Anxiety

Anxiety is a feeling of unease, such as worry or fear, that can be mild or severe.

Everyone has feelings of anxiety at some point in their life. For example, you may feel worried and anxious about sitting an exam or having a medical test or job interview. During times like these, feeling anxious can be perfectly normal.

However, some people find it hard to control their worries. Their feelings of anxiety are more constant and can often affect their daily life.

Anxiety is the main symptom of several conditions, including panic disorder, phobias, post-traumatic stress disorder and social anxiety disorder (social phobia).

However, the information in this section is about a specific condition called generalised anxiety disorder (GAD).

Generalised anxiety disorder (GAD)

GAD is a long-term condition that causes you to feel anxious about a wide range of situations and issues, rather than one specific event.

People with GAD feel anxious most days and often struggle to remember the last time they felt relaxed. GAD can cause both psychological (mental) and physical symptoms. These vary from person to person, but can include feeling restless or worried and having trouble concentrating or sleeping.

Read about the symptoms of GAD

When to see your GP

Although feelings of anxiety at certain times are completely normal, you should see your GP if anxiety is affecting your daily life or is causing you distress.

Your GP will ask you about your symptoms and your worries, fears and emotions to try to find out if you could have GAD.

Read more about diagnosing GAD

What causes GAD?

The exact cause of GAD is not fully understood, although it's likely that a combination of several factors plays a role. Research has suggested these may include:

• overactivity in areas of the brain involved in emotions and behaviour
• an imbalance of the brain chemicals serotonin and noradrenaline, which are involved in the control and regulation of mood
• the genes you inherit from your parents – you're estimated to be five times more likely to develop GAD if you have a close relative with the condition
• having a history of stressful or traumatic experiences, such as domestic violence, child abuse or bullying
• having a painful long-term health condition, such as arthritis
• having a history of drug or alcohol misuse

However, many people develop GAD for no apparent reason.

Who is affected?

GAD is a common condition estimated to affect about 1 in every 25 people in the UK.

Slightly more women are affected than men, and the condition is more common in people between the ages of 35 and 55.

How GAD is treated

GAD can have a significant effect on your daily life, but several different treatments are available that can help ease your symptoms. These include:

• psychological therapy– such as cognitive behavioural therapy (CBT)
• medication – such as a type of antidepressant called selective serotonin reuptake inhibitors (SSRIs)

There are also many things you can do yourself to help reduce your anxiety, such as going on a self-help course, exercising regularly, stopping smoking and cutting down on the amount of alcohol and caffeine you drink.

With treatment, many people are able to control their levels of anxiety. However, some treatments may need to be continued for a long time and there may be periods where your symptoms worsen.

Read more about treating GAD and self-help tips for GAD

Generalised anxiety disorder (GAD) can affect you both physically and mentally.

How severe the symptoms are varies from person to person. Some people have only one or two symptoms, while others have many more.

You should see your GP if anxiety is affecting your daily life or is causing you distress.

Psychological symptoms of GAD

GAD can cause a change in your behaviour and the way you think and feel about things, resulting in symptoms such as:

• restlessness
• a sense of dread
• feeling constantly "on edge"
• difficulty concentrating
• irritability

Your symptoms may cause you to withdraw from social contact (seeing your family and friends) to avoid feelings of worry and dread.

You may also find going to work difficult and stressful and may take time off sick. These actions can make you worry even more about yourself and increase your lack of self-esteem.

Physical symptoms of GAD

GAD can also have a number of physical symptoms, including:

• dizziness
• tiredness
• a noticeably strong, fast or irregular heartbeat (palpitations)
• muscle aches and tension
• trembling or shaking
• dry mouth
• excessive sweating
• shortness of breath
• stomach ache
• feeling sick
• headache
• pins and needles
• difficulty falling or staying asleep (insomnia)

Anxiety triggers

If you are anxious as a result of a specific phobia or because of panic disorder, you will usually know what the cause is. For example, if you have claustrophobia (a fear of enclosed spaces), you know that being confined in a small space will trigger your anxiety.

However, if you have GAD, it may not always be clear what you are feeling anxious about. Not knowing what triggers your anxiety can intensify it and you may start to worry that there will be no solution.

See your GP if anxiety is affecting your daily life or is causing you distress.

Generalised anxiety disorder (GAD) can be difficult to diagnose. In some cases, it can also be difficult to distinguish from other mental health conditions, such as depression.

Talking to your GP about anxiety

Your GP may ask you questions about your worries, fears and emotions. They may also ask about your personal life. Tell your GP about all your symptoms – physical and psychological – and explain how long you have had them for.

You may find it difficult to talk about your feelings, emotions and personal life. However, it is important that your GP understands your symptoms and circumstances so that the correct diagnosis can be made.

You are most likely to be diagnosed with GAD if you have had the symptoms for six months or more. Finding it difficult to manage your feelings of anxiety is also an indication that you may have the condition.

To help with the diagnosis, your GP may carry out a physical examination or blood tests to rule out other conditions that may be causing your symptoms, such as anaemia (a deficiency in iron or vitamin B12 and folate) or an overactive thyroid gland (hyperthyroidism).

Do you have GAD?

You may have generalised anxiety disorder if:

• your worrying significantly affects your daily life, including your job and social life
• your worries are extremely stressful and upsetting
• you worry about all sorts of things and have a tendency to think the worst
• your worrying is uncontrollable
• you have felt worried nearly every day for at least six months

Generalised anxiety disorder (GAD) is a long-term condition, but a number of different treatments can help.

Before you begin any form of treatment, your GP should discuss all your treatment options with you. They should outline the pros and cons of each and make sure you are aware of any possible risks or side effects.

With your GP, you can make a decision on the treatment most suited to you, taking into account your personal preferences and circumstances.

If you have other problems alongside GAD, such as depression and drug or alcohol misuse, these may need to be treated before having treatment specifically for GAD.

Initial treatment

At first, your GP may suggest trying an individual self-help course for a month or two to see if it can help you learn to cope with your anxiety.

This will usually involve working from a book or computer programme on your own (you will be given advice about how to use the book or programme before you start), with only occasional contact with your doctor.

Alternatively, you may prefer to go on a group course where you and a few other people with similar problems meet with a therapist every week to learn ways to tackle your anxiety.

Read more about these treatments

If these initial treatments do not help, you will usually be offered either a more intensive psychological treatment or medication. These are described below.

Psychological treatment

If you have been diagnosed with GAD, you will usually be advised to try psychological treatment before you are prescribed medication.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is one of the most effective treatments for GAD. Studies of different treatments for GAD have found that the benefits of CBT may last longer than those of medication, but no single treatment is best for everyone.

CBT helps you to understand how your problems, thoughts, feelings and behaviour affect each other. It can also help you to question your negative and anxious thoughts, and do things you would usually avoid because they make you anxious.

CBT will usually involve meeting with a specially trained and accredited therapist for a one-hour session every week for three to four months.

Your therapist should carry out CBT in a standardised way according to a treatment manual, and they should receive regular supervision to support them in providing the most effective treatments.

Applied relaxation

Applied relaxation is an alternative type of psychological treatment that can be as effective as CBT in treating GAD.

Applied relaxation focuses on relaxing your muscles in a particular way during situations that usually cause anxiety. The technique needs to be taught by a trained therapist, but generally involves:

• learning how to relax your muscles
• learning how to relax your muscles quickly and in response to a trigger, such as the word "relax"
• practising relaxing your muscles in situations that make you anxious

As with CBT, applied relaxation therapy will usually mean meeting with a therapist for a one-hour session every week for three to four months.

Medication

If the psychological treatments above have not helped you or you would prefer not to try them, you will usually be offered medication.

Your GP can prescribe a variety of different types of medication to treat GAD. Some medication is designed to be taken on a short-term basis, while other medicines are prescribed for longer periods.

Depending on your symptoms, you may require medicine to treat your physical symptoms as well as your psychological ones.

If you are considering taking medication for GAD, your GP should discuss the different options with you in detail, including the different types of medication, length of treatment, side effects and possible interactions with other medicines, before you start a course of treatment.

You should also have regular appointments with your doctor to assess your progress when you are taking medication for GAD. These will usually take place every two to four weeks for the first three months, then every three months after that.

Tell your GP if you think you may be experiencing side effects from your medication. They may be able to adjust your dose or prescribe an alternative medication.

The main medications you may be offered to treat GAD are described below.

Selective serotonin reuptake inhibitors (SSRIs)

In most cases, the first medication you will be offered will be a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI). This type of medication works by increasing the level of a chemical called serotonin in your brain.

Examples of SSRIs you may be prescribed include sertraline, escitalopram and paroxetine.

SSRIs can be taken on a long-term basis but, as with all antidepressants, they can take several weeks to start working. You will usually be started on a low dose, which will gradually be increased as your body adjusts to the medicine.

Common side effects of SSRIs include:

• feeling sick
• low sex drive
• blurred vision
• diarrhoea or constipation
• dizziness
• dry mouth
• loss of appetite
• sweating
• feeling agitated
• problems sleeping (insomnia)

Some of the side effects – such as feeling sick, an upset stomach, problems sleeping and feeling agitated or more anxious – are more common in the first one or two weeks of treatment, but these will usually settle as your body adjusts to the medication.

If you or your GP feels that your medication is not helping after about two months of treatment, or if it is causing unpleasant side effects, your GP may prescribe an alternative SSRI to see if that has any effect.

When you and your GP decide that it is appropriate for you to stop taking your medication, you will normally have your dose slowly reduced over the course of a few weeks to reduce the risk of withdrawal effects. Never stop taking your medication unless your GP specifically advises you to.

Serotonin and noradrenaline reuptake inhibitors (SNRIs)

If SSRIs do not help ease your anxiety, you may be prescribed a different type of antidepressant known as a serotonin and noradrenaline reuptake inhibitor (SNRI). This type of medicine increases the amount of the chemicals serotonin and noradrenaline in your brain.

Examples of SNRIs you may be prescribed include venlafaxine and duloxetine.

Common side effects of SNRIs include:

• feeling sick
• headaches
• drowsiness
• dizziness
• dry mouth
• constipation
• insomnia
• sweating

SNRIs can also increase your blood pressure, so your blood pressure will be monitored regularly during treatment.

As with SSRIs, some of the side effects – such as feeling sick, an upset stomach, problems sleeping and feeling agitated or more anxious – are more common in the first one or two weeks of treatment, but these will usually settle as your body adjusts to the medication.

Pregabalin

If SSRIs and SNRIs are not suitable for you, you may be offered pregabalin. This is a medication known as an anticonvulsant, which is used to treat conditions such as epilepsy (a condition that causes repeated seizures). However, it has also been found to be beneficial in treating anxiety.

Side effects of pregabalin can include:

• drowsiness
• dizziness
• increased appetite and weight gain
• blurred vision
• headaches
• dry mouth
• vertigo (the sensation that you, or the environment around you, is moving or spinning)

Pregabalin is less likely to cause nausea or a low sex drive than SSRIs or SNRIs.

Benzodiazepines

Benzodiazepines are a type of sedative that may sometimes be used as a short-term treatment during a particularly severe period of anxiety because they help ease the symptoms within 30 to 90 minutes of taking the medication.

Examples of benzodiazepines you may be prescribed include chlordiazepoxide, diazepam and lorazepam.

Although benzodiazepines are very effective in treating the symptoms of anxiety, they cannot be used for long periods of time because they can become addictive if used for longer than four weeks. Benzodiazepines also start to lose their effectiveness after this time.

For these reasons, you will not usually be prescribed benzodiazepines for any longer than two to four weeks at a time.

Side effects of benzodiazepines can include:

• drowsiness
• difficulty concentrating
• headaches
• vertigo
• tremor (an uncontrollable shake or tremble in part of the body)
• low sex drive

As drowsiness is a particularly common side effect of benzodiazepines, your ability to drive or operate machinery may be affected by taking this medication. You should therefore avoid these activities during treatment.

Referral to a specialist

If you have tried the treatments mentioned above and have significant symptoms of GAD, you may want to discuss with your GP whether you should be referred to a mental health specialist.

A referral will work differently in different areas of the UK, but you will usually be referred to your community mental health team. These teams include a range of specialists, including psychiatrists, psychiatric nurses, clinical psychologists, occupational therapists and social workers.

An appropriate mental health specialist from your local team will carry out an overall reassessment of your condition. They will ask you about your previous treatment and how effective you found it.

They may also ask about things in your life that may be affecting your condition, or how much support you get from family and friends.

Your specialist will then be able to devise a treatment plan for you, which will aim to effectively treat your symptoms.

As part of this plan, you may be offered a treatment you have not tried before, which might be one of the psychological treatments or medications mentioned above.

Alternatively, you may be offered a combination of a psychological treatment with a medication, or a combination of two different medications.

If you have generalised anxiety disorder (GAD), there are many ways you can help ease the symptoms of anxiety yourself.

Anxiety self-help guide

Our mental health self-help guides are based on Cognitive Behavioural Therapy (CBT) and have proven highly successful in helping people with anxiety and other mental health issues.

Try a book or online course

When you are diagnosed with GAD, your GP may recommend trying self-help treatments before having more intensive psychological therapy or medication.

This will usually involve working from a book or computer programme for around six weeks or longer. In some cases, you may be closely supported by a trained therapist who you will speak to every week or two, although some treatments only involve minimal or occasional contact with a therapist who will monitor your progress.

There are a number of different books and courses available that can help you learn to cope with your anxiety, but the National Institute for Health and Care Excellence (NICE) only recommends trying treatments based on the principles of cognitive behavioural therapy (CBT).

CBT is a type of psychological treatment that can help you understand your condition better and how your problems, thoughts, feelings and behaviour affect each other. The aim of CBT-based treatments is to help you learn ways to manage your anxiety by modifying negative or unhelpful behaviour and thoughts.

Find out more about Living Life - a service which offers appointment-based telephone support based upon cognitive behavioural therapy.

Exercise regularly

Regular exercise, particularly aerobic exercise, may help you combat stress and release tension. It also encourages your brain to release the chemical serotonin, which can improve your mood.

Examples of good aerobic exercises to try include:

• walking fast or jogging
• swimming
• cycling
• tennis
• hiking
• football or rugby
• aerobics

You should aim to do a minimum of 150 minutes of moderate-intensity exercise a week. Moderate-intensity exercise should raise your heart rate and make you breathe faster.

Learn to relax

As well as getting regular exercise, learning how to relax is important.

You may find relaxation and breathing exercises helpful, or you may prefer activities such as yoga or pilates to help you unwind.

Avoid caffeine

Drinking too much caffeine can make you more anxious than normal. This is because caffeine can disrupt your sleep and also speed up your heartbeat. If you are tired, you are less likely to be able to control your anxious feelings.

Avoiding drinks containing caffeine – such as coffee, tea, fizzy drinks and energy drinks – may help reduce your anxiety levels.

Avoid smoking and drinking

Smoking and alcohol have been shown to make feelings of anxiety worse. Only drinking alcohol in moderation or stopping smoking if you smoke may help reduce your anxiety.

The Department of Health recommends that men should not drink more than three to four units of alcohol a day and women no more than two to three units.

Contact support groups

Support groups can give you useful advice about how to effectively manage your anxiety. They are also a good way to meet other people with similar experiences.

Examples of support groups you may find useful include:

• Anxiety Alliance
• Anxiety UK
• Mind
• Rethink Mental Illness

Support groups can often arrange face-to-face meetings, where you can talk about your difficulties and problems with other people. Many support groups also provide support and guidance over the phone or in writing.

Ask your GP about local support groups for anxiety in your area or search our support service directory for mental health information and support services near you.