel so bad. Each time you succeed in avoiding something your anxiety level starts to drop and so in the short term you feel better. But by avoiding what you fear, two things happen:

• avoiding things becomes a habit, so you start to limit what you can do . For example you may decide that you cannot go to certain places or do things you previously enjoyed.
• you never have the chance to test out whether the situation was really frightening, and you never have the chance to realise that you can cope, and that anxiety will go away.

This means that the anxiety continues, and becomes a long-lasting problem, because you have got into the habit of avoiding what you fear rather than facing up to it.

Are there different kinds of anxiety?

All forms of anxiety involve the sensations described earlier, and in almost all cases anxiety problems increase if you get into a pattern of avoiding things. But there are quite important differences in the way people think about their anxiety, and anxiety problems may arise from many different causes. Professionals treating anxiety problems therefore describe them using the following terms:

• Phobias
  A specific phobia is a fear of a particular object or place which is so severe that it affects your way of life. It is possible to develop a phobia for almost anything, but some of the most common phobias are fear of heights, fear of spiders or mice, fear of enclosed spaces (known as claustrophobia) and fear of blood or injections. Many of us feel some anxiety about these things, perhaps realistically since if we did not fear heights, for example, we might have more accidents! But there is a difference between this ordinary reaction and a phobia, which results in a person going to extreme lengths to avoid the object or situation they fear. For example if you have a phobia for injections, rather than just a natural dislike of them, you might be unable to go on holiday or travel on business to places where travel injections are required. You might also refuse blood tests even if you knew they were important for your health.
• Agoraphobia
  This is a much broader problem which can lead to people becoming too frightened to leave their home or living a restricted life. Agoraphobia is often described as a fear of open spaces, but it is actually more helpful to think of it as a fear of being in places from which it is difficult to escape. This can include crowds and public places such as shops, cinemas, and public transport. Not surprisingly, if you have severe agoraphobia you can find yourself leading a very restricted life, which is why it is important to get help as soon as possible. Another aspect of agoraphobia is the fear of ‘behaving badly' in public. For example people worry that because of their anxiety they might faint, panic, rush out or do something embarrassing. For this reason agoraphobia is sometimes described as ‘fear of fear'.
• Social phobia
  If you have social phobia this means that you are extremely anxious about what other people will think of you, or how you will be judged by other people. As a result you may have great difficulty in social situations, such as eating or drinking in the presence of other people. One form of social phobia is severe anxiety about speaking or performing in public. It is quite common to feel rather nervous in these situations, especially when they are unfamiliar, but people with social phobia will find these activities impossible because of the degree of anxiety they experience. At the heart of social phobia is a person's belief that other people will notice their anxiety and that this will make them look foolish or stupid.
• Obsessive-compulsive disorder (OCD)
  If you have obsessive thoughts this means that certain words or ideas keep coming into your mind automatically. This can make you feel very anxious, particularly if the thoughts are nasty, unpleasant or frightening. For example, some people have repeated thoughts about germs causing disease or death. In order to cope with the anxiety they start to do things over and over again to get rid of the thoughts, such as washing their hands every few minutes, or reciting numbers. This is known as compulsive behaviour. People with this type of anxiety also tend to make it worse by continually checking their own thoughts. There can sometimes be a physical reason for obsessive thoughts, such as an infection, so it may be worth speaking to your doctor about this.
• Panic attacks / panic disorder
  A panic attack is a very frightening experience because it seems to come ‘out of the blue'. Most people describe a sudden overwhelming sense of anxiety, fast breathing, a racing heart and a feeling that they are about to collapse or faint. If you experience repeated panic attacks in different situations this is known as a panic disorder. People who experience panic attacks tend to be unusually aware of changes in their bodies, and also tend to assume that these changes are dangerous when they may be quite harmless. For example, there are lots of reasons for increased heart rate (such as running upstairs or drinking too much coffee) but a person with panic disorder will usually choose the most frightening explanation (such as an imminent heart attack). People with a history of panic attacks also tend to worry about losing control of their bodies and their feelings.
• Post-Traumatic Stress Disorder (PTSD)
  Post-traumatic stress disorder is the name given to the after-effects of an unusually frightening or horrifying experience, for example seeing someone killed, surviving an accident, losing your home or family. If you have PTSD you will tend to re-live your traumatic experience, by dreaming about it, thinking about it, and becoming upset if you see similar events or scenes. You may find yourself avoiding places or activities which remind you of that experience, and you may also find it difficult to be positive and plan for the future. Obviously it is quite normal to feel upset immediately after a painful or distressing experience, so the term PTSD is only applicable if the feelings persist. It is also important not to confuse PTSD with grief following the death of a loved one.
• Generalised anxiety disorder
  Sometimes anxiety is experienced in a more general way. For example you may feel worried most of the time about things which might go wrong. You may feel tense or restless, or find that your heart is racing without knowing exactly what you are worried about.

What can be done about anxiety?

Helping yourself

There are a number of things that you can do yourself which may help to reduce your anxiety. This approach is known as ‘self-help', and is based on the idea that as you begin to understand your anxiety, you are able to develop more control over it, and are therefore more likely to be able to cope with it in the future.

For self-help to work, it is important that you have decided that you want to deal with your anxiety, and that you are committed to learning different ways of coping. By following self-help approaches you will be able to set your own achievable goals, following your own pace.

The following points are some practical suggestions for dealing with your anxiety. Each suggestion is intended to help you to manage your anxiety by learning from your own experiences. Confronting your fears can be extremely difficult and frightening, so it may help if you have some support from friends and family while doing this.

• Awareness / education: try to learn more about your anxiety. The more you are able to understand your anxiety, the less you will fear it. There are lots of books about anxiety that can help you to do this. You can find these in bookshops, or you could ask your local library to order them for you. Some examples of these are listed at the back of this leaflet. You can find them at your local library or bookshop. It might also help if you get your family and friends to read these books too. It may help them to understand what you are going through, and to support you in coping with your anxiety.
• Positive thinking: try to take a positive outlook on your anxiety, taking one day at a time. Don't be too hard on yourself. Learning to deal with your anxiety can be extremely difficult and may take some time. If possible, try not to avoid the things or situations that make you anxious, and feel confident about being able to cope with your anxiety, however unpleasant the feelings might be. It may be difficult at times, but try not to let worries dominate your day.
• Structuring the day: it is important to find ways of motivating yourself, such as setting small and achievable goals. This may involve writing lists of things that may help in situations where you are likely to become anxious. It is sometimes helpful to make a list of particular problems or difficult situations that you would like to overcome. You can break each problem down into tasks and rank them in order of importance. Then you can decide how and when to complete each task, and reward yourself when you achieve each goal. You can return to the list on a regular basis to reassess how things are going. Again, try to include family and friends in this.
• Relaxation: try to learn to relax by thinking about things that make you feel calm such as listening to music or reading. You could also use specific relaxation techniques such as meditation, or pre-recorded relaxation tapes. (Contact addresses are given at the bottom of this page). This may help you if you are having difficulty sleeping.
• Exercise: try to do some form of exercise on a regular basis. Physical exercise can trigger brain chemicals that will improve your mood. Being physically fit, or feeling better about your body can make you feel more positive about yourself. Also physical exercise can distract you from your worries.
• Diet: eating a low fat, high fibre diet, with lots of fresh vegetables and fruit will increase body energy. Also, try to avoid drinking too much tea and coffee as caffeine can increase anxiety levels.
• Talking to people: share and discuss your worries and the tasks you have set yourself with your friends and family.

Where to get further help

There are a number of places where you can go to get further help.

• General practitioners (GP): this is a good place to start. Your GP can help you to find the right type of help. This may include medication, or a referral to another agency for other forms of treatment such as ‘talking treatments'. Most GP surgeries will hold a range of leaflets and information giving details about local services. Also, some GPs now have counsellors or psychologists based in their practices who can offer help for a range of anxiety problems.
• Community mental health centres: you will probably require a referral from your GP in order to be eligible for treatment. Professionals such as psychologists and counsellors within these centres will be able to offer a range of treatments which will be discussed in the following section. Most mental health centres will carry out an initial assessment. This involves you and the worker identifying what your needs are, and exploring the possible ways of managing your anxiety. This will enable both of you to decide which service and type of help is most suitable.
• Social Services: your local office will be able to direct you to a range of services. Telephone numbers and addresses will be in your local telephone directory.
• Local mental health associations or voluntary organisations: some of these operate telephone helplines, others you may visit personally, usually without a formal referral. You can find out about these organisations from local directories of services, your local library, or telephone directory. Availability of these service varies across areas.
• Self-help groups: details of these groups can be found in telephone directories and from local advice and information centres. Some addresses are also given at the end of this booklet.
• Citizens' Advice Bureaux (CAB): details of your nearest CAB can be found in your local telephone directory. The CAB adviser will be able to tell you more about local services and how to access them. In some cases, they may be able to provide some basic information, or even make initial contacts with other agencies on your behalf.
• Community Health Councils (CHC): local CHCs will have keep information on local services. Their contact numbers will be in your local telephone directory.
• Friends and family: it is always worth asking other people if they can recommend services; this can relieve some of the worry about accessing services.

What can services offer in terms of treatment for anxiety?

Although self-help can be very useful, especially for mild anxiety, it may not be enough on its own. If your anxiety is severe you may need to seek professional help. Some of the treatments currently available for anxiety problems are described below.

Medical treatment - what drugs are prescribed for anxiety?

If your anxiety is severe your GP may prescribe some form of drug treatment. Drug treatments are used to provide short-term help, rather than as a cure for the underlying causes of anxiety. Drugs may be most useful when combined with other treatments or support. If your GP prescribes drug treatment for anxiety, make sure that you understand what you are taking and what to expect from the drugs, as sometimes they take some time to have an effect. Don't hesitate to ask your GP for more information if you don't take it all in at once. Drugs should only be prescribed for a few weeks and it is also important to tell your doctor immediately if you are experiencing any unpleasant or unusual side-effects.

The following types of drug may be prescribed for people experiencing severe anxiety:

• Benzodiazepines may provide short-term relief for severe anxiety problems but most GPs do not prescribe them for minor anxiety because they are addictive. They should only be taken for a short time, and they are not recommended for phobias or obsessive compulsive disorder. Side-effects may include restlessness, trembling, nausea, and depression. Some people feel more anxious and have side effects when benzodiazepine treatment stops.
• Beta blockers slow down the activity of the heart. They are prescribed to control fast or irregular heartbeat, and other bodily symptoms of anxiety. They may be useful in the short-term treatment of ‘stage fright', and the relief of panic symptoms although they do not help people to stop avoiding the things they fear. Beta blockers are not suitable for people with medical heart problems or asthma.

Drugs used to treat depression can be helpful for some forms of anxiety e.g. Post- Traumatic Stress Disorder. But medication tends to ‘block out' painful memories which may not be helpful in the long-term as you need to find a way of coping with distressing experiences. For both panic disorder and obsessive-compulsive disorder, combining antidepressant treatment with talking treatments has been found to be successful (see below). Paroxetine and, occasionally, Moclobemide (Manerix) may be used for social phobia.

Your prescription will usually give the brand name rather than the type of drug. Some of the common brand names are shown below.

Type of drug	Examples of some common brands
Benzodiazepines	diazepam (Valium)
	alprazolam (Xanax)
	oxazepam (Oxazepam
	lorazepam (Ativan)
	temazepam (Temazepam)
Beta blockers	propanolol (Inderal)
	atenolol (Tenormin)
	nadolol (Corgard)
Tricyclic Antidepressants	imipramine (Tofranil)
	Amitriptyline (Lentizol)
SSRI1 and SNRI2 Antidepressants	fluoxetine (Prozac)
	paroxetine (Seroxat)

Ask your GP if you are not clear about which type of drug you have been given, or why.

Cognitive-Behavioural Therapy (CBT)

CBT is a type of talking treatment. It is called ‘cognitive' (to do with thinking) because it emphasises the way our experience of anxiety is shaped by how we think about it. It is also called ‘behavioural because it stresses the importance of practising new behaviours, particularly facing up to whatever we fear and learning that we are able to cope.

CBT for phobias involves some specific techniques. You might be asked to draw up a list of the things or situations that make you anxious. You will probably be taught basic relaxation techniques. You may then be encouraged to imagine one of the items or situations on your list, starting with the least frightening, while remaining relaxed. For example, someone with a phobia for spiders might begin by looking at a picture of a spider and finish by touching a spider, practising relaxation throughout. This technique is generally very successful. However quicker results can often be obtained by teaching you some ways of coping and then putting you directly into the situation where you have to face up to your fear, with help and support from the therapist. This is known as exposure treatment. For example, if you are frightened of flying you can only cure the fear by actually getting on to an aeroplane.

CBT for panic disorder involves helping you to re-think the way you interpret changes in your body. For example you may need to recognise that a fast pulse could be due to running upstairs or drinking too much coffee, rather than interpreting symptoms in a ‘catastrophic' way (e.g. I'm going to die, or I'm going to faint). This kind of re-thinking is achieved through demonstrations by the therapist and through activities you carry out at home. You may also be taught how to deal with hyperventilation (dizziness caused by rapid breathing which reduces carbon dioxide levels in the blood) through a special breathing technique.

People with OCD tend to believe that if they have an unpleasant or embarrassing thought it will make them behave in an unacceptable way. The goal of treatment is therefore to demonstrate that thoughts are harmless in themselves, and it is not necessary to try and blot them out. For example, you may be encouraged to let the thoughts ‘happen' without trying to control them and without carrying out the compulsive acts.

With PTSD, it is important to face up to the painful images and memories and learn new ways of thinking about them. A new method of treatment which is currently being evaluated is EMDR (Eye movement desensitisation and reprocessing). This is a technique for helping people come up with new images and thoughts about the incident, to reduce their distress.

In some instances you may be able to follow a cognitive treatment programme at home, by using a specially designed manual or computer package. Some of these are detailed at the end of the leaflet.

Other ‘talking' therapies

• Psychotherapy: this word is sometimes used to refer to all the ‘talking treatments'. But it can also be used to refer to treatments which focus on understanding the underlying emotional causes of psychological problems, including events from childhood, unresolved problems, and family relationships. It is unlikely that you would be offered psychotherapy as a first choice of treatment for anxiety, since it is more expensive and takes longer than cognitive treatments, which may also be more effective. However psychotherapy has been found to be useful in PTSD. For example, group therapy may be helpful for people who have gone through a traumatic experience together. Research suggests that both individual and group psychotherapy can help children with anxieties related to experiencing sexual abuse.
• Counselling: many people say that when they are anxious or under stress they would like someone to talk to, particularly if their anxiety is triggered by practical problems in their lives. Sometimes a friend, family member, or religious / community leader can provide a listening ear. In other circumstances a trained counsellor can be helpful. Counselling is not the same as therapy, and counsellors do not usually give direct advice. Their aim is to help people make positive choices abut their lives.

Complementary therapies

You can learn a lot about managing anxiety from asking other people who have experienced anxiety disorders about what has helped them to cope. People have reported benefits from a range of alternative or complementary therapies, including herbal remedies (e.g. Valerian), homeopathy, and acupuncture. Some studies have also suggested benefits from massage and from aromatherapy; for example lavender oil can help if you have problems sleeping.

It is possible that aromatherapy and herbal remedies may affect mood by altering the brain chemistry in a similar way to prescribed drugs. They tend to have few side-effects and can usually be obtained from your local pharmacy. Transcendental meditation has also been found to be helpful by people experiencing general anxiety or PTSD.

It is important to note that although some complementary therapies have been used successfully for many years, others are not yet ‘tried and tested'. Therefore , as with medical prescriptions, it is important that any new or unusual therapy is delivered by a qualified practitioner. If you are trying a complementary therapy as well as receiving medical treatment you should inform your doctor so that the effects can be monitored.

Conclusion

Severe anxiety can be a very distressing experience but there are lots of different types of help available. After reading this leaflet you may want to discuss it with your GP and talk it through with your family or friends. It may take some time to resolve your problems, but anxiety doesn't have to rule your life.

Useful addresses

For anxiety and panic attacks:

• Relaxation for Living Institute - Promotes the teaching of relaxation techniques to combat stress, strain, anxiety and tension.
  1 Great Chapel Street,
  London
  W1F 8FA
  
  Telephone: (+44) 20 7439 4277 Email: andrew@rfli.co.uk Website: www.rfli.co.uk
• No Panic, 93 Brands Farm Way, Telford, Shropshire TF3 2JQ, UK. Helpline (freephone): 0808 808 0545. Tel: +44 (0)1952 590005 (Office). Email: ceo@nopanic.org.uk Website: www.nopanic.org.uk Help for people with panic attacks, phobias and obsessive compulsive disorders, general anxiety disorder and tranquilliser withdrawal. Local groups and one to one telephone counselling available. Range of leaflets, video and audio-tapes also available.
• Pax, 4 Manorbrook, Blackheath, London SE3 9AW, UK. Tel: +44 (0)20 8318 5026 (Helpline for members only). Information and advisory service for people who experience panic attacks, agoraphobia, social phobia and other related phobias and anxiety problems. Books, cassettes and bi-monthly newsletter available. Send SAE for free information pack.
• Triumph Over Phobia (TOP UK), PO Box 1831, Bath BA2 4YW, UK. Tel: +44 (0)1225 330353 (admin line, Mon-Fri 9.30am-5pm). Email: triumphoverphobia@compuserve.com Website: www.triumphoverphobia.com Network of structured self-help groups run by trained, lay volunteers teaching sufferers from phobia and OCD how to overcome their problem. Leaflets available - please send SAE.
• National Phobics Society, Zion Community Resource Centre, 339 Stretford Road, Hulme, Manchester M15 4ZY, UK. Tel: 0870 7700 456. Fax: +44 (0)161 227 9862 Email: nationalphobic@btconnect.com Website: www.phobics-society.org.uk A user-led organisation, run by sufferers and ex-sufferers of anxiety disorders supported by a high-profile medical advisory panel. Groups throughout the country for people experiencing anxiety.

For agoraphobia:

• Pax, 4 Manorbrook, Blackheath, London SE3 9AW, UK. Tel: +44 (0)20 8318 5026 (Helpline for members only). Information and advisory service for people who experience panic attacks, agoraphobia, social phobia and other related phobias and anxiety problems. Books, cassettes and bi-monthly newsletter available. Send SAE for free information pack.

For OCD:

• OCD Action, Aberdeen Centre, 22-24 Highbury Grove, London N5 2EA, UK. Tel: +44 (0)20 7226 4000. Fax: +44 (0)20 7288 0828. Email: info@ocdaction.org.uk Website: www.ocdaction.org.uk Charity providing information, advice and support for people experiencing Obsessive Compulsive Disorder (OCD) and related disorders such as Body Dysmorphic Disorder (BDD), Compulsive Skin Picking (CSP) and Trichotillomania.

For general mental health issues:

• Mind, Granta House, 15-19 Broadway, London E15 4BQ, UK. Tel: +44 (0)20 8519 2122. MindinfoLine: 0845 766 0163 (Mon-Fri, 9:15am-5:15pm). Email: info@mind.org.uk Website: www.mind.org.uk Mind works for everyone in emotional distress, campaigning for rights and developing locally based services. Mind's national Info Line covers all aspects of mental health including advocacy, treatments and therapies.
• The Samaritans, The Upper Mill, Kingston Road, Ewell, Surrey KT17 2AF, UK. National helpline: 08457 909090 Website: www.samaritans.org.uk UK Helpline for anyone experiencing emotional distress. Someone to talk to in confidence 24 hours a day. Details of local branches can be found in a local telephone directory.
• SANE is a national mental health charity which aims to raise awareness of mental illness and campaign to improve services and initiate and fund research into the causes of serious mental illness through its research centre. Information and emotional support is also provided to anyone affected by mental illness via the helpline, SANEline and by email, via SANEmail.
  1st Floor Cityside House,
  40 Adler Street,
  London,
  E1 1EE
  
  SANEline: 0845 767 8000 (open 6pm – 11pm everyday) Email: sanemail@sane.org.uk Website: www.sane.org.uk
• Scottish Association for Mental Health, Cumbrae House, 15 Carlton Court, Glasgow G5 9JP. Tel: +44 (0)141 568 7000. Email: enquire@samh.org.uk Website: www.samh.org.uk Provides an information service and leaflets on general mental health issues.
• Stress Watch Scotland, The Barn, 42 Barnwell Road, Kilmarnock KA1 4JF. Helpline: +44 (0)1563 574 144. Tel: +44 (0)1563 570 886 (Office). Email: info@stresswatchscotland.org Website: www.stresswatchscotland.org An organisation helping people with stress-related disorders including panic attacks, phobias and anxiety.

Published by The Mental Health Foundation and reproduced here with their permission
Copyright © 2000

¹Selective Serotonin Re-uptake inhibitors

²Selective Noradrenaline Re-uptake Inhibitors

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