Anxiety disorders

Written by Dr Hamish McAllister-Williams, MRC clinical scientist, senior lecturer and honorary consultant psychiatrist
Anxiety is a normal response to stress, but it can be debilitating


Anxiety is a normal response to stress or danger. At times it is helpful because it can help prepare the body for action, and it can improve performance in a range of situations. Anxiety becomes a problem when it is experienced intensely and it persistently interferes with a person's daily life.


Depression and anxiety commonly occur together. Not everybody who is anxious is depressed, but most depressed patients have some symptoms of anxiety.
Aren't some people just anxious all of the time?

People have different degrees of background, or 'trait', anxiety. High trait anxiety may stem from inherited behaviour or early relationships in childhood. It is also related to personality.

In addition to this inherent background anxiety, people react differently to everyday situations. Some people become anxious very easily, others never seem to get anxious. The anxiety that people get because of specific experiences is called 'state' anxiety.

An individual with high trait anxiety is particularly vulnerable to experiencing high state anxiety in stressful situations.
How common are symptoms of anxiety?

Anxiety symptoms are extremely common - everybody experiences them from time to time. Specific anxiety disorders or illnesses are also not as rare as you might think, being present in around 5 per cent of the population at any time.
What are symptoms of anxiety?

Anxiety can be experienced in a number of different ways.
Psychological symptoms
Inner tension.
Agitation.
Fear of losing control.
Dread that something catastrophic is going to happen, such as a blackout, seizure, heart attack or death.
Irritability.
Feelings of detachment, as if being trapped in a bubble separate from the world.
Physical symptoms
Racing heart beat (palpitations).
Breathing fast, feeling short of breath or finding it hard to 'get breath'.
Chest tightness.
Dry mouth, butterflies in the stomach, feeling sick.
An urge to pass urine.
Tremor.
Sweating.
Hyperventilation (overbreathing) syndrome

This is a particular combination of symptoms that affects some people. Both patients and doctors can often mistake it for serious medical illnesses, including epilepsy and heart attacks.

An episode of hyperventilation starts when a person begins to breathe rapidly and shallowly. This may be triggered by something obvious that leads to anxiety, but often there is no obvious cause for the change in breathing.

Breathing rapidly and shallowly causes changes to the chemistry of the body, which in turn lead to physical symptoms such as tingling in the fingers and around the mouth (paraesthesia), and light-headedness (and ultimately fainting). This pattern of breathing - without fully breathing out - leads to a feeling of chest tightness.

These symptoms are not medically dangerous, but they tend to be frightening, and this in turn causes an increase in anxiety and the development of a vicious circle.

Hyperventilation can be simply treated by breathing in and out of a paper (not polythene) bag for a short time, which reverses the chemical changes caused by overbreathing. However, in the longer term it is best dealt with by treating the underlying cause of the anxiety and learning how to relax.
What types of anxiety disorders are there?

There are a number of 'types' of anxiety disorders. They tend to overlap considerably and it is not uncommon for people to have features of several of the disorders.
Generalised anxiety disorder

Generalised anxiety disorder (GAD) is characterised by anxiety symptoms that are present for much of the time and not restricted to specific situations.

Generalised anxiety often accompanies phobias and is extremely common in people who are depressed. It can also be caused by physical illness, such as an overactive thyroid gland, or result from the emotional response to a serious illness such as a heart attack.

Some 15 per cent of people with GAD have a brother, sister or parent with a similar problem. This may reflect an inherited tendency to the disorder or the effects of the family environment. Two thirds of sufferers are women.
Panic disorder

In panic disorder, repeated panic attacks occur unpredictably and often without obvious causes. The attacks consist of severe anxiety with physical and psychological symptoms.

Physical symptoms can include any of the general symptoms of anxiety described above and often the hyperventilation syndrome.

Psychological symptoms typically include dread (particularly of extreme events such as dying), having a seizure, losing control or 'going mad'.

To the sufferer, the attacks feel as if they are going on for a long time, but actually they tend to last only a few minutes, and at their longest they last around an hour. Panic disorder is common in depression, GAD or agoraphobia.
Phobic disorders

A phobia is a fear that is out of proportion to the situation that causes it and cannot be explained away. The person typically avoids the feared situation, since this helps to reduce the anxiety.

Some phobias represent heightened normal anxiety towards situations that people are evolutionarily 'prepared' to fear, eg snakes, heights and sharp objects.

In other instances, a phobia may arise by a non-threatening situation being associated with a traumatic experience. Having a car crash in Spain may lead to a phobia of Spain itself, holidays, driving or flying.

Phobias typically occur in specific situations, eg a fear of dentists. People experience 'anticipatory anxiety' when thinking of the situation and so attempt to avoid it. They are common in the general population, but are only severe enough to prove disabling in 2 per cent of people.

Simple phobias are phobias that are specific to objects or situations. Specific phobias include:
animal phobias (eg dogs, snakes, spiders): the start of these phobias is often in childhood, usually before the age of seven years.
blood and injury phobias: the fear of blood tests or the sight of blood that results in fainting.
vertigo: a fear of heights.
agoraphobia: an intense fear of leaving the home, being in crowded spaces, travelling on public transport and being in any place that is difficult to leave. Around 75 per cent of sufferers are women, and it occurs in just under 1 per cent of people. Agoraphobia may follow a life event and be associated with a fear of 'what if it comes back while I am away from home'. It commonly occurs with panic attacks. The person may have a panic attack when outside the home and this reinforces the belief that it is safer to stay inside. Agoraphobia is often associated with depression.
social phobia: a fear of social interaction with others, talking to people, eating, drinking and speaking in public. In contrast to agoraphobia, men and women are affected equally. Many people have a mixture of both agoraphobia and social phobia. Social phobia is also a common symptom of depression.
Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a relatively rare disorder. While many people (14 per cent of the general population) have minor obsessional symptoms, OCD itself occurs in less than 1 in 1000 people (0.1 per cent). Men and women are equally affected. It frequently comes on in adolescence, but often people do not go to their GP for help for many years.

An increase in obsessional symptoms can occur in depression, though full-blown OCD is still rare. The symptoms are a little different to other anxiety disorders and include:
obsessional thoughts that come repeatedly into the person's mind, despite him or her trying to stop them. They are unpleasant and often abhorrent. The thoughts are clearly recognised by the person as being their own. Trying to stop the thoughts causes other anxiety symptoms.
obsessional thoughts may include a fear of dirt or germs, doubting that something important has been done (such as locking the door, turning the lights off) or unpleasant and graphic images in the mind of harming others or themselves. People who are suffering from OCD tend not to carry out any of the unpleasant thoughts they are having, though they usually fear they will.
compulsive acts (obsessional acts) are repetitive actions based on the obsessional thoughts. A person with obsessional thoughts about dirt may spend long periods cleaning the house and washing their hands. These actions are not pleasurable, but they help to reduce the anxiety associated with the obsessional thoughts.
the compulsive actions often have a 'magical quality', eg a person must check the door is locked exactly seven times, no more or less. If they are unsure how many times they have checked, they may start all over again. In severe cases, sufferers may spend many hours of the day undertaking these acts so that they have no time for anything else.

Evidence from brain scan studies shows altered brain function in people with OCD - some parts of the brain are underactive, others overactive. Inherited factors can play a role in the development of the disorder, but otherwise we have few ideas about what are the biological or psychological causes of OCD.
Stress-related disorders

There are a number of psychological consequences to major stressful events and these often include symptoms of anxiety. There are three types of reactions:
acute stress reaction starts within minutes (if not immediately) of the stressful event. It also tends to resolve rapidly, once the person is able to get out of the stressful situation. Symptoms are mixed, with the person first appearing dazed and disorientated. In addition, other symptoms of anxiety, anger and withdrawal can occur.
adjustment reaction starts within one month of the stressful event, and symptoms tend to resolve within six months. They may include depression, anxiety, irritability and a feeling of being unable to cope. Grief for the loss of a loved one can be seen as a combination of an acute stress reaction in the early stages, followed by an adjustment reaction.
post-traumatic stress disorder (PTSD) tends to come on weeks, or even months, after a stressful event that was of an exceptionally threatening or catastrophic nature, which would cause distress in almost anyone. It can persist for years. Symptoms include flashbacks (vivid memories of the event), nightmares, avoiding anything associated with the stressful event and being on edge. In addition, sufferers often experience generalised anxiety, panic disorder, depression, guilt (of surviving) and blunting of their emotions.
How are anxiety disorders treated?

Treatments include psychological and drug treatments, and depend to a certain extent on the type of symptoms or disorder the person is suffering from.

A person's full range of symptoms needs to be understood; this enables any underlying disorder that causes the anxiety symptoms to be treated. For example, if the anxiety symptoms are secondary to a depressive illness, the focus of the treatment will be on the depressive illness.
Psychological treatments
Psychological treatments are often tried first. They may include learning about the symptoms and realising that though they are frightening, they are not medically dangerous. Relaxation techniques can also be helpful.
Some disorders may be helped by more specific treatments. People with OCD can be taught 'thought stopping' techniques to prevent obsessional thoughts. Phobias can be treated by a number of techniques including 'graded exposure'. This involves taking small, but increasing, steps to challenge the fear. A person suffering from agoraphobia may start off standing at their open front door, progress to walking to the end of the street, and gradually build up to going to a busy shopping centre.
Medicines
There are a number of drugs available that are specifically anti-anxiety treatments. These include diazepam and lorazepam. These medicines are effective in quickly relieving the symptoms of anxiety. However, the body rapidly becomes used to these drugs and they can be addictive. As a result, they are good for short-term help (two to three weeks), but should not generally be used for longer periods.
Other medicines can help some of the physical symptoms of anxiety, for example propranolol (eg Inderal LA) can slow a fast heart beat and reduce tremor. If these physical symptoms are helping to maintain the anxiety, then medicines can be helpful, but they do not directly treat the anxiety.
Antidepressants are the medicines of choice for treating anxiety disorders. This is fortunate given that many people with depression have anxiety symptoms and many people with anxiety have depression. It means that it is not that important to decide whether a person is suffering from anxiety, depression or both when making a choice of medication.
Some antidepressants are better than others for certain types of anxiety. Selective serotonin reputake inhibitors (SSRIs) such as Prozac (fluoxetine), Seroxat (paroxetine), Lustral (sertraline) and Cipramil (citalopram) appear to be better than other antidepressants for panic disorder and OCD, so they are often chosen for depressed patients who also have these symptoms. A newer antidepressant called Cipralex (escitalopram) is also proving to be beneficial in many patients with anxiety and panic disorders. Other antidepressants such as Gamanil (lofepramine) and Edronax (reboxetine) may be helpful for social phobias, especially with depression - though this is not fully proven.
What should I do if I think I have an anxiety disorder?
Firstly, anxiety symptoms are common and they do not necessarily mean you have an anxiety disorder.
Many of the symptoms of anxiety are extremely frightening. Just realising that they are not medically serious can help greatly.
If you still have concerns, seek help from your GP who can confirm that the symptoms are part of an anxiety disorder (or other mental health problem) rather than a physical illness. This may be straightforward, or it may require physical illnesses to be ruled out by means of various tests.
Above all, everybody needs to be able to relax. This is not always easy, and often people need to be taught how to relax. There are several self-help books that describe relaxation techniques, and audiotapes can be helpful. You will need to work hard at learning these skills, but they will be of benefit for the rest of your life.
Self-help books
Bourne EJ. The anxiety and phobia workbook. New Harbinger Publications Inc; 2000.
Handley and Neff. Anxiety and panic attacks: their cause and cure. Fawcett Books; 1987.
Davis, McKay and Eshelman. The relaxation and stress reduction workbook. New Harbinger Publications Inc; 2000.
Craze R. Teach yourself relaxation. Teach yourself books; 1998