Anxiety is a feeling that everyone is familiar with, and it is a normal, beneficial response when a person is in danger. With anxiety disorders, the anxiety is unfounded or grossly exaggerated; it is experienced as uncontrollable and prevents the person from acting reasonably – a sort of “false alarm”. Anxiety is found in virtually all mental disorders and illnesses. Anxiety disorders (or states of anxiety, as they are also called) include a number of mental disorders where anxiety is the dominant symptom. Anxiety disorders are very common in Western society. They often start in childhood or adolescence, but they can also begin later in life.

The main characteristic of anxiety disorders is a feeling of anxiety with many physical (bodily) symptoms even though there is no actual danger present. The anxiety could, for example, be directed towards being around other people, being alone, or leaving the house, and the anxiety sufferer has a tendency to avoid whatever it is that he/she fears.

Anxiety disorders have very different degrees of severity, from very mild conditions that are a nuisance in everyday life to a disabling fear of ordinary, everyday activities such as shopping, getting on a bus or being around other people. In some cases, the anxiety prevents people from undertaking a study programme, having a job and/or a social network, and anxiety always impairs quality of life.

The course of anxiety disorders can vary. Some people develop anxiety gradually over a number of years; for others, it starts abruptly with a violent anxiety attack. In some people, the anxiety is constantly present, and in others it comes and goes.

Anxiety disorders can become chronic if left untreated. You may experience relapses of anxiety after treatment, which can often be improved by a short course of treatment as a reminder of the methods.

There is no single explanation as to why some people develop an anxiety disorder. There are several significant factors, and they can interact in various ways. In some cases, there is a definite triggering stress factor or event. In other cases, the anxiety seems to come out of the blue. Something that can lead to anxiety in one person may simply be a temporary stress factor for someone else.

Heredity plays some part in the likelihood of a person developing an anxiety disorder. Many anxiety sufferers have a family member who suffers from anxiety or depression. Anxiety disorders and depression are related disorders and occur more frequently in some families than in others. The disorder itself is not hereditary, but susceptibility to developing it is. In some people, the heredity factor is very significant, and even short-term stress or a few stressful events can trigger anxiety. Others are protected by their genes, so it takes more for them to develop anxiety.

The results of research are somewhat inconclusive concerning psychological and social factors in a person’s formative years which could increase the risk of succumbing to an anxiety disorder. Perceived lack of control can pave the way for anxiety. For example, this could be parents with unpredictable reactions due to alcohol abuse. Certain personality traits also increase the risk of developing an anxiety disorder. This applies particularly to anxiety-avoidance traits (neuroticism), where a person is characterised by caution, nervousness and a tendency to react strongly to negative events.

In many cases, perfectly ordinary events immediately precede an outbreak of the anxiety disorder: family arguments, physical illness, a death in the family or, most commonly, stress at work.

Abuse of alcohol, marijuana, amphetamines or other substances increases the risk of acquiring an anxiety disorder and aggravates its progression. Abuse can make treatment more difficult, as it reduces motivation and problemsolving ability. Finally, abuse is detrimental to health and must be stopped before or concurrent with treatment for anxiety.

In a healthy, properly functioning individual, behaviour and emotions are controlled by the frontal part of the brain. This part of the brain is the seat of reason and planning and therefore controls the emotions. In anxiety, control of the emotions is taken over by the deeper areas of the brain (the amygdala system), which has evolved to react rapidly to danger. Often, this happens entirely automatically. That makes our behaviour more irrational. We become more impulsive; increasingly, our emotions take over, and fear and avoidance become ingrained automatically. In actual danger, e.g. when faced with an aggressive dog, this is appropriate, but not if the same reaction occurs while shopping in a supermarket. Once the amygdala system has taken over control, the anxiety tends to expand into more and more areas of everyday life.

Among other things, the amygdala activates the autonomic nervous system. The autonomic nervous system is divided into the sympathetic nervous system and the parasympathetic nervous system and is characterised by the fact that we have no influence over it. The sympathetic nervous system gets the body ready for fight or flight when a person feels in danger, whether real or imagined. This triggers a number of physical symptoms such as palpitations, shortness of breath and muscle cramps, evident in all anxiety disorders. The parasympathetic nervous system is active on the one hand when a person feels secure and on the other when the sympathetic nervous system has been active for a while, to ensure that the anxiety is quelled.

All anxiety disorders have physical, emotional, mental and behavioural symptoms, but the content and relative weighting of these four aspects will vary from one disorder to another.

• Autonomic symptoms: palpitations, sweating, trembling, dry mouth.

• Chest and stomach symptoms: shortness of breath, a suffocating feeling, pressure or pains in the chest, nausea or butterflies in the stomach.

• Symptoms of tension: muscle tension or pains, restlessness, difficulty relaxing, mental tension, difficulty swallowing.

• Other: dizziness, a feeling of unreality, feeling hot or cold, pins and needles or numbness, tendency to be jittery, difficulty concentrating, irritability or difficulty getting to sleep.

The degrees and types of anxiety are many and varied, ranging from anxiousness, nervousness and worry to mortal dread and panic.

When anticipating or when exposed to whatever provokes the anxiety, the person usually has a disaster mindset, i.e. highly exaggerated thoughts about the danger of the situation and the lack of one’s own ability to cope. Examples of such thoughts could be: “I’m dying of anxiety” and “I’ll never manage it”.

In the majority of anxiety disorders, early in the process, the person starts avoiding whatever provokes the fear. This could be a few minor things, but it could also be extreme avoidance of leaving the house, getting on a bus or train, or being around other people. In such cases, the avoidance becomes a disabling factor.

The person may also develop safety behaviour – trying to gain a sense of security by having things or people with him or her. This can help relieve the person of the need to avoid a certain situation, but in the long term, it can create dependency and impair confidence.

The four aspects of anxiety disorders are mutually reinforcing and result in the person maintaining the anxiety. Thoughts of impending disaster lead to avoidance and flight as well as safety behaviour. It is understandable that the person will try to avoid experiencing anxiety. Avoidance and safety behaviour provide immediate relief, but lead to maintaining and aggravating the anxiety disorder

People with anxiety disorders often experience anxiety before they are exposed to certain events. This is known as anticipatory anxiety. The level of anxiety associated with anticipatory anxiety can be very high and often contributes to avoidance. Additionally, the situation itself involves anxiety. Anxiety sufferers tend to be highly critical of themselves after having been in a situation that causes anxiety.

All anxiety disorders can have different levels of severity.

With mild anxiety, the person can lead a normal life, raise a family, have friends, undertake a study programme and hold down a job. But anxiety in social or other situations can inhibit the development of the individual and can be a nuisance in everyday life.

The person may find it so difficult to be around other people that he/she avoids socialising altogether, resulting in isolation and loneliness. Anxiety attacks can also occur so frequently and with such severity that the person is constantly afraid of having more attacks; does not dare to be left alone; and avoids leaving the house unaccompanied. Severe anxiety prevents the person from leading a conventional life.

Social measures may be necessary in more severe cases of anxiety. For a while, the person may need a support worker or mentor; to attend drop-in centres; or to have flexible employment, etc. Cooperation between regional psychiatry and municipal bodies can often be very valuable. For example, getting started in employment or similar may be crucial to the outcome of psychological and medicinal treatment. With all anxiety disorders, avoidance is a major problem that can easily lead to isolation and loss of social skills.

If possible, it is preferable to be employed or studying outside the home. In severe cases, this could be under protective conditions, or the person could pay regular visits to a drop-in centre.

Anxiety symptoms may resemble symptoms of various physical ailments. An anxiety disorder does not exclude the possibility of an ailment, and vice versa. When someone experiences anxiety for no reason, the person should be examined in case this is a sign of a physical ailment, such as hypermetabolism or cardiac disorder. Anxiety can also be one of the first signs of other mental disorders, notably depression, but psychotic disorders (mental illness) and dementia can also begin with anxiety. Finally, consumption of stimulants and alcohol can lead to anxiety.

The first thing to do always is to check that the anxiety is not a symptom of another disorder. A GP will examine the person for this by means of interviews, physical examinations and blood tests.

Once it has been established that the symptoms of anxiety are not due to a physical ailment, the therapist will question the person in detail about the present state and progression of the anxiety. What arouses anxiety? What symptoms of anxiety does the person have? What actions result in anxiety? How has the anxiety developed? The therapist here will be a GP or psychologist.

In addition, the therapist will investigate whether there are stress factors in the person’s everyday life, particular personality traits, or whether there are mental disorders in the person’s biological family in the form of anxiety or related disorders.

Based on this, a diagnosis will be made via the diagnostic system used in Denmark (ICD-10). Although there are similarities between people with the same disorder, there are also major individual differences. This depends on the individual’s situation and history, and whether the person also suffers from other disorders.

Generalised anxiety is characterised by excessive worry about major and minor things (e.g. personal health, everyday chores, and the woes and wellbeing of family members). The person has difficulty controlling these worries and often acts on them, e.g. by phoning to make sure nothing is wrong, or by having health examinations. Generalised anxiety involves frequent or constant torment from physical symptoms of anxiety, e.g. inner restlessness, tension, palpitations, outbreak of perspiration and dry mouth.

For a diagnosis of anxiety disorder, these symptoms must have been present for at least six months.

Panic disorder is characterised by sudden, recurring attacks of anxiety not restricted to particular situations. Physical symptoms occur during a panic attack, e.g. palpitations, sweating and/or shaking, dry mouth, breathing difficulties, pressure in the chest, dizziness and a feeling of unreality. Due to the violent physical symptoms, people who suffer panic attacks often start to fear they are suffering from a serious physical illness, that they are about to collapse, lose control, die or go mad.

To be diagnosed as suffering from panic attacks, the panic attacks must occur at least once a week within the space of a month. If the panic attacks occur particularly in specific situations, e.g. on a bus or at gatherings of a lot of people, the person will often try to avoid these situations in an attempt to avoid the panic attacks.

Agoraphobia frequently occurs in connection with panic attacks. People with agoraphobia feel anxious about being in various situations – often because they are anxious about having symptoms of anxiety in these situations. For example, sufferers might be anxious about leaving the house on their own, using public transport, driving, being among large groups of people, going to the shops or being alone. To avoid the anxiety, they will often try to avoid the situations that provoke anxiety.

Social phobia means a person is afraid in one or more kinds of social gathering. The person will usually try to avoid these situations. He/she is afraid of criticism from others and fears doing something embarrassing or wrong. The person is also anxious about demonstrating visible signs of anxiety, e.g. blushing, trembling hands, gagging or the urge to urinate.

Anxiety disorders often overlap and also often occur simultaneously with other mental disorders. In particular, there is a heightened risk of concurrent depression

Treatment is administered either in the municipality by the GP, a practising specialist in psychiatry or a psychologist, or in the region, where it is undertaken by a psychologist, a doctor or other professionals. In 10% of the most severe cases, hospital psychiatric services will administer the treatment. Hospitalisation is hardly ever prescribed for anxiety disorders alone.

Both psychological and medicinal treatment are used for anxiety disorders. The two treatment methods are effective independently or in combination. The types of treatment are basically equally effective, but there is a difference in that medication only works while it is being taken, whereas psychotherapy teaches the person to use methods that he/she can employ subsequently if symptoms of anxiety persist.

It is important for the patient, and possibly relatives, to learn about the causes of the disorder, its symptoms and progression, and about medicinal and psychotherapeutic treatment. This information process is called psychoeducation, and it is a necessary part of the treatment for anxiety disorders. Misconceptions about the condition are common if a person does not know very much about anxiety.

The person might believe he/she has a physical ailment, that he/she is ugly or conspicuous in other ways, that people are very critical, etc. This is why it is important for the anxiety sufferer to be taught the characteristic features of his/ her disorder. In some cases, this in itself has a calming effect.

The best-documented type of psychological treatment is cognitive behavioural therapy. This is psychotherapy based on the person’s present difficulties and focuses on the inappropriate thinking and behaviour that is present and which maintains the anxiety. The patient and therapist analyse current situations that trigger anxiety. They agree on exercises in which the anxiety sufferer learns to modify his/her thinking to make it more realistic and self-reinforcing. At the same time, the person learns to modify his/ her behaviour through gradual exposure to situations that provoke anxiety. One of the purposes of exposure is to dispel the disaster mindset – because the thing the person feared did not happen. At the same time, the person becomes accustomed to the fact that the anxiety symptoms are not dangerous, and that they reduce incrementally as the person is exposed to what he/she is afraid of. The therapist will also investigate whether the person has developed inappropriate Anxiety disorders in adults 13 rules of living that contribute to maintaining the anxiety, e.g. “I must always think of others before myself”; “If I am not 100% perfect, I am a failure.”

The person is always given tasks to perform at home to make sure that the modifications are transferred from the therapy room to everyday life. It is important to work with exposure every single day. This applies to all anxiety disorders.

The treatment primarily comprises antidepressants which are also effective for anxiety disorders. The medication works on some of the chemical processes in the brain associated with an anxiety disorder. Among other things, the antidepressants normalise the amount of the neurotransmitter serotonin in the brain. Medication can be used as the primary treatment, or when psychotherapeutic treatment is not sufficiently effective. Medication will often be needed for a severe or chronic anxiety disorder, or if depression occurs alongside the anxiety disorder. The medication reduces the frequency and severity of anxiety attacks and other anxiety symptoms. This often makes it easier to work with exposure during psychotherapy.

One problem with medication is that anxiety patients are often sensitive about the side-effects that may be present at the start of the treatment, and some may find their anxiety is aggravated during the first week. To avoid this, the dose is increased slowly at first to the amount that is expected to be effective. It generally takes 4–6 weeks for the effect of the medicine to kick in.

In some cases, it may be necessary to increase the dose, or to switch to a different preparation, in order to achieve sufficient effect. It is advisable to continue medication for between six months and one year after improvement has begun. Then the medication can be tapered off over 2–3 weeks by agreement with the person’s GP. It is important to do this during a period in which the person is doing well and is not exposed to external stresses.

If antidepressants are not sufficiently effective, a drug called Pregabalin (Lyrica) may have a good effect in some cases of generalised anxiety. It is an anti-epilepsy agent which can also be effective in the treatment of anxiety. In the past, benzodiazepines (anxiolytics such as Stesolid) were frequently used for anxiety disorders. As these preparations involve a risk of dependency, they are now only recommended for short-term use – 4–6 weeks at most, e.g. for acute aggravation of anxiety or insomnia.

In some cases, it may be relevant to use substances (antipsychotics) that are normally used for psychotic disorders. In small doses, these can have an anxiolytic effect without creating dependency.

All types of medication may produce side-effects which can be worrying for patients and relatives. Initially, therefore, the treatment starts with small doses in order to reduce the risk. Many side-effects are most pronounced at the start, and they often disappear once the body has become accustomed to the substance and disappear entirely when the person comes off medication.

In connection with medication, it is important to have check-ups with the GP or a psychiatrist. If the effect is insufficient or if there are a lot of side-effects, it will often be possible to find a different preparation that is more effective and has fewer side effects.

The intention of both medical and psychotherapeutic treatment is to prevent relapses.

In psychotherapy, the person learns a number of anxiety-inhibiting methods; it is sometimes possible to prevent relapses by applying these.

In addition, the therapist will work with the person to identify future stresses or circumstances that could pose a risk of relapse. For instance, depression poses a risk of a relapse into anxiety symptoms. Some lifestyle factors can also pose a risk: too little sleep or poor quality sleep, stress, and any type of abuse. Finally, important, sad or happy events can result in a relapse, e.g. loss of a loved one; a physical ailment; moving house; a wedding, etc.

Before the end of therapy, a plan will be prepared, outlining what to do in the event of a mild relapse. The person must apply the anxiety-reducing methods intensively each day, including exposure, and possibly seek help from the therapist. This could result in resumption of cognitive behavioural therapy, an increase in the dose of medication or having a different drug prescribed.

Reduce unreasonable stress factors in your everyday routine

If there are things in your life that produce anxiety and which can be changed, you should do this yourself, or enlist the help of others to do it. This applies to exposure to bullying at your place of study or in the workplace, for example.

Write down your thoughts of impending disaster

You can write a list of your usual thoughts of impending disaster and your more rational thoughts to counter these. You should do this at a time when your anxiety level is low, and you should keep the list handy so it is easy to find when your anxiety is aroused.

Seek out what you avoid because of your anxiety disorder

You can work with both flight and avoidance through exposure. This means exposing yourself to the things you otherwise try to avoid or flee from. It is a good idea to set yourself some targets for the things you would like to be able to participate in and do. Then you can approach your goal step by step by setting yourself tasks. These tasks must not arouse either excessive anxiety or too little anxiety – they must be somewhere in between.

Let go of your “safety behaviour”

When you are going to work on your safety behaviour, you need to notice the things and people you use to gain a sense of security. Then you must try to stop using them, so that you can experience managing a task on your own. It is best to start with “easy” situations so that you experience small amounts of progress all the time and gradually grow in confidence.

Focus on the situation rather than on yourself

When a person is anxious, there can be a tendency to draw attention to oneself, e.g. the person blushes or breathes faster and his/her heart races. You can practise directing the attention away from yourself and onto what is going on apart from you.

Participate in social activities

Precisely because social activities can seem to cause anxiety, many anxiety sufferers isolate themselves and avoid being around other people or being in the company of others. This is a vicious circle, because avoidance maintains thoughts that the person cannot be around others. These thoughts become entrenched as time goes by. To help maintain contact with other people, you can make a pact with yourself that you will never say “No, thank you” to an invitation. You can always make do with just going along for a couple of hours.

Consider how much you want to say and who you want to tell about your disorder

Some anxiety sufferers find it very beneficial to tell other people that theyhave an anxiety disorder. They find that many others have the same problems themselves, or know someone who does, and they encounter understanding and interest. Others prefer to keep their problems private, and there is nothing wrong with that. However, you should always consider whether efforts to conceal your problems are contributing to aggravating them.

Take your need for sleep seriously

Anxiety is the worst enemy of sleep, which is why anxiety and disrupted sleep often go hand in hand. It can be difficult to get to sleep if you are tormented by restlessness and worries – and when you finally do fall asleep, you might find you wake up in the middle of the night with an anxiety attack or a nightmare. Lack of sleep reinforces anxiety during the day, and this can easily develop into a vicious circle. This is why it is important to take your sleep seriously and to seek help if you have chronic sleeping problems.

Follow the dietary advice of the Danish Health and Medicines Authority

No diets or dietary supplements will cure anxiety, but healthy eating is good for a person’s general well-being. During periods of anxiety and worry, it is easy to slip into unhealthy habits, such as overeating, or eating sweet or fatty foods. It may seem comforting and calming at the time, but it can also result in weight gain and low self-confidence. Coffee, tea and cola contain caffeine, which has a stimulating effect, but caffeine can also produce palpitations and increase the feeling of anxiety and nervousness.

Avoid alcohol, marijuana and other substances

Alcohol can soothe and calm a person, but only temporarily. The nervousness and anxiety the person is trying to suppress will only be aggravated by alcohol, and more and more alcohol will be needed to soothe the increasing anxiety and nervousness. It is not a big step from this to actual alcohol abuse. For this reason, all use of substances must be avoided, and alcohol must be kept within the Danish Health and Medicines Authority’s limits (max. 7 units a week for women, and max. 14 for men).

Avoid smoking

Anxiety can also lead to starting smoking or increasing tobacco consumption. Smoking is not advisable anyway, as it is very harmful to health. Combined with anxiety, smoking can even aggravate the feeling of anxiety: nicotine releases adrenalin, which puts the body in a state of readiness for an emergency and causes the heart to beat faster.

Get some exercise

A high pulse rate and palpitations can cause so much anxiety that the person stops exercising entirely. That is an extremely bad idea. Exercise is not only good for the body; it is also very good for the mind. When we exercise, the body releases a number of hormones and neurotransmitters such as endorphins and dopamine, which mitigate stress and discomfort and increase the feeling of well-being. At the same time, exercise provides a number of positive experiences of increased pulse rate, racing heart, reddening of the face, outbreaks of perspiration, etc. – things that are otherwise often associated with something negative when a person is anxious. Experiencing these symptoms as something completely natural is a good thing.

Seek professional help

There is a lot you can do for yourself, but sometimes battling on your own to feel better is not enough. There is nothing at all unusual about needing treatment for an anxiety disorder.

Anxiety affects many everyday functions such as schooling, work, transport, shopping and generally being around other people. Thus, parents, spouses, children and, in some cases, close friends often become involved when a family member or a friend has an anxiety disorder. Most relatives feel very sorry for the anxiety sufferer and want to offer help and support. But anxiety and avoidance can also seem incomprehensible to some people, leading to irritation and rejection.

What can you, as a relative, do for yourself and the anxiety sufferer?

If you are to be able to support a person suffering from anxiety over the long term, you must make sure there is room to take care of your own needs, and that you are able to lead as normal a life as possible. It is important not to allow your whole life to revolve around the anxiety sufferer, and it is important that you do not take on the role of a therapist. First and foremost, carry on being what you are to the anxiety sufferer: spouse, partner, son/daughter, brother/sister, fellow student, etc.

Support the anxiety sufferer in getting professional help

If you notice distinct anxiety and avoidance in someone you know well, you could suggest that he/she makes a doctor’s appointment. You can support the anxiety sufferer in seeking treatment from a therapist specialising in anxiety disorders who uses tried-and-tested scientific methods. If your child has an anxiety disorder, it is important to participate actively in the treatment by researching what the treatment involves. If the sufferer is a young person or an adult, you can ask him/her if it is OK for you to enquire how the treatment is progressing, and what home assignments he/she has had.

Get the facts about anxiety disorders

If you have the energy to support and help, it is important for you to research anxiety disorder so you can help to assess anxiety-inducing situations and the actual anxiety realistically.

Make pacts during “tranquil times”

Together with the anxiety sufferer, you can make definite pacts about what you are to do if the person becomes anxious and does not go to school, for example, or breaks off a social engagement at the last minute. These pacts must be made between the anxiety sufferer and yourself when the person is not anxious, and it is a good idea to write them down. These pacts can also specify how often you, as a relative, may remind the person to perform the home assignments from the therapy or to keep on using the methods after the end of the therapy, or (if relevant) to take his/her medication.

Better a small amount of the right kind of help than a lot of the wrong kind of help

You can research some of the methods that help to counter anxiety, e.g. those described in this brochure, and encourage the person to apply these methods to avoid isolation. In some cases, your attempts to help could actually be contributing to maintaining the person’s state of anxiety. This can happen if you take over all his/ her tasks, e.g. shopping, picking up the children from school or making phone calls. This can reinforce the person’s avoidance behaviour, and it may increase dependency on you and compromise his/ her independence.

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