Take control of anxietyThe best care series by Manulife

Each day, many people struggle with worry, tension and nervousness which are common signs of anxiety. But there is good news! Some forms of anxiety have very little effect on one’s personal or work life (e.g., some phobias) whereas others can be managed and even prevented with the right treatment, support and self-care.

What is anxiety?

Anxiety is a common experience and something that everyone encounters to some degree as they face their fears and life’s challenges and stresses. Anxiety can range from mild to severe and it is the key feature of a group of mental health illnesses called “anxiety disorders”.

About one in 10 people experience severe anxiety in the form of an anxiety disorder. Some of the features of anxiety disorders include anxiety that occurs more days than not for weeks or months, fear of being publicly embarrassed, panic, or constant worries that are out of proportion to the environment and situation.

For many people, anxiety is not severe enough to interfere with work and personal life. But for others, and for some forms of anxiety, serious problems can arise if anxiety is ignored or left untreated. For example, some anxiety can cause family and social problems and leave its sufferers housebound. Additionally, attempts to reduce anxiety and self-medicate with alcohol or other drugs can lead to substance abuse problems. Untreated anxiety can also contribute to the onset of depression.

Symptoms of anxiety

Stress and uncertainty can leave anyone feeling anxious. This is normal and nothing to be particularly concerned about. But anxiety is a problem when it is overwhelming or when it interferes with personal and work life. Having any of the following symptoms continuously for more than two weeks requires seeking medical assistance or advice, such as talking to a health care provider (e.g., family doctor).

• Muscles are tense or ache.
• Feelings of nervousness, being “keyed up” or irritable.
• Being physically agitated (heart palpitations, rapid breathing, sweating, stomach upset or nausea, numbness or “pins and needles” in arms, hands, or legs).
• Worrying all the time to the point that it interferes with attention and concentration.
• Not sleeping well.
• Having vague pains, headaches or dizziness.

Note: No single symptom is diagnostic of an anxiety disorder but all of these symptoms should be taken seriously and all can be treated. Some symptoms may also indicate an underlying medical condition (though this is rare) and only expert evaluation can rule this out.

Types of anxiety disorders

Generalized anxiety disorder

Generalized anxiety disorder (GAD) is characterized by non-specific and excessive worries about almost anything, all the time (called “free floating anxiety”). People with GAD experience chronic and uncontrollable worry and feel constantly “on edge.” GAD leads to fatigue, difficulty concentrating, and insomnia, among other problems.

Panic disorder

Panic is an unexpected “burst” of excessive anxiety usually interpreted as a signal that something is terribly wrong (e.g., the person believes they are dying or having a heart attack). It is characterized by panic attacks - sudden and intense fear that may cause physical feelings such as a racing heart, shortness of breath or nausea. These attacks may seem to happen for no reason at all and people who experience panic disorder fear more attacks. In an effort to avoid triggering them, some people may change their routine.

Agoraphobia

Agoraphobia is the fear of being in a situation where escape is difficult or help is hard to obtain if they experience a panic attack or other feelings of anxiety. Left untreated, more and more places are avoided and a person can become housebound.

Social anxiety disorder (Social phobia)

Social anxiety disorder is an exaggerated fear of social situations in which one’s behaviour can be scrutinized and evaluated by others. Thus, eating, writing, speaking, or any occasion where a person can be observed by others can provoke intense anxiety. Social phobia is sometimes confused with shyness but it is far more severe and leads to isolation and severely impaired social relationships.

Specific phobia

Ranging from mild to severe and encompassing any number of possible fears, phobias are a heightened and irrational fear of a specific object or situation that poses no real threat. Common phobias include fear of enclosed spaces (claustrophobia), fear of heights (acrophobia) and fear of flying (aviophobia). Phobias don’t usually interfere with personal and work life unless the feared situation is something encountered often or that cannot be avoided (e.g., fear of flying for a business traveller).

Other conditions

Some mental illnesses are no longer classified as anxiety disorders although anxiety or fear is a significant component of these illnesses.

Post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder can affect individuals who have survived a severe physical or mental trauma or have witnessed such an event (e.g., abuse, assault, robbery, accident or natural disasters). Symptoms include emotional numbness, intense flashbacks, nightmares and avoidance of situations or activities that are reminders of the event.

Obsessive-compulsive disorder (OCD)

Obsessive-compulsive disorder is associated with repetitive, uncontrollable, and irrational thoughts that usually involve themes of harm, danger or contamination (e.g., fear of leaving a stove on or becoming contaminated from touching doorknobs). The anxiety that accompanies these obsessions is relieved only when certain behaviours are performed (e.g., constant checking, excessive hand washing). These behaviours are called “compulsions” because the anxiety sufferer is compelled to do them to find some relief. However, the compulsions themselves consume so much time and energy that they may impair a person’s ability to function in social and occupational situations.

Treatment

Anxiety disorders are the most treatable of all mental illnesses. Medication and counselling are two very effective treatments for anxiety. Medications are typically prescribed by physicians and psychiatrists, while counselling is provided by mental health professionals (e.g., psychologists, counsellors). Health care providers should be licensed to practice and trained to treat anxiety. Self-care and treatment/therapy recommendations should also be continued between sessions for optimal results.

About medication

If anxiety is severe and interferes with a person’s ability to function effectively, medication may be called for. Antidepressant medications are often used to treat anxiety: citalopram (e.g., Celexa^®), fluoxetine (e.g., Prozac^®), paroxetine (e.g., Paxil^®), sertraline (e.g., Zoloft^®) and venlafaxine (e.g., Effexor^®), among others. Not all antidepressants have official indications for the treatment of all anxiety disorders and sometimes it is a matter of trying different medications to determine the most effective kind and dose. Health care providers will prescribe the most suitable treatment medication, when necessary.

Anxiolytic medications (includes benzodiazepines and buspirone) may help with acute anxiety or agitation or while other medications have not yet taken effect. While benzodiazepines may reduce anxiety quickly, their use should be carefully monitored because of their potential for dependence.

Questions to ask a health care provider

It is important to be educated about any medications that are taken for any illness, and it is no different for medications taken for anxiety. Here are some general questions to ask a doctor or pharmacist:

• How long will it take before I feel better?
• How often, and how much, do I take?
• What are the possible side effects, if any, and what can I do to best manage them?
• Will this medication interfere with other medication(s) or herbal remedies that I take?
• Could I have allergies to this medication?
• What should I do if I don’t feel better or if I miss a dose?
• Is there any written information I can get about this medication?
• Is there anything I should not do when I take this medication (e.g., operate heavy machinery, consume alcohol)?

Consult a doctor or pharmacist if you have any questions about medication.

Counselling and psychotherapy

As with medications, there are different kinds of counselling and psychotherapy.

• Cognitive behavioural therapy (CBT). This may be an effective counselling method for treating anxiety and it can help to eliminate severe or mild levels of anxiety. Some of the techniques of CBT that are most helpful are relaxation techniques, gradual exposure to situations that trigger anxiety, problem-solving skills to deal with stressors, and challenging anxiety-provoking thoughts.

  A large component of CBT is educational - learning the source of anxiety, recognizing that symptoms are not a sign of ill health, and realizing how avoidance of fearful situations prolongs anxiety.

• Mindfulness. Mindfulness-based interventions may also be integrated into therapy and are becoming increasingly common. Mindfulness refers to developing the ability to connect to the present moment rather than dwelling on regrets about the past or worries about the future. Connecting to the present allows us to create new and healthier ways to respond to life’s challenges.

  “Mindfulness is the practice of present moment, non-judgemental awareness of one's life experience. Through the use of mind/body techniques, one begins to relate to the stress and anxiety in life differently in ways that allow for more creative solutions and possibilities.” (Mindfulness Everyday^®)

  If anxiety is complicated by other problems, like depression or substance abuse, treatment may involve a few more techniques and it may take a bit longer, but it can be effective.

Note: Ask questions and learn about treatment options. Regardless of the type of therapy chosen (medication and/or counselling), personal preferences and motivation will be important for success.

The importance of self-care

When a person experiences anxiety, key ingredients of a healthy lifestyle can suffer - diet, physical activity levels and sleep. Relaxation is one of the most straightforward and effective ways to manage anxiety. Additionally, maintaining good nutrition, staying active and sticking to a regular sleep schedule can help relieve tension and stress and leave a person less vulnerable to anxiety and its symptoms.

Breathe low and slow

Shallow breathing and dizziness play a dual role in anxiety. They are symptoms and they also make anxiety worse. Thus, slow, relaxed breathing may help eliminate anxiety. Here is one technique to slow breathing:

1. Sit in a comfortable chair with hands resting on the abdomen below the navel. Breathe slowly through the nose until the abdomen expands and the hands are pushed outwards by inhalation.
2. Once a full in-breath is achieved, all at once allow the breath to gently escape through the mouth, keeping the jaw relaxed and lips slightly parted.
3. Repeat these steps as needed until relaxed. Remember, breathe low and slow.

Practicing low and slow breathing before entering situations that are stressful or that trigger anxiety (e.g., rush hour traffic, public speaking and difficult workplace meetings) may help to make them less stressful. Begin with situations that are mildly stressful or anxiety-provoking and gradually work up to more stressful situations.

Keep track of anxiety triggers

It is important to learn about anxiety and its triggers to better plan to change or avoid these triggers. One technique for keeping track of triggers is to keep a diary of levels of anxiety throughout the day (e.g., every half hour) using a rating scale from zero (no anxiety) to 10 (extreme anxiety). Is there a pattern to the anxiety? Do certain situations or circumstances trigger anxiety? Does anything help alleviate it?

Learn positive self-talk

Self-talk refers to the dialogue that goes on inside a person's head when faced with a challenge that causes anxiety. Negative self-talk worsens anxiety (e.g., "I can't do this.") and positive self-talk can reduce it (e.g., "I can get through this."). Changing negative self-talk involves first becoming aware of this inner dialogue (e.g., writing down negative thoughts when they occur, noticing if certain thoughts occur when anxiety is worse or better). Next, change patterns of self-talk by changing negative words to something neutral or positive (e.g., "I CAN handle this," "things will be okay," "this is a good time to breathe low and slow.").

Cut back on caffeine

Reducing or eliminating caffeine may help to reduce anxiety. Since caffeine has addictive properties, gradual reduction is usually recommended (e.g., cutting coffee or tea consumption in half for a week, then in half again, continuing until there is no more caffeine to be cut out of the diet). Herbal teas that do not contain caffeine can be used to replace caffeinated beverages.

Take short “stress breaks”

Physical tension accumulates throughout the day, and this tension may contribute to anxiety. Frequent, short "stress breaks" may help to prevent this tension from accumulating. Some examples of effective stress breaks are walking during lunch hour, reading a magazine during an afternoon break and partaking in an enjoyable hobby on evenings and weekends.

Stick to a regular sleep schedule

• Establish a regular, consistent time for sleeping and waking.
• Do something relaxing before going to sleep like reading (in a different room) or taking a warm bath.
• Don’t use the bedroom for non-sleep activities (e.g., watching TV or eating in bed).
• Avoid strenuous exercise, caffeine, alcohol or tobacco a few hours before bedtime.
• Avoid naps during the day. Get outdoors for some activity (e.g., a short walk) to refresh.
• Talk to a health care provider about using a sleep medication.

Stay active

• Choose activities that are enjoyable.
• Plan activities for the times when they can be performed consistently.
• Be active on a regular basis. Aim for 10 minutes of continuous activity, three times a week, as a start. As fitness increases, the duration and intensity of activity can be increased.
• Take advantage of opportunities to be more active by making small changes each day (e.g., take stairs instead of an elevator, exit a bus one stop earlier than a destination and walk).

Keep up with proper nutrition

• Meals should be eaten at regular times (breakfast, lunch, dinner with a mid-morning and a mid-afternoon snack).
• Include a variety of healthy foods at mealtimes (e.g., whole grains, dark green vegetables, brightly coloured fruits, lean proteins, milk (products). Avoid food with added fats, sugar and salt.
• Drink alcohol and caffeine in moderation.
• Drink several glasses of water each day (five to eight glasses is a good goal).

It is always easier to make positive lifestyle changes with the support of others. Involving friends and family in the “get-better” plan may be helpful if a person is comfortable discussing their goals and treatment plan with them. For example, exercise with a friend, make healthy recipes for the entire family at mealtimes and participate in group activities.

Maintain gains and prevent setbacks

Anxiety sometimes returns months or years after it first goes away. This is called relapse. The good news is that relapse can be prevented if the right plan is put into place.

We believe these tips are part of a good relapse prevention plan:

• Continue with self-care. Anything that helps reduce anxiety (as long as it is a healthy choice) should be continued on a regular basis. This might mean practising relaxation techniques each day, using positive coping thoughts at every appropriate occasion, attending counselling sessions and doing counselling homework.
• Follow health care provider advice. As anxiety gets better or when symptoms are no longer a problem, it can be tempting to stop medication or counselling. Sudden stops to treatment may lead to relapse (or withdrawal symptoms in the case of medication). Consult with a health care professional before making changes to any treatment plan.
• Avoid alcohol and recreational drugs. These substances can slow or prevent full recovery and they can become problems if relied upon for symptom relief. Alcohol especially causes a ‘rebound’ effect in which anxiety returns with more intensity after its consumption when trying to alleviate the symptoms of anxiety.
• Take part in social activities. Staying connected to others (e.g., getting together to share activities, socializing with friends) is a powerful way to help prevent anxiety from returning.
• Take it slow. If roles and responsibilities have been reduced, return to them in a gradual, step-by-step fashion rather than all at once.
• Create an “Anxiety 911” plan. Develop a list of warning signs that indicate anxiety might be on the rise again, and have a plan ready to deal with these signs early. For example, if certain workplace situations trigger anxiety, create a plan of action for handling them before they are encountered, and put that plan into place when the troublesome situation arises.
• Arrange for continued support. Ongoing support can help keep anxiety in check for a lifetime. Self-help groups organized by mental health advocacy associations are a great resource for information, counselling, and support. Self-help workbooks and websites (from a trusted source such as a national mental health association) can provide practical advice.

Make the return to work easier

If there was an absence from the workplace, preparing to return to work may seem overwhelming, especially after being away for an extended period of time. These tips may help:

• Think about what helps the most. Each person is different. Some people need more flexible work arrangements (e.g., reduced hours, modified job duties) and others feel capable of returning to full capacity immediately.
• Clearly understand the return to work plan and be an active participant in its creation. What are the hours? What are the expectations, roles, and responsibilities? Who needs to be informed?
• Understand privacy rights and be prepared for any disclosure (if necessary). Details of an absence are private and confidential. However, there may be workplace policies that require that certain kinds of information be reported (e.g., safety sensitive positions, information needed for job accommodation purposes). If any disclosure is required, plan what to say and how much information to share. Questions about who to disclose information to, and how much information to disclose, should be directed to a third party such as a human resources representative or employee health professional.
• Learn about support options. Good support is essential to a successful return. Find out what resources are available.
• Continue self-care efforts. Be alert to changes in your mental and physical well-being, seek medical care when needed, use the skills and strategies you learned in psychotherapy or counselling and seek support from people you trust.
• Watch for signs that anxiety may be returning.
• Apply the tools developed in counselling.
• Be aware that symptoms (agitation, worry) may fluctuate throughout the return to work process. Adjustments in the return to work plan, or the treatment plan, may be necessary.

Support and education

With the right help, the right information and the right support anxiety can be controlled. People with anxiety can maintain a productive and rewarding life.

Visit these websites for more information:

• Canadian Mental Health Association
• Mood Disorders Society of Canada
• Canadian Psychological Association
• The Centre for Mindfulness Studies

References

• http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf
• Statistics Canada: Section B - Anxiety disorders
• Canadian Mental Health Association
• PyschCentral^® Learn. Share. Grow