Anxiety is common and usually normal – all of us have experienced the sensation at some point in our lives. It is usually precipitated by the situations we find ourselves in, situations that possess an element of fear for us – exam time, interviews, public speaking and so on. In such situations, the anxiety response is normal and can work in our favour. The heightened awareness and rush of adrenaline can improve our performance. Of course, if the degree of anxiety is excessive, the effect can be the opposite, and our performance suffers.
The point at which anxiety stops being an appropriate response and becomes a hindrance to us can be considered the point at which it becomes a problem, a condition. This inappropriateness is the fundamental aspect of anxiety when viewed as a psychological condition. Typically the anxiety response will be prolonged (i.e. not restricted to the precipitating situation) or severe (i.e. excessive anxiety given the situation) or a combination of both. Clearly, these judgements are arbitrary – one person’s excessive anxiety may be considered by another as appropriate or normal. This is a situation in which “the customer is always right” – if an individual feels their anxiety is excessive or prolonged, then that is, in fact, the case. Anxiety becomes a problem when it adversely affects the individual to the point that they recognise it as such.
The common symptoms of anxiety are well known to all of us. They can be divided into two categories – the psychological response (mediated by the brains neurotransmitters) and the physical response (mediated by the hormone adrenaline in the bloodstream).
Psychological features of anxiety response:
- Heightened response to stimuli (“jumpiness”)
- Racing thoughts
- Excessive worry or “tension”
- Fear of losing control/dying/going mad (in severe cases)
- Physical features of the anxiety response:
- Palpitations (the sensation of the heart beating excessively or irregularly)
- Shortness of breath
- Faintness/dizziness
- Shakiness/tremulousness
- Sweating
- Urge to urinate/defecate
- Numbness of fingers (in severe cases)
- Vomiting (in severe cases)
Many of us have experienced these features at various times in our lives. It is a matter of personal judgement if one feels they are excessive or prolonged. Some people will expect to feel breathless and nauseous prior to speaking publicly – others will find this intolerable. Some people may expect to be anxious for several weeks before an exam or interview – others will see this as a problem. Psychiatrists will diagnose anxiety as a mental condition if the individual’s symptoms cause them significant distress.
The anxiety response in humans is akin to the “flight or fight” response in animals. It is a survival mechanism precipitated by perceived threat – a surge of adrenaline is released into the blood by the adrenal cortex (just above the kidneys), which then acts on the body to provide the ability to fight or flee the threat (i.e. the heart pumps faster, breathing is increased). The mental correlate is a “speeding up” of thoughts (to allow quick decision making) and an increased sensitivity to the environment (to allow accurate and fast assessment of the situation). It is a very useful response – in animals.
Modern human beings (in the industrialised societies at least) no longer face the sort of threat that the flight or fight response is designed to meet. We aren’t likely to be eaten by predators or attacked by other humans. Our threats today are usually less life threatening – but they are still important to us. And an inappropriate anxiety response can hinder our ability to cope.
The treatment of anxiety can be divided into two categories – drug treatments and talking treatments (or therapies). The choice of treatment offered by the GP will depend on the nature and severity of the condition, on the availability of treatments and (hopefully) on the wishes of the patient.
The drug treatment of anxiety symptoms can be very effective – it can also be very unhelpful and lead to other problems. The drug treatment of anxiety is at it’s best in those cases where the anxiety is limited to a discrete time or situation. Examples might include a trip to the dentist or a plane journey for a nervous flyer. Drugs are commonly used to reduce anxiety prior to operations (the “pre-med”). The drugs used in these situations are usually tranquillizers such as the Benzodiazepines (e.g. temazepam, lorazepam, diazepam). They are effective and act quickly. Unfortunately they are both sedative (therefore best not used before a speech or interview!) and highly addictive if taken regularly for more than a few weeks, the body becomes used to them and they no longer work unless the dose is constantly increased. Furthermore, if one tries to come off them after this period, one is likely to experience withdrawal symptoms – a return of the anxiety symptoms (but worse than before) or even convulsions. Once habituated to sedatives it is a long hard road to come off them. But this is not an issue with limited, short-term use.
Another drug that is frequently used to treat anxiety is a Beta-blocker (a medication used in cardiology to lower blood pressure and slow an abnormally fast heart rate) such as Atenolol. This is certainly less sedative than the benzodiazepines and is not addictive. It does have other side effects such as faintness/giddiness, lethargy, erectile dysfunction, and is very dangerous in overdose. Further, it is effective only on the physical symptoms of anxiety – the psychological symptoms are usually unaffected.
The final class of drugs available for the treatment of anxiety are the antidepressants. Some of these medications appear to have some efficacy in relieving anxiety symptoms as well as depression. They are typically the modern drugs and have fewer side effects than the older antidepressants, and are not considered to be addictive. They take longer to work than the benzodiazepines or a beta-blocker (e.g. weeks rather than hours).
Thus, drug treatments for anxiety are available and can be effective but they do have their down side. So what is available for those who whom such treatment is not appropriate or is ineffective, or those who prefer not to take tablets? There is the option of “talking therapies”.
There is a wide range of such therapies available, each with it’s own theory, method and applications. Therapies such as counselling and the traditional psychotherapies (e.g. psychoanalytic psychotherapy) are probably less suited to the treatment of anxiety than the more modern cognitive therapies such as Cognitive Behavioural Therapy (CBT). This latter treatment focuses less on the individuals past (and issues arising from it) and more on the “here and now”. It encourage the individual to become aware of how he or she thinks and feels, both in the anxiety-provoking situation(s) and in the normal course of life. It is usually possible to identify unhelpful patterns of thinking and reacting in people suffering from anxiety. These patterns serve to increase the anxiety response and thus increase the individual’s anxiety symptoms. Once such patterns have been recognised (individuals are usually unaware of them initially) it becomes possible to examine them and develop more useful and adaptive methods of thinking and reacting. This in turn will lessen the anxiety symptoms experienced.
CBT involves the client and therapist meeting on a one-to-one basis, typically for one-hour sessions. A course of therapy can last anything up to twenty or more sessions, though six to twelve sessions on a once – weekly basis is more typical. Such therapy involves a commitment by both parties. The therapist commits to regular sessions and will use their expertise to hep the client. The client commits to an intensive therapy that will challenge them mentally and frequently require work outside of the sessions e.g. the reading of literature recommended by the therapist, the monitoring and recording of their thoughts, feelings and behaviours in varying situations etc. An important aspect of the therapy is that the more the effort the client makes, the better the results.
Cognitive therapies are undoubtedly effective in the treatment of anxiety. Many psychiatrists consider such therapies as the “gold standard” in anxiety conditions – they are frequently more effective than drug treatments and do not have side effects. Furthermore, a course of cognitive therapy has the potential to help an individual for the remainder of their life. Once the techniques have been mastered, and the individual is aware of “problem” thinking and it’s solution, the techniques can be applied to any situation at any time in the future. A persons distressing anxiety may be a thing of the past.
Unfortunately, such therapies are not widely available on the NHS – a familiar story! If your GP is unable to refer you for the therapy on the NHS, he or she may be able to recommend a suitable private therapist.