When does anxiety become problematic? Symptoms of GAD range from restlessness and fatigue to poor concentration and sleep disturbances. Photo / 123RF
If you’re concerned your feelings are more than just everyday stresses, here’s the lowdown on symptoms, possible causes and how to get help.
Everyone feels anxious at times, not least since the pandemic, which took our usual everyday worries and super-charged them into the stratosphere. Almost one in four people reported high levels of anxiety in 2022/23, according to the Office for National Statistics. And more than a third of young people aged 18-24 suffer from symptoms of depression and anxiety, says the Resolution Foundation.
While some anxiety is normal, too much can interfere with your everyday life and become a problem. So when does it tip over into something more serious? And how can you tell if you are suffering with the more complex mental health condition of generalised anxiety disorder (GAD)?
Anxiety is different to simply just worrying about issues in our day to day lives. “Anxiety is first and foremost a feeling of nervousness and anticipation,” explains Dr Mike Capek, a retired GP with more than 30 years’ experience who now works as a hypnotherapist.
This is typically felt around big events, changes or periods of uncertainty, he explains, but can, of course, include positive things, like nerves before a big exam or pre-wedding jitters. “It’s a perfectly normal, natural feeling. But I think anxiety tends to be thought of by the general public as something abnormal,” Capek adds.
According to Dr Jon Van Niekerk, chairman of the Royal College of Psychiatrists’ General Adult Faculty, some anxiety can be a good thing. “In layman’s terms, we’re talking about stress. Sometimes it’s very helpful to have some stress or anxiety because it makes you alert when you need to be,” he says.
In the case of an exam or important work presentation, for example, anxiety can be a good motivator. Similarly, he adds, anxiety during the pandemic made us more careful about things like hand-washing and wearing masks, which helped to protect ourselves and others.
When it starts to affect your day-to-day functioning is when it becomes a problem, says Van Niekerk.
Abnormal levels of anxiety can be a symptom of several different conditions, Capek says. “It can be thought of as a condition or diagnosis in its own right, such as generalised anxiety disorder or panic disorder. It can be a symptom of a physical illness, like an overactive thyroid, for example. Or it can be a symptom of another psychological condition, like post-traumatic stress disorder,” he explains.
Generalised anxiety disorder is a mental health condition. It is usually diagnosed once all other reasonable causes have been eliminated, Capek says.
Signs of generalised anxiety disorder include:
“If someone has three of those features, there’s no other better diagnosis,” Capek explains, “and it’s not due to drugs or medication, then a diagnosis of generalised anxiety disorder may be appropriate.”
To be diagnosed with GAD, he adds, these symptoms need to have persisted for more than six months and to be present on most days. “Six months is a fairly arbitrary line, but it’s to show that the anxiety has been present for some time and isn’t in reaction to an immediate source of distress,” says Capek.
“GAD is an excessive, persistent, unreasonable anxiety state. People who have been diagnosed with GAD are often struggling with lots of different worries at the same time and may have difficulty controlling these fears,” says Van Niekerk. “It’s something that affects your day-to-day functioning, like being able to do your work.”
What distinguishes GAD, Van Niekerk adds, is that the anxiety doesn’t have a specific situational trigger. Other types of anxiety include phobias, which usually relate to a particular object (such as spiders) or experience (like flying); or social anxiety, which is triggered in social settings. Instead, people with GAD may worry about all kinds of different things in different situations. These worries may also be out of proportion to the situation they’re in.
While GAD symptoms are psychological in origin, they can also present in very physical ways, like panic attacks or gastrointestinal symptoms. “Some people may experience an increased heart rate or breathing fast, or even a panic attack. This can feel very scary and real, so they may feel like they’re having a heart attack or stroke,” Van Niekerk says.
“Panic attacks can be associated with GAD but may also be a symptom of panic disorder. Sometimes the two can co-exist, but we tend to screen for panic disorder before we make the diagnosis of GAD. This is to make sure someone’s anxiety can’t be better explained by panic disorder, so they receive the most appropriate treatment.”
Gastrointestinal symptoms, he adds, can be related to changes in eating habits – for example, if someone is using food as a way of trying to cope with their anxiety.
Generalised anxiety disorder is a common condition, but can present in varying severity, says Professor Kamila Hawthorne, chairwoman of the Royal College of General Practitioners.
In general, Capek says, around a third of all GP consultations will have some sort of psychological or mental health component. “At any one time, about 25 per cent of the population will be experiencing some sort of ongoing distress. Figures for GAD vary between about 4-7 per cent of the population,” he says.
Research suggests GAD is most common between the ages of 35 and 55, and affects more women than men. However, Van Niekerk says this may partly be down to under-diagnosis in men. “Some figures say it’s twice as common in women as in men, but there are concerns that it’s underdiagnosed in men,” he explains.
“It may also be to do with differences in how it presents. In men you may see more of the irritability, the anger. They tend to complain more about physical symptoms, like back ache or muscle aches, rather than anxiety. They may also self-soothe using alcohol or other unhelpful coping mechanisms.”
These coping mechanisms can also lead to additional problems. “Trying to treat anxiety yourself, through things like alcohol, excessive smoking or sometimes even drug misuse, can of course have its own effect on your mental and physical health,” Van Niekerk says.
Chronic, unresolved anxiety itself can put you at risk of certain health issues, as well as damaging your career prospects and interpersonal relationships.
“People who are chronically stressed may be able to suppress the emotion and appear to be coping with it on the outside. But they are certainly going to be more prone to cardiovascular problems, high blood pressure and strokes,” Capek says.
Physiologically, anxiety can also trigger conditions like irritable bowel syndrome or eczema, he says. Meanwhile, chronic tiredness can lead to people having accidents or making mistakes.
Externalising anxiety through anger is something else that’s particularly seen in men, Van Niekerk adds. This can be problematic both in the workplace and at home, harming relationships with your colleagues, romantic partners, children and other loved ones.
It’s likely to be a combination of genetic and environmental factors, Niekerk says. “There’s some evidence to show that if you have a family member with GAD, you’re four to six times more likely to have GAD yourself, so it tends to run in families,” he explains.
In Capek’s experience, GAD is often caused by an ongoing stress that lasts for a long period of time without settling, or a series of stressors one after the other. “Often it can stem from childhood, because that’s where most of our patterns of behaviour are laid down,” he says.
“Somebody will get into a pattern of being under stress, feeling anxious about whatever it is, and they learn that anxiety as being their own personal ‘normal’. You can then see how they might develop sleep disturbances or become hyper-vigilant, because they’re constantly expecting something to go wrong.”
This, Capek adds, may be a perfectly normal and understandable reaction to what they’ve been through. He therefore prefers to think of GAD as a condition, rather than a “disorder”. “Normalising a person’s experience, and understanding where their behaviour stems from, is a good step on the way to recovery,” he says.
People struggling with anxiety will usually present first to their GP, Hawthorne says. “GPs are highly trained to have frank and sensitive conversations with patients when they present with feelings of anxiety or have concerns around their wider mental health,” she says.
“Ensuring patients feel heard and receive the best possible mental health care is a priority for GPs, so we take presentations of GAD with due concern. If they can, GP practices will offer longer appointments for mental health patients, but it is increasingly difficult to offer patients the complex care they need within the constraints of a standard 10-minute consultation,” Hawthorne adds.
Patients affected by GAD can exhibit a range of different symptoms and there are a variety of appropriate treatments, depending on their individual circumstances. “These will be determined by a GP, in conversation with the patient, based on the severity of their symptoms, their medical history and any other medication they may be taking,” she explains.
Treatment options include anti-anxiety medications and/or talking therapies, like counselling or cognitive behavioural therapy (CBT).
In severe cases of GAD, medications like benzodiazepines can be prescribed in the short term, Van Niekerk says. These include diazepam and lorazepam, which can make people feel very calm. However, side effects include drowsiness, and these medications can be addictive. They shouldn’t be used for more than four weeks, at the lowest dose required.
SSRI antidepressants (such as citalopram, sertraline and fluoxetine) can also be effective for anxiety disorders, and tend to work best when combined with therapy, Van Niekerk explains.
Anxiety is driven by hormones and neurotransmitters called adrenaline (epinephrine) and noradrenaline (norepinephrine). These play a role in your body’s stress response, commonly known as “fight or flight”. Medication can therefore change the chemical imbalance inside the brain and benefit the patient so they can feel and function better, Capek explains.
“Medication works from the outside, whereas any form of psychotherapy is internal, and the outcome is that the patient actually learns a skill,” he adds. “They learn how to challenge their thoughts, or how to use their anxious energy for other benefits, for example. Therapy may take a bit longer, but the benefits will last much longer as you gain a skill that can be applied to different situations.”
There is no one-size-fits-all solution. “For some patients, it can be manageable with simple, self-directed tools, such as learning how to control their breathing, but for others it can have a pronounced impact on their quality of life,” Hawthorne says.
“Firstly, avoid any unnecessary anxiety-provoking situations,” Capek says. “For example, during the pandemic, someone who was watching the news 24/7, waiting for the next local outbreak, was not doing themselves any good whatsoever.”
Similarly, Van Niekerk suggests limiting time spent mindlessly scrolling on social media, particularly late at night. “Scrolling can be a coping strategy, but our devices emit unnatural light, so they can actually become part of the problem,” he says.
Instead, he adds, “The first big thing you can do to help yourself is to acknowledge that you have a problem and talk about it with someone you trust and feel comfortable with. That could be a friend, GP, religious leader, or so on.”
Van Niekerk says a healthy, balanced diet is always preferable for your mental health. Avoid eating as a coping mechanism, he adds, as this can lead to gastrointestinal symptoms.
Exercise is a healthy coping strategy that can take your mind off your worries, as well as providing an outlet for the excess of adrenaline and releasing muscle tension, he adds.
It’s also a good idea to limit stimulants like caffeine, particularly after lunchtime, to minimise the vicious cycle of disturbed sleep and tiredness.
Capek recommends allowing two hours to wind down before bed. This means finding something that takes your mind off your worries and helps you to chill out.
For some people, that might involve limiting screen time if you find it over-stimulates your mind. For others, though, watching a film might be the perfect way to switch off before bed.
Another way to minimise anxiety is to cut yourself a bit of slack, Capek adds. “Often people develop a fear of feeling anxious, and that becomes a vicious cycle of worrying about the worry. The paradox is that if they can simply accept their anxiety, that actually reduces it,” he explains.
Tools such as breathing exercises, meditation and mindfulness can be helpful with this. Mindfulness is about being aware of the here and now, for example by focusing on your breathing or each of your five senses, rather than ruminating on anxious thoughts.
As Hawthorne mentions, there are plenty of self-help tools available, including peer support groups, self-help books, online courses and apps. Many of these are based on techniques like CBT or mindfulness, and your GP should be able to point you in the right direction.
Let’s take a look at the science.