Anxiety in adults

The course of anxiety disorders may 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, while it comes and goes in others.

Anxiety can become chronic if left untreated. Even after treatment, there is a risk of recurrence. If you experience a recurrence, you may need a short course of treatment, where you refresh methods for managing your anxiety.

Heredity plays a part in the likelihood of a person developing anxiety. Many anxiety sufferers have a family member who suffers from anxiety or depression. Anxiety and depression are related illnesses that are seen more frequently in some families.

The disorder itself is not hereditary, but susceptibility to developing it is. If you have inherited this susceptibility, it only takes short-term stress or perhaps a few stressful events before anxiety may be triggered.

Researchers are still not entirely sure which psychological and social conditions in childhood may increase the risk of developing an anxiety disorder. But some factors may be:

• Lack of control
  A feeling of having a lack of control may increase the risk of anxiety. For example, this could be parents with unpredictable reactions due to alcohol abuse.
• Personality traits
  Some personality traits increase the risk of developing anxiety. This is especially true of so-called anxious-avoidant traits (neuroticism). If you have these traits, you are cautious and nervous and tend to react strongly to negative events.

These are often quite common events that occur just before the anxiety erupts. For example, conflicts in the family, physical illness, death in the family and as the most frequent factor: work-triggered stress.

• Abuse of alcohol, hashish, amphetamines or other substances increases the risk of developing an anxiety disorder. It also aggravates the course of the illness.
• Substance abuse makes it difficult to examine a person for concomitant anxiety disorder, as many substances of abuse in themselves cause anxiety symptoms during or after intoxication.
• Substance abuse can make it difficult to receive treatment, as the person’s motivation and ability to solve problems is impaired.
• Finally, substance abuse is health hazardous. And the substance abuse must be stopped, either before or concurrently with the treatment for anxiety.

Emotions and behaviour are generally controlled by the anterior (frontal) part of the brain. However, when you experience anxiety, the deeper brain regions (the amygdala system) take over control.

The amygdala system has been developed to respond to danger. You will therefore experience:

• that your behaviour becomes more irrational and controlled by emotions rather than reason
• that you feel fear and automatically seek to avoid what is triggering your anxiety
• that your body prepares for fight or flight. You experience heart palpitations, difficulty breathing and muscle tension.

There are physical, emotional, thought-related and behavioural symptoms associated with all anxiety disorders. 

You may experience:

• Heart palpitations, sweating, trembling, dry mouth.
• Difficulty breathing, a suffocating feeling, pressure or pains in the chest, nausea or restless stomach.
• Muscle tension or pain, restlessness, difficulty relaxing, mental tension, difficulty swallowing.

Dizziness, a feeling of unreality, feeling hot or cold, pins and needles or numbness, tendency to be jittery, difficulty concentrating, irritability or difficulty falling asleep.

The feeling of anxiety can be experienced to varying degrees – ranging right from anxiousness, nervousness and worry to fear of death and panic.

You will typically have danger-related catastrophic thoughts if you are facing something that you expect will cause you anxiety.

One example could be that you are afraid of taking the bus. If you are waiting at the bus stop, you will typically have catastrophic thoughts such as ‘I'm dying of anxiety’ or ‘I'll never make it’.

A person with anxiety will typically try to avoid situations that triggers the anxiety. This may be things in everyday life or it may be bigger things that may prevent the anxiety sufferer from leaving his or her home. For example if you are afraid of taking the bus or train or of being with other people. In some cases, you can say that the anxiety is limiting and, in extreme cases, it may be totally debilitating to those who experience it.

It may also be that you develop a kind of ‘security behaviour’. This means that you try to gain a sense of security by having things or people with you. On the face of it, this may seem like a good idea. For example if you dare take the bus when accompanied by a friend. But, in the long term, it can make you dependent on others. And it can weaken your self-confidence.

The four aspects of anxiety reinforce each other. Body, emotions, thoughts and behaviour interact and you can easily end up maintaining your own anxiety. This is called the vicious circle of anxiety.

You will often experience anxiety before certain events. This is known as anticipatory anxiety. The level of anxiety associated with anticipatory anxiety can be very high. It often leads to avoidance of the event. For example, you may be on your way down to the bus stop, but you end up turning around because of your strong anxiety.

If you succeeded in participating in the event (for example taking the bus), you will also experience anxiety in the situation itself.

Many people with anxiety may subsequently tend to be very critical of themselves. For example, they might think “Why did I act like that?” or “What do the other passengers think”? 

Symptoms of anxiety may resemble symptoms of physical illnesses. You can also have both an anxiety disorder and a physical illness at the same time.

Your doctor will therefore start by ruling out that your symptoms may have other causes. This will be done through consultation, physical examinations and blood tests. 

Symptoms of anxiety may resemble:

• some physical illnesses. For example increased metabolism or cardiovascular disease.
• other mental illnesses. Especially depression, but also psychotic disorders and dementia
• reactions to consumption of alcohol or other intoxicants. 

Once it has been determined that your symptoms are not due to physical illness, you will be examined further by a doctor or a psychologist. The therapist will ask about your background and current condition:

• What causes your anxiety?
• What symptoms of anxiety do you have?
• What actions cause you anxiety?
• How has the anxiety developed?
• Are there any particular stressors in your daily life?
• Do you have any special personality traits?
• Are there others members of your family who suffer from anxiety or other mental illnesses?

On this basis, the therapist will make your diagnosis. 

Signs of generalised anxiety:

• Excessive concern about major and minor things. For example, own health, daily chores and the well-being of family members.
• Difficulty controlling concerns and worries and often acting on them. This may, for example, be calling someone to make sure that everything is alright, or having health examinations done.
• Frequent or constant bodily symptoms such as inner agitation, tension, heart palpitations, sweating and dry mouth.

To be diagnosed with anxiety disorder, these symptoms must have been present for at least six months.

Signs of panic disorder:

• You have sudden and recurring anxiety attacks. The attacks are not triggered by specific situations.
• During a panic attack, you experience, for example, heart palpitations, sweating and/or shaking, dry mouth, difficulty breathing, pressure in the chest, dizziness and a feeling of unreality.
• Due to the severe physical symptoms, you will typically begin to fear that you are suffering from a serious physical illness or that you will suddenly drop dead. You may also fear losing control or going insane.

To be diagnosed with panic attacks, such panic attacks must occur at least four times within a month.

If the panic attacks are especially triggered in certain situations, for example on a bus or in places where there are many people gathered, you will often try to avoid these situations.  

Signs of agoraphobia:

• Agoraphobia frequently occurs in connection with panic attacks.
• Being in specific situations triggers anxiety. Typically because you are afraid of having panic attacks in these particular situations.
• For example, you may be afraid to leave your home on your own, to take the bus or train or to drive a car. Being among many people, visiting shops or being at home alone may also trigger anxiety.

To avoid the anxiety, you will try to avoid these situations.

Signs of sociophobia:

• Fear of one or more kinds of social gatherings. Typically, you will therefore try to avoid such social gatherings.
• Fear of criticism from others and fear of doing something embarrassing or wrong.

You may also have anxiety about showing visible signs of anxiety. For example, blushing, sweating, shaking hands or suddenly having to vomit or go to the toilet. 

In severe cases of anxiety, social measures and help from the municipality may be necessary. It may be that you need a support person or a mentor for a period. You may also benefit from being on sick leave for a period of time, visiting drop-in centres or having a flexi-job. 

You can often have several types of anxiety concurrently. Anxiety is also often seen together with other mental illnesses – especially depression.

It is important that you and your relatives learn about the causes of anxiety, symptoms and illnesses as well as medication and psychotherapy. This is called psychoeducation.

Psychoeducation is a necessary part of the treatment, because if you have no special knowledge about anxiety, you often have a wrong perception of yourself. You may, for example, think that you have a physical illness or that other people will be very critical of you.

Therefore, it is very important that you learn what characterises the type of anxiety you have. It will often have a calming effect in itself.

Cognitive behavioural therapy is the best-documented type of psychological treatment. It is psychotherapy based on what is difficult for you right now. In cognitive behavioural therapy, you and your therapist focus on the inappropriate thinking and behaviour that maintain your anxiety.

Together with the therapist, you analyse current situations that cause you anxiety. You agree on exercises in which you learn to modify your thinking to make it more realistic and self-supporting.

You also learn to modify your behaviour by gradually confronting situations that provoke anxiety – so-called exposure.

One of the purposes of exposure is to dispel your catastrophic thoughts – because the thing you fear does not occur. At the same time, you will get used to the fact that your anxiety symptoms are not dangerous. They gradually subside as you expose yourself to what you are afraid of.

You and your therapist will also look at whether you have developed inappropriate rules of conduct that contribute to maintaining your anxiety. For example “I must always think of others before myself” or “If I’m not 100% perfect, I’m a failure.”

You will always be given home assignments to ensure that the modifications are transferred from the therapy room to everyday life. It is important that you work with exposure every single day.

Antidepressants

The treatment consists primarily of the same type of medication used against depression (antidepressants) because it also works against anxiety disorders.

Antidepressants

The treatment consists primarily of the same type of medication used against depression (antidepressants) because it also works against anxiety disorders.

Facts: Antidepressants

• The medication works on some of the chemical processes in the brain that occur in connection with an anxiety disorder. For example, antidepressants normalise the quantity of the neurotransmitter serotonin in the brain.
• Medication may be the primary treatment, or you may be given medication if you do not experience sufficient effect from psychotherapy.
• You will often need medication if you have severe or long-term anxiety, or if you also have a depression.
• The medication reduces both anxiety attacks and anxiety symptoms. This usually makes it easier to work with exposure when you receive psychotherapy.

Other forms of medication

If you have generalised anxiety and you do not have a sufficient effect from antidepressants, the drug called Pregabalin (Lyrica) may provide a good effect in some cases. It is an anti-epilepsy drug, 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 the drugs pose a risk of addiction, it is now recommended that they be used for short periods only – maximum 4-6 weeks – for example in case of acute aggravation of anxiety or insomnia.

In some cases, it may be relevant to use medication against psychoses (antipsychotics) that is normally used for psychotic disorders. In small doses, this type of medication may have an anxiolytic effect without creating dependency.

Facts: Antidepressants

• The medication works on some of the chemical processes in the brain that occur in connection with an anxiety disorder. For example, antidepressants normalise the quantity of the neurotransmitter serotonin in the brain.
• Medication may be the primary treatment, or you may be given medication if you do not experience sufficient effect from psychotherapy.
• You will often need medication if you have severe or long-term anxiety, or if you also have a depression.
• The medication reduces both anxiety attacks and anxiety symptoms. This usually makes it easier to work with exposure when you receive psychotherapy.

Other forms of medication

If you have generalised anxiety and you do not have a sufficient effect from antidepressants, the drug called Pregabalin (Lyrica) may provide a good effect in some cases. It is an anti-epilepsy drug, 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 the drugs pose a risk of addiction, it is now recommended that they be used for short periods only – maximum 4-6 weeks – for example in case of acute aggravation of anxiety or insomnia.

In some cases, it may be relevant to use medication against psychoses (antipsychotics) that is normally used for psychotic disorders. In small doses, this type of medication may have an anxiolytic effect without creating dependency.

All types of medication can cause side effects. When starting treatment, you commence with small doses to reduce the risk of side effects.

Many side effects are greatest at the beginning of the treatment. They often disappear when your body has gotten used to the drug. The side effects disappear completely when you stop taking the medication.

In connection with medication, it is important to have check-ups with your own doctor or a psychiatrist. If you have too little effect or too many side effects, it will often be possible to find another medicinal product that works better.

You can read more on the page about antidepressants.

The purpose of both medication and psychotherapy is to prevent recurrence.

Through psychotherapy, you will learn a number of methods for alleviating your anxiety. When you apply these methods, you may, in some cases, prevent new anxiety attacks.

In addition, together with your therapist, you will examine what future burdens and strains may pose a risk of recurrence of your anxiety symptoms. For example, depression poses a risk of recurrence. Some lifestyle factors can also pose a risk: too little or too poor quality sleep, overburdening (stress) and any type of substance abuse. Finally, important events, both sad and joyful, may cause recurrence, for example, loss of a loved one, physical illness, relocation, becoming a parent, a wedding, etc.

Before you conclude your therapy, you will prepare a plan together with your therapist for what you can do if you experience mild anxiety symptoms. If this happens, you should daily use the anxiety-reducing methods (including exposure) that you have learnt through your psychotherapy. You may also seek help from a therapist. You may need to resume treatment with cognitive behavioural therapy, to increase your medication dosage or to take a different type of medication.

Reduce unreasonable stress factors in your daily life

If there are things in your life which cause anxiety and which can be changed, you should do this either yourself or with the help of others.  This may, for example, be if you experience bullying at your place of study or at work.

Write down your catastrophic thoughts

Make a list of your typical catastrophic thoughts. Then – to counter these – write down your more rational thoughts on the list. You must do this at a time when your anxiety level is low. Put the list in a place where it is easy to get hold of if your anxiety increases.

Seek out what you are afraid of

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

Let go of your ‘security behaviour’

To work on your security behaviour, you need to notice the things and people you use to gain a sense of security. You must then 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 steps forward all the time and gradually grow in confidence.

Focus on the situation rather than on yourself

When you have anxiety, you may tend to focus attention on yourself. For example that you blush or that your breathing becomes faster and that your heart beats very fast in your chest. You can practise directing your attention away from yourself and onto what is going on outside yourself.

Participate in social activities

Many people with anxiety avoid social activities because they can cause anxiety. Instead, they isolate themselves and avoid socialisation and communities. This is a vicious circle, because avoidance keeps you locked in the view that you cannot be around others, and 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 settle for 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 they have an anxiety disorder. They find that many others have 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 fall asleep if you are plagued by inner agitation and worries. And when you have finally fallen asleep, you may experience waking up during the night due to an anxiety attack or 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 Authority

No diets or dietary supplements will cure anxiety, but healthy eating is good for your general well-being. During periods of anxiety and worries, 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 heart palpitations and increase the feeling of anxiety and nervousness.

Avoid alcohol, hashish and other substances

Alcohol can soothe and calm you, but only temporarily. The nervousness and anxiety you are trying to suppress will only be aggravated by alcohol, and more and more alcohol will be needed to soothe your increasing anxiety and nervousness. It is not a big step from this to actual alcohol abuse. Therefore, the amount of alcohol should be kept within the limits of the Danish Health Authority (maximum ten units per week, maximum four units on the same day). Hashish and other drugs should be avoided altogether.

Avoid smoking

Anxiety can also mean that you start smoking or increase your tobacco consumption. Smoking is generally discouraged, as it is very health hazardous. Combined with anxiety, smoking can even aggravate the feeling of anxiety: nicotine releases adrenaline, which puts the body in a state of alert and makes the heart beat faster.

Exercise

A high pulse rate and heart palpitations can cause so much anxiety that you stop exercising entirely. That is a really bad idea. Exercise is not only good for your body; it is also very good for your mind. When you exercise, your body releases a number of hormones and neurotransmitters, including endorphins and dopamine. It dampens stress and discomfort and increases 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, 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 get better is not enough. There is nothing unusual at all about needing treatment for your anxiety disorder.

Anxiety affects many everyday functions such as schooling, work, transport, shopping and generally being around other people. Parents, spouses, children and, in some cases, close friends will thus often become involved when a family member or a friend develops 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 that 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 that your whole life is not based around the needs of the anxiety sufferer.  And it is important that relatives do not take on the role of therapist. You are first and foremost to carry on being what you are to the anxiety sufferer: spouse, partner, son/daughter, brother/sister, fellow student, etc.

On the Danish Anxiety Association’s website for relatives, you can find good advice on how to take care of both yourself and the anxiety sufferer:

Tag min hånd (Take my hand) (angstforeningen.dk)

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 or she should make 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.

You can ask the anxiety sufferer if it is OK for you to enquire about how the treatment is progressing, and what home assignments he/she has been given.

Acquire knowledge about anxiety disorders

If you have the energy to support and help an anxiety sufferer, it is important that you familiarise yourself with what an anxiety disorder is.

Make agreements during ‘peacetime’

Together with the anxiety sufferer, you can make a clear agreement on how you are to act when he or she has anxiety. For example if he or she does not come to school or cancels a joint social event at the last minute. You must enter into that agreement at a time when the person does not have anxiety. It is an advantage that you write down the agreement.

You can also make an agreement on how often you as a relative are allowed to remind the person to do his or her therapy homework. Or perhaps an agreement on whether you are to help him or her to remember to take his or her medication.

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

You can familiarise yourself with some of the methods that help against anxiety. And you can encourage the anxiety sufferer to apply these methods.

In some cases, your attempts to help as a relative could actually result in maintaining the person’s state of anxiety. This may happen if you take over all the anxiety sufferer’s tasks. For example shopping, picking up children from a childcare institution or calling other people. This may reinforce the person’s avoidance behaviour, increase his/her dependency on you and compromise his/her independence.