Anxiety is a feeling of unease that is experienced on both a cognitive and physical level. It is a normal reaction to feel anxious when faced with a stressful situation such as an exam or an interview, or during a worrying time such as illness. The key difference is the cognitive interpretation of the feelings. A lot of the physical feelings of anxiety are in fact very similar to those of excitement. Although mild anxiety can be a positive and useful experience many people feel scared by the sensations.
Often these are misinterpreted as being a sign of illness or of imminent risk to the person’s health. The more the person misinterprets the feelings the more anxious they become. Often the person then learns to associate the feelings with a particular place or situation, which can lead to avoidance and in turn increases the fear. For example, a bad experience at the dentist can lead to reluctance to return there and, if ongoing, leads to a real difficulty in going back in the future.
Excessive anxiety can be also be a component feeling in other mental health problems, such as depression. Anxiety is only considered to be a mental health problem when it is long lasting, severe and interfering with everyday activities.
Anxiety can present itself in many ways. There is a range of formal diagnoses but the main variation is how specific or general the anxiety is. Some people only experience anxiety in a few (or even singular) settings, such as with a phobia. If the person does not need or wish to tackle this fear it may be of little or no inconvenience to them. If the fear is of something that the person needs to encounter on a regular basis then they would be more likely to seek help.
For others the anxiety is a more generalised experience. The feelings of anxiety tend to be felt most of the time and are not so related to specific situations or events.
Types of anxiety disorders include:
- phobia
- panic disorder
- agoraphobia
- generalised anxiety disorder
- social anxiety disorder
- health anxiety
- obsessive compulsive disorder
According to the original NICE guidance on anxiety, Clinical Guidance 022 [PDF 359kb]:
- anxiety disorders are:
- o common
- o chronic
- o the cause of considerable distress and disability
- o often unrecognised and untreated
- if left untreated they are costly to both the individual and to society
- a range of effective interventions are available to treat anxiety disorders, including medication, psychological therapies and self-help
- individuals do get better and remain better
- involving individuals in an effective partnership with healthcare professionals, with all decision-making being shared, improves outcomes
- access to information, including support groups, is a valuable part of any package of care
Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: management in primary, secondary and community care [PDF 6.7MB]
In January 2011, the NICE guidance on anxiety was partially revised, and replaced with CG113.
Anxiety problems are very common. The Royal College of Psychiatrists, in its most recent leaflet on anxiety, states that around 1 in 10 people is likely to have a ‘disabling anxiety disorder’ at some stage in their life. It is likely that many others experience short spells of troubling anxiety but do not seek or require formal help.
How does anxiety make us feel?
In the mind:
- feeling worried all the time
- feeling tired
- unable to concentrate
- feeling irritable
- sleeping badly
- feeling depressed
In the body:
- fast or irregular heartbeats (palpitations)
- sweating
- face goes pale
- dry mouth
- muscle tension and pains
- trembling
- numbness or tingling
- breathing fast
- dizziness
- faintness
- indigestion
- passing water frequently
- nausea, stomach cramps
- diarrhoea
Each person’s experience of anxiety is unique. For some people anxiety is a more cognitive experience, where worrying and brooding might be the major component.
For others anxiety is physical, with bodily sensations which can often be very frightening and disturbing. The feeling can be so strong that it is common for people to fear that that their heart will stop or explode.
To a degree, these sensations are quite normal
The increased adrenaline that triggers many of the physical sensations helps us to prepare for action more quickly. This is useful when we take part in sport, need to be alert for an exam or interview or need to think and act quickly in a difficult situation. The key factor is not just the strength of these feelings and sensations, but whether they are functional or dysfunctional.
Help for sufferers of anxiety includes:
- clear information to ensure the person understands what is happening to them
- self-help materials including online resources
- occasional use of medication following NICE guidance
DESIRED OUTCOMES
Reduced incidence, prevalence and burden associated with anxiety
In commitment 18 of Delivering for Mental Health the Scottish Government pledged to work with NHS Boards to implement the ‘Equally Well’ recommendations that work to address depression, stress and anxiety is targeted in deprived communities.
This will build on the action already being taken forward under the Keep Well programme, which is focused on anticipatory care, and the Living Better programme, which is focused on the mental health of those suffering from long-term conditions such as diabetes and chronic heart disease.
CURRENT EVIDENCE
Physical exercise
The recent UK Department of Health publication, ’At least five a week: evidence on the impact of physical activity and its relationship to health’ states:
‘Physical activity helps people feel better through improvement in mood, reduced anxiety and enhanced self-perceptions. Physical activity can also help people to function better through alleviation of stress, and improved sleep, and – in older people – through some aspects of cognitive function.’
‘At least five a week: evidence on the impact of physical activity and its relationship to health’, 2004 [PDF 1.9MB]
Information and support
Giving clear information about anxiety to both those affected and their carers or family is important to reduce some of the fear and misunderstandings. The information should include an outline of the treatment and help options. It is important to assist people to make initial contact with support groups. Social anxiety can lead to a person finding this first contact impossible without direct support.
Self-help literature or bibliotherapy is recommended in the NICE guidance. It should be based on CBT principles and would normally include guidance on:
- goal-setting using a stepped approach
- problem solving skills
- anxiety management skills, both cognitive and physical
Psychotherapy
Research shows that Cognitive Behavioral Therapy (CBT) can help with anxiety problems including panic disorder, social phobia, and General Anxiety Disorder.
- CBT can be used successfully in a variety of formats. Both non-faciliatated and facilitated self-help have been found to help people. Group delivery methods are also effective and are very cost-effective interventions. See ‘Stresspac: A controlled trial of a self-help package for the anxiety disorders.’ Behavioural and Cognitive Psychotherapy
- White, J. (1998) ‘Stress control’ large group therapy for generalised anxiety disorder two year follow up. Behavioural and Cognitive Psychotherapy
- Computerised CBT is well-established in helping people with depression. There is also some evidence of its usefulness for anxiety. Titov, N., Andrews, G., Robinson, E., et al. (2009)
- Clinician-assisted internet-based treatment is effective for generalised anxiety disorder: randomised controlled trial. Australian and New Zealand Journal of Psychiatry
Medication
The use of medication varies according to the precise nature of the anxiety problem. Detailed advice is given within the NICE guidance. A summary of the guidance is given below in the recommendations section.
RECOMMENDATIONS
There is a series of linked steps in providing the right type and level of help for people:
- provision of high quality, accessible information about anxiety
- guidance and support to access self-help approaches geared to the individual
- access to psychological interventions
- consideration of medication usage
Provision of high quality, accessible information about anxiety
Giving clear information about anxiety to those affected by it and their carers or family is hugely important in reducing some of the fear and misunderstandings. The information should include an outline of the treatment and help options available.
It is important not just to give out contact details of support groups but to assist people to make the initial contact with them. Social anxiety can lead to a person finding this first contact impossible without direct support, even though other people who have anxiety disorders can be a good source of support and advice.
Information should be given using a variety of methods, including booklets, website guidance, and providing contact details of local and national groups. This process both reduces misconceptions about what is happening and increases the concept of a shared approach to resolving issues.
Self-help approaches geared to the individual
Some feelings of anxiety may be relieved by the use of relaxation techniques and exercise. Progressive relaxation training is helpful in relieving panic feelings and can help people to gain some control over what is happening to them. Yoga, Tai Chi and other exercises are also believed to be beneficial. The key is in finding the approach which helps each person. For some people, relaxation is best found by taking part in physical activities, such as running, walking or gardening, rather than by relaxation.
Physical exercise appears to work on two levels. The first is that aerobic exercise leads to increased levels of brain chemicals such as endorphins. This gives a feeling of relaxation and wellbeing as well as helping with sleep-related problems. Exercise also acts as a distraction from worries and can lead to a sense of achievement.
Access to psychological interventions
Psychological interventions include formal approaches and guided self-help. CBT in particular has been found to be very effective in treating Generalised Anxiety Disorder and panic disorder. CBT is based on the idea that negative thinking results in negative reactions. It involves assessing the reasoning behind a person’s thinking, then gradually exposing them to the situation that causes anxiety in order to change behavior and boost self-confidence.
CBT can be used successfully in a variety of formats; non-facilitated and facilitated self-help have both been found to help people. Group delivery methods are also effective and are very cost-effective interventions. These approaches should be based on CBT principles and would normally include guidance on:
- goal-setting using a stepped approach
- problem solving skills
- anxiety management skills, both cognitive and physical
Consideration of medication usage
The most recent NICE guidance gives full and detailed information on the use of medication. Medication has a clear and important role to play. Below is a summary of the recommendations:
Generalised Anxiety Disorder
In the short term (two to four weeks) Benzodiazepines should only be used as a very short term intervention – normally just in crisis scenarios. In the longer-term some people benefit from the use of anti-depressants. Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) have an evidence base with Paroxetine and Venlafaxine (extended release version) being licenced for use for anxiety and depression.
Panic Disorder
For longer term conditions, antidepressants have been found to be helpful for some people. They are only normally used after psychological interventions have been tried.