Anxiety disorders

Overview

• Anxiety can make you feel worried or scared.
• Anxiety can cause physical symptoms such as a fast heartbeat or sweating.
• It is a normal human response to be anxious in certain situations. You may have an anxiety disorder if you feel anxious all or most of the time.
• You can recover from anxiety disorders. Treatment and support are available for you.
• Your doctor can offer you treatment. What you are given will depend on your symptoms and how severe they are.

About

What are anxiety disorders?

We all have feelings of anxiety, worry and fear sometimes. These can be normal responses to certain situations. For example, you might worry about a job interview, or about paying a bill on time. These feelings can give you an awareness of risks and what you need to do in a difficult or dangerous situation. This reaction is known as ‘fight or flight’.

Your brain responds to a threat or danger by releasing stress hormones such as adrenaline and cortisol. Even if the danger is not real, these hormones cause the physical symptoms of anxiety. Once the threatening situation has stopped, your body will usually return to normal.

But if you have an anxiety disorder these feelings of fear and danger can be ongoing and interrupt your daily routine long after the threat has gone. They can make you feel as though things are worse than they actually are.

Everyone’s experience of anxiety disorders is different. Not everyone who has an anxiety disorder will experience the same symptoms.

Mental symptoms of anxiety can include:

• racing thoughts,
• uncontrollable over-thinking,
• difficulties concentrating,
• feelings of dread, panic or ‘impending doom’,
• feeling irritable,
• heightened alertness,
• problems with sleep,
• changes in appetite,
• wanting to escape from the situation you are in, and
• dissociation.

If you dissociate you might feel like you are not connected to your own body. Or like you are watching things happen around you, without feeling them.

Physical symptoms of anxiety can include:

• sweating,
• heavy and fast breathing,
• hot flushes or blushing,
• dry mouth,
• shaking,
• hair loss,
• fast heartbeat,
• extreme tiredness or lack of energy
• dizziness and fainting, and
• stomach aches and sickness.

Anxiety can lead to depression if left untreated.

You can read more about breathing techniques further down this page. And you can find details of the Every Mind Matters website in the further reading section at the bottom of this page.

For more information see our webpages on the following:

• Depression
• Talking therapies

Types of anxiety & causes

What are the different types of anxiety disorder?

This section provides an overview of the most common types of anxiety disorders.

• Generalised anxiety disorder (GAD)
• Panic disorder
• Social anxiety disorder
• Phobias
• Obsessive compulsive disorder (OCD)
• Skin picking
• Hair pulling
• Health anxiety
• Body dysmorphic disorder (BDD)
• Post-traumatic stress disorder (PTSD)

Generalised anxiety disorder (GAD)

GAD is common. The main symptom of GAD is over worrying about different activities and events. This may feel out of your control. You feel anxious a lot of the time if you have GAD. You might feel ‘on edge’ and alert to your surroundings.

This can affect your day-to-day life. You might find that it affects your ability to work, travel places or leave the house. You might also get tired easily or have trouble sleeping or concentrating. You might have physical symptoms, such as muscle tension and sweating.

It is common to have other conditions such as depression or other anxiety disorders if you have GAD.

GAD can be difficult to diagnose because it does not have some of the unique symptoms of other anxiety disorders. Your doctor is likely to say you have GAD if you have felt anxious for most days over six months and it has had a bad impact on areas of your life.

Panic disorder

You will have regular panic attacks with no particular trigger if you have panic disorder. They can happen suddenly and feel intense and frightening. You may also worry about having another panic attack.

Panic disorder symptoms can include the following.

• An overwhelming sense of dread or fear.
• Chest pain or a sensation that your heart is beating irregularly.
• Feeling that you might be dying or having a heart attack.
• Sweating and hot flushes or chills and shivering.
• A dry mouth, shortness of breath or choking sensation.
• Nausea, dizziness and feeling faint.
• Numbness, pins and needles or a tingling sensation in your fingers.
• A need to go to the toilet.
• A churning stomach.
• Ringing in your ears.

You may also dissociate during a panic attack e.g. feeling detached from yourself.

Certain situations can cause panic attacks. For example, you may have a panic attack if you don’t like small places but you have to use a lift. This doesn’t mean that you have panic disorder.

Social anxiety disorder

Social anxiety disorder is sometimes known as social phobia. Lots of people may worry about social situations but if you have social anxiety you will have an intense fear or dread of social or performance situations. This can happen before, during or after the event.

Some common situations where you may experience anxiety are the following.

• Speaking in public or in groups.
• Meeting new people or strangers.
• Dating.
• Eating or drinking in public.

You may be worried that you will do something or act in a way that is embarrassing.

You might feel aware of the physical signs of your anxiety. This can include sweating, a fast heartbeat, a shaky voice and blushing. You may worry that others will notice this or judge you. You might find that you try to avoid certain situations. You might realise that your fears are excessive, but you find it difficult to control them.

Your GP will ask you questions about your symptoms and might ask you to fill out a questionnaire. This will help them find out how anxious you feel in social situations. They may refer you to a mental health specialist for a full assessment.

You can ask for a telephone appointment with your GP if it would be too difficult for you to see them in person.

Phobias

A phobia is an overwhelming fear of an object, place, situation, feeling or animal.

Phobias are stronger than fears. They develop when a person has increased feelings of danger about a situation or object. Someone with a phobia may arrange their daily routine to avoid the thing that's causing them anxiety.

Common examples of phobias include the following.

• Animal phobias. Such as spiders, snakes or rodents.
• Environmental phobias. Such as heights and germs.
• Situational phobias. Such as going to the dentist.
• Body phobias. Such as blood or being sick.
• Sexual phobias. Such as performance anxiety.

Agoraphobia
Agoraphobia is a fear of being in situations where escape might be difficult. Or situations where help wouldn't be available if things go wrong. This could be the following.

• Leaving your home.
• Being in public spaces.
• Using public transport.
• Being in crowded spaces.

You might find that these situations make you feel distressed, panicked and anxious. You may avoid some situations altogether. This can affect day-to-day life.

Agoraphobia can make it difficult to make an appointment with your GP to talk about your symptoms. You might not feel able to leave your house or go to the GP surgery. You can arrange a telephone appointment if you have symptoms of agoraphobia. A GP will decide on the best treatment options for you depending on what you tell them.

Obsessive-compulsive disorder (OCD)

You will have obsessions, compulsions or both if you have OCD.

• Obsession. An obsession is an unwelcome thought or image that you keep thinking about and is largely out of your control. They can be difficult to ignore. These thoughts can be disturbing, which can make you feel distressed and anxious.
• Compulsion. A compulsion is something you think about or do repeatedly to relieve anxiety. This can be hidden or obvious. Such as saying a phrase in your head to calm yourself. Or checking that the front door is locked.

You might believe that something bad will happen if you do not do these things. You may realise that your thinking and behaviour is not logical but still find it very difficult to stop.

Speak to your GP if you think you have OCD. They should discuss treatment options with you. Or you could try to self-refer to an NHS talking treatment service.

See our webpage on Obsessive-compulsive disorder for more information.

Skin-picking

Skin picking is medically known as dermatillomania. It is an impulse control disorder. You will regularly pick at your skin. Often you will pick healthy skin. This can cause damage to your skin, including bleeding, bruising and sometimes permanent marks.

You will usually pick the skin on your face but might also pick other areas of the body. You will find it difficult to stop yourself doing it.

No one knows the cause for skin-picking. It is thought that it could be a type of addiction. Or it relieves tension and stress. It is common to have OCD and dermatillomania at the same time.

Your GP may arrange for you to see a specialist mental health doctor like a psychiatrist for diagnosis.

Hair pulling

Hair pulling is medically known as trichotillomania. It is an impulse control disorder. You feel the urge to pull out your hair if you have this condition. This can be from your scalp or other places such as your arms, eyelashes, legs or pubic area. You will find it difficult to stop yourself doing this.

You might experience a build-up of tension which you can relieve by pulling out the strand of hair. You might not even be aware that you’re doing it.

It can be difficult to stop, which can lead to hair loss. This in turn can make you feel guilty, embarrassed and affect how you feel about yourself or how your friends and family see you.

Your doctor will look at the following to diagnose your condition.

• You repeatedly pull your hair out, causing noticeable hair loss.
• You feel increasing tension before you pull your hair out.
• You feel relief or pleasure when you have pulled your hair out.
• There are no underlying illnesses, such as a skin condition, causing you to pull your hair out.
• Pulling your hair out affects your everyday life or causes you distress.

Health anxiety

You may have health anxiety if you spend a lot of time worrying about if you are ill. Or worrying about getting ill. You may:

• worry that your doctor has missed something,
• check your body a lot for signs of illness,
• constantly worry about your health,
• spend a lot of time asking people if they think you are ill,
• spend a lot of time looking at health information on the internet, on the TV or in newspapers, or
• act as if you were ill.

Symptoms like headaches or a racing heartbeat can be caused by anxiety. But if you have health anxiety you may mistake these for signs of illness.

Body dysmorphic disorder (BDD)

You will have upsetting thoughts about the way you look if you have BDD. The thoughts don’t go away and have a big effect on daily life.

This is not the same as being vain about your appearance. You may believe that you are ugly and that everyone sees you as ugly, even if they reassure you that this isn’t true. Or you may believe that people are focused on an area of your body such as scar or birthmark. It can be very distressing and lead to depression.

You may spend a large amount of time doing the following.

• Staring at your face or body in the mirror.
• Comparing your features with other people’s.
• Covering yourself with lots of makeup.
• Thinking about plastic surgery when you do not need it.

Speak to your GP if you think you have BDD. They should discuss treatment options with you. The GP may arrange for a team with more BDD experience to help you.

Post-Traumatic Stress Disorder (PTSD)

You may have PTSD if your anxiety symptoms developed after a stressful or distressing event. Or if you have experienced trauma over a long period of time.

See our webpage on Post-Traumatic Stress Disorder for more information.

What causes anxiety disorders?

We don’t fully understand what causes anxiety disorders. But it is thought that the following factors can cause anxiety.

Genetics. Some people seem to be born more anxious than others. You may get anxiety through your genes.

Life experience. This could be bad experiences such as being abused or losing a loved one. It could also include big changes in life such as moving home, pregnancy or losing your job.

Drugs. Caffeine in coffee and alcohol can make you feel anxious. Illegal drugs, also known as street drugs, can also have an effect.

Circumstances. Sometimes you know what is causing your anxiety. When the problem goes, so does your anxiety.

Help & treatment

How can I get help if I think I have an anxiety disorder?

You should make an appointment to talk with your GP if you are worried about your symptoms. Or they are causing problems in your day-to-day life.

Your doctor will look at different things when deciding on your treatment such as the following.

• Your diagnosis and symptoms.
• What options you have tried already.
• Your goals and preferences.
• Any other conditions you have.
• Guidance from the National Institute for Health and Care Excellence (NICE).

Talking therapies
The NHS’ ‘Improving Access to Psychological Therapies’ (IAPT) programme has made psychological therapy more available on the NHS. IAPT services mainly provide support for low to moderate anxiety and depression.

The service can be run by the local NHS Trust or a non-NHS agency, like a charity who work with the local Trust.

IAPT should be available in your area. You can often self-refer or ask your GP to refer you.

To find your local IAPT service you can search online here:
www.nhs.uk/service-search/other-services/Psychology-service/LocationSearch/10004

You can also ask your GP or PALS service for details of local IAPT services.

For more information see our webpages on the following:

• GPs and your mental health
• Medication. Choice and managing problems
• Talking therapies.

How are anxiety disorders treated?

You can check what treatment and care is recommended for anxiety disorders on the National Institute for Health and Care Excellence (NICE) website: www.nice.org.uk/

NICE produce guidelines for how health professionals should treat certain conditions. NICE only provide guidelines for:

• Generalised anxiety disorder (GAD) and panic disorder,
• Obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD),
• Post traumatic stress disorder (PTSD), and
• Social anxiety disorder.

The NHS doesn't have to follow these recommendations. But they should have a good reason for not following them.

We have described some of the treatments for anxiety disorders below. The treatments you will be offered depend upon the type of anxiety disorder you are experiencing.

For more information see our webpages on the following:

• Post-traumatic stress disorder (PTSD
• Obsessive-compulsive disorder (OCD)

Monitoring your symptoms
Some anxiety disorders, such as generalised anxiety disorder (GAD) may get better by themselves with no treatment at all. Or they may improve after education and advice from your doctor. Your doctor will monitor your symptoms to see if they improve. And they will talk to you about medications that you can get without a prescription. These are sometimes called over-the-counter medications.

Individual non-facilitated self help
This involves working from a book or a computer program. You will be supported by a trained professional. It could include:

• written or electronic information based on cognitive behavioural therapy principles.
• instructions to work through the material over at least 6 weeks.
• very brief support from a therapist such as a 5-minute telephone conversation.

Individual guided self-help
You should:

• get written or electronic materials,
• be supported by a trained professional, who delivers the self-help programme and reviews progress and outcomes, and
• get support to use the materials, either face-to-face or over the telephone.

Psychoeducational groups
Psychoeducation means that you will learn about your symptoms and how to manage them.

Your learning should:

• be based on CBT,
• get you involved,
• include presentations from a trained professional,
• include self-help manuals,
• have 1 therapist to about 12 people, and
• usually be 6 weekly sessions, each lasting 2 hours.

If these treatments don't work you should be offered cognitive behavioural therapy (CBT), applied relaxation or medication.

Cognitive behavioural therapy (CBT)
CBT helps you understand the links between your thoughts, feelings and behaviour. It can help you to find ways to overcome your anxiety by challenging negative thoughts and beliefs.

Depending upon the type of anxiety disorder you have, you may be offered individual or group sessions. , If you have social anxiety disorder you should not be offered group CBT sessions.

Applied relaxation
Applied relaxation means that you will focus on relaxing your muscles in a certain way and at a certain time. For example, learning how to relax your muscles so that you are able to fall asleep easier.

A trained therapist will teach you different techniques to manage your situation.

Depending on the anxiety that you have, you will usually get 12–15 weekly sessions each lasting 1 hour. You will get less if you recover sooner and more if you need it.

Short term psychodynamic therapy
This type of therapy focuses on the different forces in your life that are causing you problems. The aim is to look at, understand and work through these difficulties, which may have begun in childhood. Your therapist will also help you to improve your social skills.

This type of therapy is specifically used for people with social anxiety disorder. You will usually have up to 25 or 30 sessions which last 50 minutes. The therapy will usually take place over a 6-to-8-month period.

Exposure and response prevention (ERP)
This treatment is particularly used for people living with obsessive-compulsive disorder (OCD). Your therapist will encourage you to experience your obsessive thoughts and help you to manage them in a different way. They will build up the difficulty of each task.

Eye movement desensitisation and reprocessing (EMDR)
This talking therapy is used mainly for people living with post-traumatic stress disorder (PTSD).

You will make eye movements while thinking about the traumatic event. EMDR helps make your brain deal with painful memories in a different way so these can become less painful for you.

Medications

Selective serotonin reuptake inhibitors (SSRIs)
SSRIs are a type of antidepressant used to treat anxiety disorders. Sertraline is the most common SSRI suggested for anxiety, but there are other SSRIs available.

Serotonin and noradrenaline reuptake inhibitors (SNRIs)
SNRIs are a type of antidepressant. You may be prescribed an SNRI if SSRIs did not help your anxiety.

Pregabalin
Pregabalin is a type of medication known as an anticonvulsant. Anticonvulsants are usually used to treat epilepsy. But pregabalin has been found to help people living with anxiety disorders.

Pregablin is not recommended if you are pregnant or may become pregnant. This is because it may harm your baby.

There is an increased risk that your baby may not develop properly in the womb if you take pregabalin while pregnant. So, the NHS recommend you use effective contraception if you are taking pregablin.

If you take pregablin and become pregnant, the NHS say don't stop taking the medicine suddenly. Get advice from you GP as soon as you can.

Benzodiazepines
Doctors should only prescribe benzodiazepines if your anxiety is extreme or if you are in crisis. This is because they are addictive, and they may become less effective over time.

Beta-blockers
These can help with the physical signs of anxiety. They can help to lower a fast heartbeat.

Complementary therapies
Complementary therapies are treatments that are not usually part of mainstream NHS care. Some people find them useful for helping with symptoms of anxiety. They can include yoga and hypnotherapy.

For more information see our webpages on the following:

• Talking therapies
• Antidepressants
• Benzodiazepines
• Complementary and alternative therapies for mental health

Unhappy with treatment

What if I am not happy with my treatment?

If you are not happy with your treatment you can:

• talk to your doctor about your treatment options,
• ask for a second opinion,
• get an advocate to help you speak to your doctor,
• contact Patient Advice and Liaison Service (PALS) and see whether they can help, or
• make a complaint.

There is more information about these options below.

Treatment options

You should first speak to your doctor about your treatment. Explain why you are not happy with it. You could ask what other treatments you could try.

Tell your doctor if there is a type of treatment that you would like to try. Doctors should listen to your preference. If you are not given this treatment, ask your doctor to explain why it is not suitable for you.

Second opinion

A second opinion means that you would like a different doctor to give their opinion about what treatment you should have. You can also ask for a second opinion if you disagree with your diagnosis.

You don’t have a right to a second opinion. But your doctor should listen to your reason for wanting a second opinion.

Advocacy

An advocate is independent from the mental health service. They are free to use. They can be useful if you find it difficult to get your views heard. There are different types of advocates available. Community advocates can support you to get a health professional to listen to your concerns. They can help you to get the treatment that you would like.

You can search online for a local advocacy service. If you can’t find a service you can contact the Rethink Mental Illness Advice Service on 0300 500 927, and we will look for you. However this type of service doesn’t exist in all areas.

The Patient Advice and Liaison Service (PALS)

PALS is part of the NHS. They give information and support to patients.

You can find your local PALS’ details through this website link:
www.nhs.uk/Service-Search/Patient-advice-and-liaison-services-(PALS)/LocationSearch/363.

For more information see our webpages on the following:

• Medication - Choice and managing problems
• Second opinions about your mental health diagnosis or treatment
• Advocacy
• Complaining about the NHS or social services

Managing symptoms

What can I do to manage my symptoms?

You can learn to manage your symptoms by looking after yourself. Self-care is how you take care of your diet, sleep, exercise, daily routine, relationships and how you are feeling.

Lifestyle

Making small lifestyle changes can improve your wellbeing and can help your recovery.

Routine helps many people with their mental wellbeing. It will help to give a structure to your day and may give you a sense of purpose. This could be a simple routine such as eating at the same time each day, going to bed at the same time each day and buying food once a week.

Breathing exercises

Breathing exercises can help to calm you when you are feeling anxious. Or having a panic attack. You will get the most benefit if you do them regularly, as part of your daily routine.

There is more information about breathing exercises in the further reading section at the bottom of this page.

Support groups

You could join a support group. A support group is where people come together to share information, experiences and give each other support.

You might be able to find a local group by searching online.

Rethink Mental Illness have support groups in some areas. You can find out what is available in your area if you follow this link: www.rethink.org/about-us/our-support-groups. Or you can call the Rethink Mental Illness Advice Service on 0300 5000 927 for more information.

Recovery college

Recovery colleges are part of the NHS. They offer free courses about mental health to help you manage your symptoms. They can help you to take control of your life and become an expert in your own wellbeing and recovery. You can usually self-refer to a recovery college. But the college may inform your care team.

Unfortunately, recovery colleges are not available in all areas. To see if there is a recovery college in your area you can search online or contact Rethink Mental Illness Advice Service on 0300 5000 927.

See our webpage on Recovery for more information.

Carer's, friends & relatives

Information for carers, friends and relatives

You can get support if you are a carer, friend or relative of someone with anxiety.

How can I get support?

You can do the following.

• Speak to your GP about medication and talking therapies for yourself.
• Speak to your relative’s care team about a carer’s assessment.
• Ask for a carer’s assessment from your local social services.
• Join a carers service. They are free and available in most areas.
• Join a carers support group for emotional and practical support. Or set up your own.

What is a carer’s assessment?
A carer’s assessment is an assessment of the support that you need so that you can continue in your caring role.

To get a carers assessment you need to contact your local authority.

How do I get support from my peers?
You can get peer support through carer support services or carers groups. You can search online for local groups in your area. Or you can contact the Rethink Mental Illness Advice Service and we will look for you.

How can I support the person I care for?

You can do the following.

• Read information about anxiety disorders.
• Ask the person you support to tell you what their symptoms are and if they have any self-management techniques that you could help them with.
• Encourage them to see a GP if you are worried about their mental health.
• Ask to see a copy of their care plan, if they have one. They should have a care plan if they are supported by a care coordinator.
• Help them to manage their finances.

What is a care plan?
A care plan is a written document that says what care your relative or friend will get and who is responsible for it.

A care plan should always include a crisis plan. A crisis plan will have information about who to contact if they become unwell. You can use this information to support and encourage them to stay well and get help if needed.

Can I be involved in care planning?
As a carer you can be involved in decisions about care planning. But you don’t have a legal right to this.

Your relative or friend needs to give their permission for the NHS to share information about them and their care.

For more information see our webpages on the following:

• Supporting someone with a mental illness
• Getting help for someone in a mental health crisis
• Suicidal thoughts - How to support someone
• Responding to unusual behaviour linked to mental illness
• Carer’s assessment
• Confidentiality and information sharing for carers, friends and family
• Worried about someone’s mental health
• Stress - How to cope

Further reading

NHS – Breathing Techniques

This NHS website has information on calming breathing techniques These techniques can help you when you feel anxious or are having a panic attack.

Website: www.nhs.uk/mental-health/self-help/guides-tools-and-activities/breathing-exercises-for-stress/

NHS – Every Mind Matters
This website has lots of useful information and practical tips on how to manage symptoms of anxiety.

Website: www.nhs.uk/oneyou/every-mind-matters/anxiety/

No Panic - Resources
The No Panic website has lots of resources to help people who are living with anxiety. This includes information on breathing techniques, relaxation techniques and advice on how to stop a panic attack.

Website: www.nopanic.org.uk/resources/

Centre for Clinical interventions
This website is provided by the department of Health in Western Australia. They have some useful information sheets and a workbook for people who are experiencing Body dysmorphic disorder (BDD).

Website: www.cci.health.wa.gov.au/Resources/For-Clinicians/Body-Dysmorphic-Disorder

Useful contacts

Anxiety UK
A user-led organisation that supports anyone with anxiety, phobias, panic attacks or other anxiety disorders.

Telephone: 03444 775 774
Text: 07537 416905
Address: Anxiety UK, Nunes House, 447 Chester Road, Manchester, M16 9HA
Email: support@anxietyuk.org.uk
Website: www.anxietyuk.org.uk

Social Anxiety UK
Offers support with social anxiety disorder. They are a web-based organisation and offer forums, a chat room and information about social anxiety.

Email: contact@social-anxiety.org.uk
Website: www.social-anxiety.org.uk

OCD-UK
Gives information, advice and support on obsessive compulsive disorder (OCD) and related disorders such as body dysmorphic disorder (BDD), skin-picking and hair pulling.

Telephone: 01332 588 112
Address: OCD-UK, 8 Chapel Street, Belper, Derbyshire, DE56 1AR
Email via website: www.ocduk.org/contact-us/
Website: www.ocduk.org

No Panic
Offers emotional support and information on anxiety disorders and medication including tranquilizers. They have a 1 to 1 mentoring scheme and a telephone recovery group available to their members.

Telephone: 0300 772 9844
Address: No Panic, 51a Market Street, Oakengates, Telford, Shropshire. TF2 6EL
Email: sarah@nopanic.org.uk
Website: www.nopanic.org.uk