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Anxiety Disorders in adults

Anxiety is a normal response to a stressful life situation such as illness, job loss, relationship breakdown, imminent danger etc. At these times, it is normal to feel tense and irritable and sometimes even to panic. These feelings are often accompanied by physical symptoms such as palpitations, sweating, chest tightness, tremors, difficulty in breathing, hot and cold flushes, nausea, difficulty swallowing, diarrhoea, headaches and muscle tension.

Anxiety disorders, on the other hand, are associated with persistent feelings of high anxiety that are inappropriate for the situation. These feelings lead to irrational responses that are significant enough to interfere with daily life activities, often involving the avoidance of situations associated with these concerns. These disorders are common and affect at least five per cent of the population at any one time with about ten per cent of people being affected at some stage during their lifetime. Like most mental illnesses, they are chronic in nature.

Anxiety symptoms usually develop during early childhood and anxiety conditions are at least as common in childhood as they are in adults. Up to 15 per cent children and teenagers experience significant anxiety conditions. These children have a significantly increased likelihood of developing adolescent depression and substance/alcohol abuse and they are much more likely to become anxious and depressed adults.

The exact cause of anxiety disorders is still unclear. However, in most cases there are both inherited and learned (environmental) components present. The learned component has mostly occurred by the time young adulthood is reached. The good news is that there are many good programs for the management of anxiety that have strong evidence for their benefit. It can be unlearned as well by using stress management  programs and good parenting techniques.

Many people with an anxiety disorder also have depression and it is important to recognise when these conditions occur together as these people are harder to treat. Generally speaking the condition which came first is the one that needs most attention, although anyone with significant depressive symptoms needs them treated as a priority.

There are various types of anxiety disorders. (See below). Unfortunately, many people suffering from them do not seek help, with only about 30 per cent of suffers seeking professional mental health assistance. This is a pity as treatment with psychotherapy, usually cognitive behavioural therapy (CBT), commonly works well. The basics of CBT are discussed in the chapter on Achieving change and in the section on depression.

Incidence of anxiety in adults: Anxiety disorders occur in about 14% of the adult population with the rate in women (18%) being significantly higher than the rate in men (11%). The most common type is post-traumatic stress disorder which affects 6.4% of the adult population. In all about 20% of women and 10% of men report having a specific phobia.

Anxiety disorders are often associated with other mental illness, especially depression and alcohol abuse and it is common for more than one type of anxiety disorder to be present.

Generalised anxiety: (Affects about 2.7% of the general adult population)

People with this disorder worry inappropriately about all manner of things, such as finances, health and relationships. Their worry is often associated with restlessness or feeling ‘on-edge’, irritability, insomnia, fatigue, muscle tension and impaired concentration. It occurs in about three per cent of Australians each year and is at least twice as common in women. It is often accompanied by agoraphobia.

Agoraphobia: (Affects about 2.8% of the general adult population)

These people have a fear of places or situations that may trigger a panic attack or from which escape is difficult if a panic attack occurs. This is a very common disorder, especially in women, and is usually experienced in crowded situations, such as lifts or public transport. Hence sufferers often tend to stay at home.

Panic disorder: (Affects about 2.6% of the general adult population)

These people experience recurrent extreme panic attacks which come on quickly and last usually for a short period. These attacks are associated with numerous symptoms including palpitations, shaking, numbness, sweating, chest pains, shortness of breath, nausea, choking, dizziness / faint feelings and feelings of being detached from oneself and losing control. Usually one symptom, such as shortness of breath, will become the focus of the disorder and the episodes are often misinterpreted as being due to or associated with a catastrophic medical condition such as a stroke or hear attack; sometimes sufferers fear that they will even die. They are followed by a prolonged period of worry about another attack occurring and the person usually responds by taking steps to avoid situations where they fear another attack will occur. This often leads to an association with agoraphobia, as sufferers avoid places where panic attacks have previously occurred, and social phobia, as sufferers often associate attacks with specific social situations in which attacks have previously occurred. (Panic disorder can occur in association with any anxiety condition.) It occurs in about three per cent of Australians each year, is at least twice as common in women and peaks in the mid 20s. About 30 to 50 per cent also have co-existing depression. This condition responds very well (90 per cent) to cognitive behavioural therapy. Antidepressants are also quite effective but there is a higher relapse rate than occurs with CBT.

Specific phobia: (Affects about 4.7% of the general adult population)

Sufferers are inappropriately fearful of a specific situation or thing, such as spiders.

Social phobia (Social anxiety disorder):

Social phobia is very common, with as many as 10 per cent of the population suffering from the disorder at some time during their life and about two per cent suffering more severe impairment.
These people feel that their character is flawed in some way, e.g. that they are stupid, incompetent, uninteresting or unattractive, and that other people will think badly of them in some way. Thus, they fear public scrutiny and experience feelings of shame, fear and embarrassment when exposed to such scrutiny. This causes physical symptoms of blushing, rapid breathing, breathlessness, sweating, palpitations, nausea, dizziness or shaking and these symptoms may be bad enough to cause panic attacks. (The fear that symptoms such as blushing will expose their underlying anxiety about the social situation they are presently in only makes the situation worse.) Behavioural responses in sufferers range from excessive shyness to avoidance of the situation, flight from the situation or freezing during the situation. These symptoms and responses may occur in generally in public or in specific situations such as when the person speaks in public, takes tests or is examined, eats or drinks in public or performs work duties under observation.
The disorder can significantly impair educational attainment and workplace advancement, and thus economic prospects.
Sufferers tend to be oversensitive to signals from others and can misinterpret these signals, often seeing every response as a negative one). There is also an inherited / ‘family learned’ component in many affected individuals, with parents and other family members often exhibiting similar social phobia traits.

Obsessive compulsive disorder: (Affects about 1.9% of the general adult population)

These people inappropriately worry about recurrent, specific intrusive thoughts, ideas or impulses, such as cleanliness. They placate these obsessive thoughts etc by developing highly repetitive, stereotyped behaviours (compulsions).

Post-traumatic stress disorder:  (Affects about 6.4% of the general adult population)

These people have unresolved anxiety associated with a particular traumatic event in their lives.
All the above anxiety disorders can be associated with panic attacks with associated hyperventilation. (These are discussed in detail in the treatment section.)

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Treating anxiety disorders in adults

Anxiety is a serious problem and left untreated can affect lives for many years. It therefore needs to be treated seriously and treatment should be sought from a practitioner interested in and competent at treating this range of conditions. It is not a condition that people can cure themselves and requires the help of a therapist. (There are, however, some online programmes that therapists can use to augment treatment.) The information provided in this web site regarding such treatment is intended as an introduction only.

As anxiety and depression often co-exist, treatment of depression is also necessary. (Often the treatments are similar anyway.) (See section on depression.)

Cognitive behavioural therapy (CBT)

The treatment for anxiety disorders is often similar to the treatment of depression and not uncommonly, the two conditions coexist. The approach taken depends on the type of disorder present. Treatment in most cases involves a counsellor and uses a form of cognitive behavioural therapy (CBT). CBT is the first line therapy for many anxiety conditions, including agoraphobia and panic attacks. However, very few people receive CBT for these conditions. (Only about two per cent of people with panic attacks receive CBT.) An outline of the principles of this therapy is given in the section on treating depression. CBT courses can be delivered with the help of a practitioner (usually 8 to 12 sessions) or online with the help of a practitioner. (This is a significantly cheaper option that does work.) Some online provider options include:

  • Clinical Research Unit for Anxiety and Depression (CRUfAD) -THIS WAY UP
    • Used for mild-to-moderate panic disorder, generalised anxiety disorder, depression, social anxiety, mixed anxiety and depression and obsessive compulsive disorder
  • Macquarie University -Mindspot
    • Used for mild-to-moderate obsessive compulsive disorder, post-traumatic stress disorder, stress, anxiety and depression
  • Swinburne University - Mental Health Online.
    • Specific programs for a variety of anxiety disorders

Medication

Antidepressant medications are also of assistance in the treatment of anxiety cases but are usually kept for cases where CBT has been unsuccessful or where depression co-exists. These are discussed in the section on treatment of depression.
Benzodiazepines, a group of sedative medications that include diazepam (Valium) and oxazepam (Serepax), are also used in some cases. They are however addictive and should only be used for short periods (two to four weeks) while CBT is taking effect. These medications need to be ceased gradually.

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Controlling physical symptoms of anxiety - Panic Attacks and muscle tension

Both acute anxiety episodes and chronic anxiety conditions can be associated with debilitating physical symptoms. The most serious are those associated with acute panic attacks.

Panic attacks (or acute anxiety) symptoms

An important aspect of treatment in many anxious people is the control of the physical symptoms that occur when a person is in an anxiety provoking situation.
Controlling associated hyperventilation symptoms
Many frightening anxiety symptoms, including shortness of breath, chest tightness, light headedness or feeling faint and tingling feelings in the hands and lips, are due to over-breathing or hyperventilation. The average person requires about 10 to 12 breaths of normal depth per minute. (One breath means breathing in and out once.) The normal breathing rate and breath depth increase when people are anxious, resulting in a reduction in the carbon dioxide level in your blood. This causes the above symptoms. Whilst this is not dangerous, it is frightening and acts to worsen the anxiety levels being felt, making the situation even worse. Over-breathing can be identified by counting the person’s breathing rate when he or she is feeling normal and comparing it to when he or she is feeling anxious.
Controlled breathing
The use of ‘Controlled Breathing’ helps avoid over-breathing and helps reduce hyperventilation symptoms while they are occurring. (This usually takes only a minute or two.) This technique gives a breathing rate of ten breaths per minute. It is best to use a watch with a second hand to count the seconds. An alternative is to count one second by saying ‘one-hundred-and-one’ etc.
The exercise is performed as follows.

  1. Breathing through the nose, take a medium breath in, hold it for 6 seconds and then breathe out.
  2. After exhaling, say the word relaaaaaaaaaaaaaax calmly.
  3. Breathe in and out slowly taking three seconds to breathe in and three seconds to breathe out. Say the word ‘relaaaaaaaaaaax’ after each breath. Make sure breaths are not too deep.
  4. After one minute hold the person should hold their breath again for six seconds and repeat the process.

This technique should be practiced regularly when you are not feeling anxious so that it becomes second nature and is easy to use when symptoms are likely to occur or are occurring. A good practice regimen is four times a day; before each meal and at bedtime.

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Relieving chronic anxiety symptoms

Relieving muscle pain /tension with Progressive Muscular Relaxation

Another common physical symptom experienced by stressed people is muscle pain and tiredness due to constantly tensed muscles. Muscles are meant to be in a relaxed state unless being used. In people with chronic anxiety their chronically heightened flight-and-flight response means that muscles are held tight ‘ready-for-use’, causing tiredness and pain.  

Muscle relaxation exercises can be used when people experience such symptoms and are also useful for relieving the mental ‘tension’ associated with anxiety. See boxed section for one such exercise.

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Muscle relaxation exercises

1.  First sit on a comfortable chair in a quiet room with feet on the ground and eyes closed.
2.  Do the ‘Controlled Breathing’ exercise mentioned above for three minutes.
3.  Then, starting with your hands, tense the muscles in each body segment mentioned for ten seconds and then relax for ten seconds.
It is important not to tense muscles too tightly during the exercise and certainly not to the point where pain is felt. Do the muscle groups in the following order.

  • hand - clench fists for ten seconds and then relax for ten seconds
  • lower arms - bend hands up at the wrists and then relax
  • upper arms - bend arms up at the elbow and then relax
  • shoulders - lift shoulders up and then relax
  • neck – rotate neck slowly, starting by bending to the left, then to the front and continuing in a clock-wise direction
  • forehead - raise eyebrows and then relax
  • eyes - close tightly and then relax
  • jaw - clench teeth and then relax
  • chest – breath deeply in and then out (do only once)
  • abdomen  - pull in ‘tummy’ and the relax
  • upper back - roll shoulders forward and then relax
  • lower back - roll back into a smooth arc (while still sitting) and then relax
  • buttocks – tighten buttocks and then relax
  • thighs - push feet into floor and then relax
  • calves - lift toes off the ground and then relax
  • feet - curl toes down and then relax

4.  Then do the breathing exercise again for about five minutes.

The whole exercise should take about twenty minutes. People can also think about pleasurable thoughts as they do it, especially as the process becomes second nature.

Initially the exercise should be done once a day in a quiet room so that the person can relax better and focus on what they are doing without distractions. Finding a quiet place at work to do relaxation exercises is also beneficial. If there is none, go outside to a nearby park. Listening to relaxation tapes while doing the exercises is very helpful.

The whole exercise should take about twenty minutes. People can also think about pleasurable thoughts as you do it, especially as the process becomes second nature.

Initially the exercise should be done once a day in a quiet room so that the person can relax better and focus on what they are doing without distractions. Finding a quiet place at work to do relaxation exercises is also beneficial. If there is none, go outside to a nearby park. Listening to relaxation tapes while doing the exercises is very helpful.

Short relaxation exercises that can be done away from home when feeling stressed
Exercises designed to tighten and then relax a particular muscle group(s) (e.g. hands, shoulders, forehead) can be done in almost any situation to help relieve tension and most can be done without attracting attention. People should try to do the exercises as soon as they start feeling tense rather than waiting till the feeling worsens. Here are some examples that people can use and adapt. Try not to hold muscles tensed for more than seven seconds and again don’t tense muscles excessively.
In a private place: Take a shallow breath and hold it for about seven seconds and while doing this stretch out arms and legs. Then breathe out, say the word ‘relaaaax’ and completely relax arms and legs. This can be done several times but not too close together.
In a public space while sitting: Take a shallow breath and hold it for about seven seconds and while doing this cross ankles and press feet into the ground while at the same time trying to lift lower legs (calves). Then breathe out, say the word ‘relaaaax’ and completely relax arms and legs. Again this can be done several times but not too close together.
In a public space while standing: Take a shallow breath and hold it for about seven seconds and while doing this straighten both legs by tensing all the muscles. Then breath out, say the word ‘relaaaax’, and completely relax arms and legs. Again this can be done several times but not too close together.

Be aware that learning to relax takes time and people need to allocate enough time in their day to give it a chance!!

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Avoid stimulant substances that increase anxiety

Caffeine and nicotine.
The most common of these are caffeine containing substances, mainly tea and coffee, and nicotine contained in cigarettes. These substances increase excitement and the fight-and-flight response, and their use is thus associated with an increase in unhelpful anxiety-like symptoms such as palpitations and tremors. The regular consumption of any of these substances increases anxiety generally and can precipitate an acute anxiety (panic) attack, especially caffeine. Coffee should be restricted to one to two cups a day or none at all if it precipitates acute anxiety attacks. Cigarettes should be avoided altogether as they are such a general health hazard. If people cannot stop, they should try not to smoke before they are likely to be faced with an anxiety provoking situation.

Illicit drugs
Many commonly used illicit drugs are stimulants that can cause or exaccerbate acute and chronic anxiety in their users. Such drugs include amphetamines and the related compounds ‘Ecstasy’ and ‘Ice’, and cocaine. These drugs should obviously be avoided in anyone with anxiety or depression or any other mental illness.

Alcohol use
Initially after consumption, alcohol acts as a depressant and is thus used by some people to reduce anxiety symptoms. (A drink before a social occasion to ease the nerves is common practice for many people.) However, a few hours after its use, alcohol acts as a stimulant and at this time anxiety sufferers are more likely to have acute anxiety / hyperventilation attacks. (Such attacks can also occur when experiencing a ‘hang-over’.) Dependence is also quite likely to develop in people with anxiety or depression. Alcohol is best to avoided in people with anxiety and depression.

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Further information on mental illness

Mental health resources

Mental Health Branch of the Department of Health and Aged Care  www.mentalhealth.gov.au
This site provides information about crisis supports and contacts, general mental health information, mental health information brochures / publications about specific topics such as depression, anxiety, information about suicide prevention etc.
Ph 1800 066 247

Beyond Blue: The National Depression Initiative www.beyondblue.org.au

ybblue (Beyond Blue’s youth program)  www.youthbeyondblue.com
Beyond Blue’s youth program

Black dog institute www.blackdoginstitute.org.au
Provides information for clinicians and patient education.

Black dog institute for young people aged 12 to 18 years www.biteback.org.au
Provides information for clinicians and patient education.

Sphere (For GPs) www.spheregp.com.au
Sphere is a national education health project aimed at increasing GPs rates of identification, effective treatment and management of common psychological problems.

Moodgym   www.moodgym.anu.edu.au
An interactive program of CBT, more aimed at depression, developed by the Centre for Mental Health Research at the Australian National University.)

Reachout www.reachout.com.au
A resource for young people with depression.

Self-Injury www.self-injury.net
A web site with information about youth self-injury; an increasing problem in western society. It is run by a young adult who has previously self injured and gives information about overcoming the problem.

Lifeline www.lifeline.org.au  Ph 13 1114
Lifeline provides an immediate counseling service for all people)

Kids Help Line www.kidshelp.com.au
A national 24 hour counseling service for children and young people)
Ph 1800 551 800

CRUfAD, The Clinical Research Unit for Anxiety and Depression www.crufad.com 
CRUfAD is a group of researchers and clinicians concerned with anxiety and depression. It is a joint facility of St Vincent's Hospital Ltd and the University of New South Wales in Sydney, Australia. The self-help section of the web site has useful information about both anxiety and depression for the general public.

Anxiety Panic Hub www.panicattacks.com.au
A consumer web site with a focus on meditation / mindfulness.

The Panic Anxiety Disorder Association www.panicanxietydisorder.org.au 
Provides good consumer information

Toughin it out  www.toughinitout.com  
A program detailing survival skills for dealing with suicidal thoughts.

Mindmatters   http://cms.curriculum.edu.au/mindmatters/index.htm
A program that introduces mental health education to secondary schools.

Inspire Foundation  www.inspire.org.au/   
For people aged 14 to 25

National e-Therapy Centre Swinburne University  www.anxietyonline.org.au  
Help with all types of anxiety disorders

 

Further reading on mental health topics

Rapee, R., Spence, S., Cobham, V. and Wignall, A. Helping your anxious child. A step by step guide for parents. New Harbinger, 2000.

Macquarie University Child and Adolescent Anxiety Unit
This unit runs 12 week courses for anxious children in the 6 to 12 year age group.
www.psy.mq.edu.au/muaru.

Rapee, R.M. (2001). Overcoming shyness and social phobia: A step by step guide. Sydney: Lifestyle Press.
Deals with social phobias and shyness

Wells, A. (1997) Cognitive therapy of anxiety disorders; a practice manual and conceptual guide. Chichester. John Wiley and Sons, 1997.
  
Beating the blues by Susan Tanner and Jillian Ball. Published by Susan Tanner and Jillian Ball. Distributed by Tower books.
A good book for issues dealing with the treatment of depression.

Don’t panic. Overcoming anxieties, phobias and tensions by Andrew Page. Published by Liberty One Media.
Deals with panic disorders, phobias and anxiety.

Aisbett, B. Living with it; a suvivor’s guide to panic attacks. Pymble, NSW. HarperCollinsPublishers, 1993.

Aisbett, B.Taming the black dog. Pymble, NSW. HarperCollinsPublishers, 2000.

Calrk, S. After suicide: help for the bereaved. Melbourne. Hill of Content Publishing Company Pty Ltd, 1995.

 

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