Anxiety Disorders 

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Anxiety is a normal human emotion developed as a means of protection from danger and threat. When we sense we are in danger our body undergoes a number of automatic physiological changes so that we can respond to the threat. These changes include: the release of large amounts of the hormone adrenaline to increase alertness; an increased heart rate to move blood to the large muscles of the body; and an increased breathing rate to take in more oxygen. The purpose of these changes is to prepare us to fight or to take flight from the threat, and hence is known as the “fight or flight” response. A number of symptoms occur as a result, including sweating, trembling or shaking, nausea, racing heart, cold hands and feet, dizziness, and pins and needles (1).
While anxiety plays a role While anxiety plays a vital role in dangerous situations, some people experience anxiety when there is no real threat or, alternatively, the anxiety they experience is out of proportion to the threat present. For these people, anxiety is an extremely debilitating and disruptive factor in their lives.

It is estimated that about 25% of the population will experience an anxiety disorder at some time in their lives (2). Women are twice as likely as men to suffer from an anxiety disorder. Unfortunately, only 50% of people receive treatment for their disorder (3).

People often have multiple anxiety disorders and also commonly suffer from other mental health problems, like depression. People with anxiety disorders are more likely to be substance abusers as they frequently turn to alcohol and drugs (both legal and illicit) to help them cope with situations that make them anxious.

Risk Factors

It appears that many factors can contribute to the development of anxiety disorders including familial, environmental, personality and biological factors.

Familial – People with a family history of an anxiety or mood disorder are more likely to have an anxiety disorder. They may be genetically susceptible to developing an anxiety disorder, or they may ‘learn’ to respond in this way from family members.

Environmental – People who have experienced major life stresses such as the death of a family member, break down of a marriage/relationship, major financial difficulties or long term exposure to abuse/violence are more at risk of developing an anxiety disorder. Uncertainties, and especially the threat of loss (such as the possible loss of a job, or a health scare) can also cause anxiety. Substance abuse has also been linked to the development of anxiety disorders in certain people.

Personality – Some personality types appear to be more prone to developing an anxiety disorder. People who are nervous, emotional, overly sensitive, worry a lot or have poor coping skills are more at risk.

Biological – There is some evidence that people with anxiety disorders have abnormal levels of certain brain chemicals (4). The effectiveness of medications which work by altering brain chemistry in the treatment of anxiety disorders has led to such theories.

Types of Anxiety Disorders

Generalized anxiety disorder (GAD)
GAD is the most common anxiety disorder. It is characterised by excessive anxiety and worry about events or activities. People with GAD may constantly worry about work, finances or health of family members. Their anxiety and worry is out of proportion to the actual risk of something going wrong.

Other symptoms include restlessness or feeling ‘keyed up’ or on edge, getting easily fatigued, difficulty concentrating or mind going ‘blank’, irritability, muscle tension, sleep disturbances (difficulty falling or staying asleep, or restless unsatisfying sleep) (5). The symptoms cause significant distress and/or impair the person’s day to day functioning.

Panic disorder
People with panic disorder have recurrent and unexpected panic attacks (see below) and persistently worry about when and where the next panic attack will occur (6). Approximately, three quarters of panic disorder sufferers are women (7).

A panic attack occurs when a person experiences intense fear associated with strong physical symptoms of anxiety when there is no real danger. The attacks are characterised by both physical and psychological symptoms, including:

• Heart palpitations
  
• Sweating
  
• Hot flushes or chills
  
• Trembling or shaking
  
• Sensations of shortness of breath or smothering
  
• Choking sensation
  
• Chest pain or discomfort
  
• Nausea or gastrointestinal upset
  
• Dizziness or light-headedness
  
• Tingling or numbness
  
• Feelings of unreality or of being detached from yourself
  
• Fear of losing control or going crazy
  
• Fear of dying (8).
  

The physical symptoms associated with a panic attack can cause a person to think they have a medical condition, like a heart problem. In fact, many people call an ambulance, visit an emergency department and/or undergo extensive tests for other conditions, before an anxiety disorder is diagnosed.

People with panic disorder often come to associate particular activities or locations with having a panic attack and, therefore, start to avoid these situations. Common avoidances are travelling in aeroplanes, public transport or other people’s cars, crowded locations and elevators. Over time, the number of situations a person feels they must avoid increases, placing significant restrictions on their everyday activities. Agoraphobia is the term given to describe the avoidance of situations or activities for fear of having a panic attack (9).

Social anxiety disorder
People with social anxiety disorder, also referred to as social phobia, experience an excessive, persistent fear of being embarrassed, judged or evaluated in public. The disorder commonly develops in the mid-teenage years. Symptoms are those associated with anxiety such as heart palpitations, tremors, sweating, gastrointestinal upset, muscle tension, blushing and confusion.
Some of the situations that people with social anxiety disorder fear include public speaking, initiating conversations and eating or writing in public. Consequently, sufferers avoid situations they fear which impacts on their day to day functioning. Maintaining employment and/or relationships can be difficult for people with social anxiety disorder.

Obsessive-compulsive disorder (OCD)
Obsessive-compulsive disorder is characterised by both obsessions (recurrent, persistent thoughts, impulses or images) and compulsions (urge to perform certain mental or physical behaviours). People with OCD perform certain behaviours, or rituals in order to reduce or remove the likelihood of the feared consequence. For example, a fear of catching a disease after touching something that might be contaminated may lead to a compulsion to wash the hands repeatedly. The individual recognises that the fears are greatly exaggerated or unreasonable, but cannot seem to let go of them.

Common obsessions are concerned with contamination, the need for symmetry, pathological doubt and fear of developing a life-threatening illness (10). Compulsions may involve actions like cleaning, checking, repeating, ordering and hoarding or the mental repetition of words, numbers, images or thoughts (11).

Post-traumatic stress disorder (PTSD)
PTSD is an anxiety disorder that develops following exposure to a traumatic event. Traumatic events can include anything from a natural disaster to a violent crime or car accident. Women can often experience PTSD following a physical or sexual assault (12). Symptoms of PTSD include: repetitive, intrusive thoughts about the event; flashbacks and nightmares; insomnia; avoidance of situations associated with the traumatic event; feeling emotionally numb; and social withdrawal.

Diagnosis

People experiencing symptoms of an anxiety disorder should initially visit their general practitioner. They will firstly establish that there is no underlying physical cause. Other conditions that may present similar symptoms to an anxiety disorder are hyperthyroidism, hypoglycaemia (low blood sugar), substance abuse, substance withdrawal, psychosis and some heart conditions. This step is important as, if no physical cause is revealed, it provides the person with evidence and reassurance they are not physically unwell and allows them to consider an anxiety disorder being the cause. A general practitioner may provide a referral to a psychologist, counsellor or psychiatrist.

Treatment

Education and information about anxiety disorders are very important first steps in the treatment process. If people understand anxiety is an exaggeration of a normal response as well as why they experience particular symptoms (ie. tingling fingers occur because the body has moved blood to major muscle groups) this assists in breaking down some of the fear associated with having an anxiety disorder. There are a number of treatment options available for anxiety disorders.

Cognitive behaviour therapy (CBT)
CBT is based on the notion that people develop negative, self-defeating patterns of thought and that these thought patterns can be unlearned. CBT is conducted by a therapist (counsellor, psychologist, psychiatrist) and usually consists of a series of sessions taking place over a number of weeks. Studies have found that CBT is at least as effective as medication in treating anxiety disorders and has the advantage of costing less over time and producing longer lasting benefits. A disadvantage of CBT is that it requires a certain level of commitment, in both time and energy/motivation from a person. Also, it is not available in all areas of Australia and can be expensive.

CBT for anxiety disorders involves teaching people to examine the thought patterns that produce their anxiety (13). Underlying most types of anxiety is the tendency to overestimate both the likelihood of a feared consequence and how bad it would really be if the feared consequence actually eventuated. People are encouraged to practice realistic thinking in order to evaluate the real level of threat or risk which is anxiety-causing. They learn to use evidence to challenge unhelpful or unrealistic thoughts and fears.

Other techniques used in CBT include controlled breathing exercises and graded exposure. Graded exposure involves getting people to gradually confront situations which produce anxiety symptoms. For it to be successful, people have to remain in the situation until their anxiety has subsided and they must confront the feared situation repeatedly and frequently. People with OCD are provided with techniques to help them resist performing compulsive behaviours.

Breathing control techniques
Many people hyperventilate when anxious, and this can add to feelings of anxiety and symptoms of dizziness and tingling. A controlled rate of breathing (8-12 breaths per minute breathing in a smooth, light way) is very effective at reducing symptoms of panic and anxiety. Smooth, light breathing is preferred to deep breathing which can accentuate feelings of anxiety and light-headedness. Breathing control techniques should be practiced several times a day when not particularly anxious in order to make it habitual. This makes it more likely that an individual will be able to implement the technique even when highly anxious and perhaps not thinking clearly.

Relaxation therapy
Relaxation therapy involves several techniques designed to help people achieve a relaxed state. It includes breathing techniques, progressive muscle relaxation and meditation. Progressive muscle relaxation involves tensing and then relaxing the muscles in the body, one major muscle group at a time (14). Over time, relaxation therapy can result in a measurable reduction in the basic level of anxiety or tension which an individual experiences.

Exercise
Exercise is an important part of a treatment program for anxiety disorders. When we exercise our body releases endorphins, chemicals that make us feel happier and calmer, resulting in a general sense of well being. For people who are limiting their activities due to an anxiety disorder, exercise can provide an opportunity to get out and confront their fears.

Caffeine reduction
People with anxiety disorders will benefit from cutting down their intake of caffeine. Caffeine is a stimulant and increases the amount of the hormone adrenaline in the body. Too much caffeine, therefore, can cause symptoms associated with anxiety. Caffeine is found in coffee, tea, chocolate and some soft drinks (especially the so-called ‘energy’ drinks).

Complementary therapies
A number of complementary therapies are used in the treatment of anxiety disorders including massage therapy, acupuncture, aromatherapy, yoga, meditation and herbal treatments (passionflower, valerian, kava, St. John’s wort). There is, however, a lack of research supporting the effectiveness and safety of some of these therapies in treating anxiety disorders (15).

It is important that people using complementary therapies inform their doctor about the type of therapy they are receiving. This is particularly important when taking a herbal remedy as they can have their own side effects (eg. St. John’s wort causes photosensitivity) or interact with conventional treatments such as antidepressants. Complementary therapies do not treat the underlying cause of the anxiety.

Medication
Prescription medications only relieve symptoms associated with an anxiety disorder and, like complementary therapies, do not address the underlying cause of the anxiety. Therefore, medication does not provide a long term solution to anxiety disorders. The medications most commonly prescribed for anxiety disorders are selective serotonin re-uptake inhibitors (SSRIs), a form of antidepressant. These medications typically take several weeks to start working. It is common for the medications to cause some degree of nausea, headache and even a slight increase in symptoms of nervousness initially. These symptoms usually subside after a week or so. Other side effects include insomnia, dry mouth and, less commonly, drowsiness. People sometimes have to try several SSRIs before they find one that is suitable for them. These medications should never be discontinued abruptly. If SSRIs do not prove effective other types of antidepressants (eg. tricyclic antidepressants, monoamine oxidase inhibitors) may be of benefit.
Benzodiazepines (tranquilisers) were previously used to treat anxiety disorders but antidepressants are now the preferred option as benzodiazepines produce a sedative effect and can result in dependence or tolerance. However, benzodiazepines may be suitable for some people with severe symptoms, for short periods.

Beta-blockers can be used to treat the physical symptoms of anxiety (eg. heart palpitations and trembling). They can be helpful in controlling anxiety in public situations. Side effects can include tiredness, low blood pressure, cold hands and feet, dizziness and sleep disturbances.

References

1. 1 Anxiety Network of Australia. Anxiety Education http://www.anxietynetwork.com.au [website] date accessed: 3 September 2002
   
2. The Female Patient. What you should know about anxiety: Patient handout The Female Patient 2000 Vol 25 No 11 p55-56
   
3. Mendlowicz, MV & Stein, MB. Quality of life in individuals with anxiety disorders American Journal of Psychiatry 2000 Vol 157 p669-682
   
4. The Female Patient. Ibid
   
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th edition) Washington: American Psychiatric Association 2000
   
6. Hansen, S. Managing anxiety disorders in women The Female Patient 2002 Vol 27 No 1 p25-31
   
7. Ringel, M. Anxiety disorders: When worry becomes toxic The Female Patient S19 2000 p11-14
   
8. American Psychiatric Association. Ibid
   
9. Andrews, G. Anxiety disorders: Recognition and management Australian Family Physician 2000 Vol 29 No 4 p337-341
   
10. Jefferys, D & Burrows, G. Obsessive compulsive disorders MediMedia 1996-2002
    
11. Jefferys, D & Burrows, G. Ibid
    
12. Hansen, S. Ibid
    
13. Westra, HA & Stewart, SH. Cognitive behavioural therapy and pharmacotherapy: Complementary or contradictory approaches to the treatment of anxiety? Clin Psychol Rev 1998 Vol 18 No 3 p307-40
    
14. Evans, L. The management of generalised anxiety disorder Current Therapeutics 2001 Vol 42 No 8 p15-23
    
15. Anxiety Network of Australia. Relaxation Therapy http://www.anxietynetwork.com.au [website] date accessed: 3 September 2002
    
16. Therapeutic Goods Administration. Consumer Advice on Kava Therapeutic Goods Administration http://www.health.gov.au/tga [website] date accessed: 26 September 2002

Further help and information from Women's Health Queensland Wide

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Further reading

See our

• Depression factsheet
• Anxiety and stress library booklist

Other useful contacts

Anxiety Network Australia
www.anxietynetwork.com.au

Mental Health Association Qld
(07) 3271 5544

This factsheet was originally published by Women's Health Queensland Wide (Women's Health) in December 2002. It was revised by Kirsten Braun and the Editorial Committee in September 2006.

Last Modified: September 21, 2006