Understanding Anxiety: A deep dive

Contents

Anxiety is a normal feeling. It’s easy to understand this when you think back to when you’ve been in a dangerous situation. That anxiety served as a warning, it heightened your awareness and it likely will make you think twice about getting into that situation again. It’s a tool of evolution that has kept generations of human beings alive. Anxiety is that physical feeling, that inability to focus on anything else.

Worry is also a normal feeling. It describes the negative thoughts we have about what ‘might’ happen in the future. This could be an actual event or the consequence of an action. It can revolve around ourselves or our feelings towards others.

However, when we think about anxiety as part of our mental well-being, what we’re really talking about is feeling anxiety when faced with day-to-day worries. Why am I breathing faster when I’m worrying about a deadline? Why do I feel as though I’m fearing for my life when having to give a presentation? No lion is chasing me. These responses aren’t helping me. This is the anxiety we want to address.

What happens when anxiety impacts your ability to function? What happens when you can’t live the life you want to because of these feelings? Now we’re talking about anxiety as a mental health problem. When the signs and symptoms of this problem can be categorised into specific medical definitions, this is called an anxiety disorder.

A Bit of History...

There is evidence that anxiety was ’medically’ recognized as early as the years 4-460 BCE in Greco-Roman culture. Writings attributed to physician Hippocrates and texts of the Stoic and Epicurean schools of philosophy reference concepts we would widely recognise as anxiety today. (1)

The medical definition of an anxiety disorder as we understand it today first began to take form in the late 19th and early 20th centuries alongside the birth of modern psychology, including contributions from famous psychologist Sigmund Freud. (1)

Anxiety or Worry?

Given the wide variety of ways in which people can experience anxiety, there are many different statistics used to describe how common it is. In the UK it is estimated that 4-7.9% of patients seen at GP practices have Generalized Anxiety Disorder (GAD, the most common anxiety disorder). However, the true number is thought to be at least twice this as anxiety is underdiagnosed and patients often don’t seek professional help. (2) This is backed up by a 2021 Office for National Statistics report highlighting that 16% of UK adults are likely to suffer from some form of anxiety. (3)

Symptoms

Psychological

• Long-term excess worry

• Irritability and restlessness

• Difficulty concentrating

• Sleep problems and tiredness

Physical

• Fast breathing

• Palpitations (feeling the thumping of the heart)

• Shaking and dizziness

• Sweating and feeling sick

• Muscle tension

Depression is another common mental health condition and is often experienced by people suffering from anxiety. Around 62% of people diagnosed with Generalized Anxiety Disorder have at least one major depressive episode in their lifetime (4).

Brain Chemistry

What is going on in the body when experiencing anxiety can be easily understood by breaking it down into three key concepts. Click on each of the boxes below to read more.

Fight or Flight (or Freeze)

Neurotransmitters

Neuroplasticity

Impact of Anxiety

One of the easiest ways to understand the impact anxiety can have on someone’s life is by looking at a case study:

“Jasmine is a 20-year-old woman studying biology at university. She considers herself a good student, consistently getting excellent marks throughout school and college. Being the eldest of 5 children, home life was always busy and she was often expected to help take care of her siblings. Jasmine describes her parents as having “traditional values”, holding hard work and doing what’s best for the family above all else. She certainly felt pressure to succeed in school but viewed this as a perfectly normal expectation in her cultural background. Every exam season Jasmine would “become a nervous wreck”, often studying excessively and becoming tearful.

It’s currently her second year of university and Jasmine’s friends have noticed a change in her behaviour. When she’s at social events she remains quiet and distracted. Her ‘nervous’ behaviour around exams seems to have extended to every assignment or piece of coursework she has to do. She appears to be getting thinner and her flatmates comment on how empty her cupboards look. However, they put the reason for her current behaviour down to temporary stress.

Jasmine has recognized a rapid decline in her mental health. She has found this year academically challenging and has struggled to achieve the high marks that she is used to. She gets what she describes as ‘panic episodes’ every morning. She feels her heart beat fast, her breath quicken, her muscles tense and shake, and she is not able to focus on the day ahead. She often feels unable to attend lectures as a result. A few weeks ago she had a panic attack in the supermarket and has been unable to return since. She still makes an effort socially but finds herself worrying about what people think of her, preferring to say very little. However, she relaxes a bit more once she’s had a few alcoholic drinks. She has not spoken to anyone at the university about this as she worries how her parents would react if they found out about her dropping marks.”

Rarely does anxiety appear as obviously as it does in this case. To think about the effect anxiety can have on someone’s life, we can look at some of the key points in Jasmine’s case:

• Background - Academic and family pressures placed a lot of responsibility on her shoulders and it’s unclear if she had a healthy way to process this. However, it would be incorrect to say that her upbringing directly caused her anxiety. Jasmine herself considers her childhood to be normal. Many factors contribute to the development of mental health problems.

• Friends - Jasmine’s friends recognize changes in her behaviour but put this down to “stress”. This is often how anxiety is seen by others. With Jasmine having a hard time reaching out and her friends not being aware of her difficulties opportunities to help are missed.

• Symptoms - Some key signs and symptoms of anxiety Jasmine displays include physical panic symptoms, difficulty focussing, tension, and excess worrying leading to avoidance.

• Daily activities - Anxiety is limiting Jasmine’s ability to lead her life. She is missing university content, has less social interaction, struggles to go to the supermarket and has difficulty forming supportive relationships. However, these issues have the potential to affect more than what is directly seen in the case. Missing lectures may prevent her from getting the grades she is hoping for. Jasmine’s difficulties at social events may impact her ability to maintain friendships. Not eating properly reduces the energy Jasmine has to do important daily activities.

• Vicious cycle - As you may already be noticing, a lot of the effects anxiety is causing in Jasmine’s life could easily worsen the anxious feelings she has. Missing lectures will likely worsen her worries about academic performance. The impact on her social life may reinforce ideas she has about what others think of her. Eating less will add to the loss of energy she is already feeling and potentially worsen symptoms like shaking and lack of focus.

• Risk - Aside from the significant impact anxiety has on Jasmine’s quality of life, she is also at risk of other health problems including depression, alcohol use disorder, an eating disorder or malnutrition.

Anxiety can have a significant effect on someone’s quality of life. However, not everyone who suffers from anxiety will end up in the same situation or require significant amounts of professional help.

Mindfulness

You’ve probably heard of mindfulness. It has led the way in the modern mental well-being movement. A definition I like comes from the UK mental health charity MIND: “Mindfulness is a technique you can learn which involves noticing what's happening in the present moment, without judgement. You might take notice and be aware of your mind, body or surroundings.” The goal of practising mindfulness is to improve your overall mental well-being and help reduce feelings of anxiety.

Mindfulness simply involves noticing your thoughts, feelings, sensations and the experience of what’s going on around you. Mindfulness techniques are the learnt methods you use to achieve this. By taking the time to slow down and notice what you are experiencing, you may be able to identify the causes of anxiety and stress, challenge unhelpful thoughts, combat physical symptoms of anxiety, and appreciate sources of positivity around you.

Sit comfortably upright on a chair, placing your hands on your knees.

Close your eyes and spend a few seconds acknowledging the physical feelings of anxiety that you are currently experiencing.

Switch your focus to your breathing. Notice the speed and depth. Slowly inhale through your nose for 4 seconds. Slowly exhale out of your mouth for 4 seconds. Repeat. After a few cycles, notice any changes to how your body feels.

Move your focus to the feeling of your feet touching the floor. Tense and release the muscles in your feet, and notice any changes to how they now feel.

Repeat this process working up the body. How do your clothes feel on your lower legs? How does the chair feel against your thighs? Keep going up your torso, shoulders, arms, hands, jaw and face. This is called a body scan.

Regularly repeat the breathing exercises throughout.

When you’ve completed your body scan, spend a few minutes noticing what has changed. Appreciate any newfound positive feelings.

Example Exercise

The resources section of this article provides some handy links to more mindfulness exercises.

Anxiety Disorders

The term ‘anxiety disorder’ refers to a group of mental health conditions diagnosed by an appropriately trained healthcare professional. Many people who experience symptoms of anxiety don't have a diagnosed anxiety disorder.

As mentioned previously, the most common condition in this group is Generalized Anxiety Disorder (GAD). This is what would be recognised by most people as “having anxiety”. The ICD-10 is a manual of conditions used by psychiatrists in the UK to make a diagnosis.

The DSM-V is an alternative diagnostic manual that is commonly used internationally and follows similar criteria.

• Symptoms of anxiety or excessive worrying about general aspects of daily life, not limited to a particular situation.

• Comes with physical symptoms such as muscle tension, palpitations (feeling your heartbeat), sweating, shaking, restlessness, lack of concentration, irritability or sleep difficulties.

• The symptoms last for several months, being experienced more days than not.

• Cannot be better explained by another mental health condition, physical health condition or medication/substance use.

• The symptoms significantly impact day-to-day functioning.

Summary of the ICD-10 criteria for Generalized Anxiety Disorder diagnosis

Other recognized anxiety disorders are outside of the scope of this article. However, some examples include panic disorder, agoraphobia, specific phobia and social anxiety disorder.

Up-to-date information about what to do if you are worried that you may have an anxiety disorder can be found on the NHS website (linked in the resources section below). In general, after trying self-help interventions such as mindfulness, you will be guided to book an appointment with your GP. They will use reliable diagnostic tools (questionnaires) alongside their own clinical experience to suggest appropriate next steps. Your GP should explain a bit more about what anxiety means and any suitable interventions or medications they can offer.

Cognitive Behavioural Therapy

Cognitive behavioural therapy (CBT) is often the first-line treatment offered to people suffering from anxiety in the UK. NICE (National Institute of Clinical Excellence), is the primary source of guidance for medical professionals in the UK. They recommend self-guided CBT as the first step after simple measures such as mindfulness have not shown any improvement. Self-guided programmes can be facilitated in many ways and may involve independently using CBT materials, practitioner-supported work or group therapy approaches. Typical programmes involve an hour of content weekly for 6 weeks. For those whose symptoms haven’t improved or those who have significant difficulty with their normal daily functioning due to anxiety, NICE recommends a more intense 12-week face-to-face program and/or starting medication. A specialist mental health assessment may be requested by the GP in some cases.

CBT is a talking therapy that focuses on the thoughts, feelings and behaviours that an individual currently has, with less focus on past experiences or childhood development. Problems are broken down into 5 key areas:

Situations

Thoughts

Emotions

Physical Feelings

Behaviours

When does the difficulty occur?

What is happening when anxiety starts?

The negative beliefs that relate to the situation.

How do these thoughts make the individual feel?

Physical feelings as a result of the emotional response.

Deliberate or automatic responses to any emotions or physical feelings that arise.

The focus then moves to breaking the cycle of feelings and actions that in turn worsen negative situations and thoughts. The therapist works with the individual to identify behaviours and provide useful techniques to support change. Over time, practising the techniques taught in CBT can help build an automatic positive response that lessens the experience of anxiety.

Medication

Several medications have been shown to successfully treat symptoms of anxiety. Your GP can provide more information on medicines that may be suitable for you, and there is up-to-date information from the NHS linked in the resources section. However, we’ll quickly explore the most common group of medications prescribed for Generalized Anxiety Disorder, Selective Serotonin Reuptake Inhibitors (SSRIs).

SSRIs are sometimes referred to as anti-depressants as they are also commonly used to treat depression. As we’ve previously explored, depression often co-exists with anxiety as both conditions are thought to heavily involve the role of serotonin as a neurotransmitter. However, they are also effective in the treatment of anxiety alone.

• Serotonin is used as a messenger (neurotransmitter) between certain nerve cells (neurons) in the brain.

• Once they have delivered their message, they are taken back into the neuron that they were released from (this is known as reuptake).

• SSRIs block (inhibit) the channels used to reuptake serotonin.

• This results in more serotonin being left in the gap (synapse) between neurons.

• The serotonin can then continue to repeatedly send messages along the chain of neurons that form the nerve.

• Signals from these nerves are thought to contribute to improved mood, reduced anxiety, better sleep and emotional stability.

A summary of how SSRIs work

Like any medication, SSRIs can come with side effects. Your GP will give you advice about the side effects you could experience if you are prescribed one of these medications. These may include:

• Agitation, shaking, dizziness or blurred vision.

• Feeling sick or having diarrhoea.

• Loss of sex drive, difficulty having an orgasm or difficulty maintaining an erection.

• Difficulty sleeping or vivid dreaming.

The majority of people who take SSRIs will only ever experience mild side effects that improve over time. People starting SSRIs are monitored by their GP who will provide advice and check for any negative effects the medication may be causing.

It usually takes 2-4 weeks to notice any benefits from taking SSRIs. If after 6 weeks an individual hasn’t noticed any improvement, their GP may want to increase the dose of the medication or switch to another medicine.

As SSRIs have a wide variety of impacts mentally and physically, it is important to never stop taking them suddenly. People wishing to come off SSRIs should do this with GP advice and support, gradually reducing the dose being taken.

Common SSRI medications include sertraline, fluoxetine, citalopram, escitalopram and paroxetine. They all work in ways similar to what is described above.

Summary

To summarize, here are some of the key points about anxiety that we’ve covered:

• Anxiety involves experiencing regular, often irrational, worries alongside negative emotions and physical feelings.

• Anxiety is a common experience. People may only experience brief moments of anxiety, or it may severely limit their ability to live a normal life. Depression is commonly experienced alongside anxiety.

• When anxiety impacts function, this is a mental health problem. When diagnosed by a suitably trained healthcare professional it is called an anxiety disorder.

• Concepts such as fight or flight (or freeze), neurotransmitters and neuroplasticity play an important role in our understanding of anxiety.

• The effects of anxiety can be wide-reaching and often affect far more than what might be immediately obvious.

• Mindfulness can be used to improve overall mental well-being and reduce the impact of anxiety.

• Professional assessment by a GP is important if an individual is worried about the impact of anxiety on their life.

• Cognitive behavioural therapy is the main talking therapy used to treat anxiety. It helps the individual break down their current problems and provides practical techniques to manage and improve day-to-day thoughts, feelings and emotions.

• SSRIs are the most common medications used to treat anxiety. There are several important things to be aware of when taking them.

Resources

Having explored this introduction to anxiety, you may be asking: what now? Firstly, it’s worth checking in on how you are feeling having covered a topic that may have brought up certain personal experiences or emotions. This is a great opportunity to practise the mindfulness exercise above. Below are some links to resources that provide further information on anxiety, practical mindfulness techniques and support available to you.

Further info

Mindfulness

Support

Further references

1 - Crocq A. 2015. "A history of anxiety: From Hippocrates to DSM." Dialogues in Clinical Neuroscience, 17(3), 319-325. https://doi.org/10.31887/DCNS.2015.17.3/macrocq

2 - NICE. 2024. "Clinical Knowledge Summaries: Generalized Anxiety Disorder". https://cks.nice.org.uk/topics/generalized-anxiety-disorder

3 - Office for National Statistics. 2021. "Depression or anxiety in adults, Great Britain: 22 September to 3 October 2021" https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/mentalhealth/adhocs/13844depressionoranxietyinadultsgreatbritain22septemberto3october2021

4 - Stein DJ. 2001. "Comorbidity in generalized anxiety disorder: impact and implications." The Journal of Clinical Psychiatry. 62 (Suppl. 11), 29–36. PMID: 11414548.

© Oliver Smith 2024