Anxiety is a general term to describe feelings such as tension, uncertainty, worry and even fear. The worry caused by such feelings can affect your sleep, appetite and ability to concentrate.

Short-term anxiety can be useful as it can make you feel more alert, and enhance your performance. However, if the feelings of anxiety overwhelm you, then your ability to concentrate and to function may well suffer. This makes you less able to cope with whatever is causing the anxiety.

GAD is the abbreviation used for Generalised Anxiety Disorder. There are many types of anxiety such as panic disorder, phobias (e.g. agoraphobia), obsessive-compulsive disorder and post-traumatic stress disorder.

^{Updated 9.11}

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Anxiety is something that everyone gets from time to time, and is perfectly normal. If it goes on for several months and starts to affect the way a person can cope with daily living then it becomes known as Generalised Anxiety Disorder (GAD). It is a distressing condition, and the effect it has on you is often under-rated by other people. There are many symptoms of (generalised) anxiety disorder, although anxiety can in itself be a symptom of many conditions. They can be put into two main groups:

Psychological symptoms, which include:

• fear
• irritability
• poor concentration
• restlessness
• being easily tired
• sensitivity to noise
• disturbed sleep (lying awake worrying, waking irregularly and unpleasant dreams, but not usually early morning waking)
• poor memory (due to poor concentration).

Physical symptoms, which include:

• gastrointestinal (dry mouth, difficulty swallowing, wind, loose motions, etc)
• Central Nervous System [CNS] (ringing in the ears, blurred vision, dizziness) 
• breathing (tight chest, difficulty breathing in, overbreathing) 
• heart (palpitations, heart pain, missed beats, ectopic beats [where a heart beat is delayed until just before the next one], throbbing neck) 
• genitourinary (passing more urine than usual, lack of sex drive and impotence) 
• muscular tension (tension headache, tremor, shakiness)
• panic attacks (sudden episodes of extreme anxiety or apprehension)

^{Updated 11.11}

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Because everyone is unique, everyone's symptoms are different. So, it's not always clear what the right diagnosis is. Here is a list of some other possible causes for the symptoms of generalised anxiety disorder (GAD). This is not meant to be a textbook list, just some ideas. Some of these can be very rare indeed. Sometimes it doesn't matter anyway as the symptoms need to be treated anyway, no matter what causes them.

• Depression can occur in many people with GAD, can be very similar, and may even have the same genetic vulnerability
• A bit of anxiety, which we all get
• Personality disorders
• Physical illness e.g. heart problems (irregular heart beats, chest pain, prolapsed mitral valve), hormone imbalances (overactive thyroid, underactive parathyroid, low blood sugar, Cushing's disease), brain imbalances (epilepsy, vestibular disease), breathing problems (e.g. asthma)
• Panic disorder - which tends to have a more sudden start with a "memorable onset". GAD tends to start more gradually
• Prescribed medicine-induced - over 100 medicines have been reported to cause anxiety symptoms e.g. starting antidepressants, some anticonvulsants, some heart drugs, asthma treatments such as theophylline, and steroids.
• Hypochondria - which is more focused on anxiety about having a disease rather than anxiety about lots of things
• Alcohol dependence - although people sometimes take alcohol to reduce anxiety symptoms 
• Other substance misuse e.g. excess caffeine, cocaine abuse, amfetamines, and stopping alcohol or other sedative drugs
• ADHD (Attention Deficit Hyperactivity Disorder) - almost always starts in early childhood
• Social anxiety
• PTSD (Post-Traumatic Stress Disorder)
• Seasonal Affective Disorder
• Schizophrenia, especially early on in the illness

Just to confuse matters further, sometimes people have more than one illness (sometimes called "co-morbidity"). For example, if 1 in 10 people get depressed and 1 in 10 people get anxiety symptoms, then just by chance 1 in 10 of the depressed people get anxiety symptoms as well. However, if you're depressed, you're more likely to be anxious. Co-morbidity means what else the person is more likely to have at the same time. This can make diagnosis more difficult.

• Depression - very common, may be 2 in 3 people (60-90%) have both GAD and depression
• Dysthymia - 1 in 2 or 3 (40%) people with GAD may also have dysthymia (which is low mood but not quite depression)
• Bipolar mania or hypomania - up to 1 in 10 (10%) people with GAD may also have bipolar mania
• Panic disorder - maybe 1 in 4 (24%) people with GAD also have panic disorder
• Agoraphobia - maybe 1 in 4 (21-35%) people with GAD also have agoraphobia
• Social anxiety - maybe 1 in 4 (23-34%) people with GAD also have social phobia
• Alcohol dependence or abuse - maybe 1 in 3 (38%) people with GAD also abuse alcohol
• Other substance misuse e.g. drug dependence or addiction. Maybe 1 in 4 (28%) people with GAD also misuse other substances
• Personality disorders
• ADHD (Attention Deficit Hyperactivity Disorder)

^{Updated 11.11}

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As mentioned above, we all get a bit of anxiety at some time or another but GAD is more than a bit of anxiety. Basically, anyone can get Generalised Anxiety Disorder (GAD) but there are some "risk factors" that make it more likely that someone will get the symptoms of GAD. This is not a complete list but some of the main risk factors include:

• Genetics - GAD may run in families

• Being single

• Female - it is twice as common in women than men

• Being younger

• Stressful life events

• Having depression as well, even mild depression as a teenager (twice the risk)

• Parenting e.g. where parents were over-controlling or where the child had little chance of influencing what happens to her or him

We are not sure what actually causes the symptoms of anxiety. We know that too little GABA (a chemical messenger in the brain that generally calms the brain down) can make someone more anxious. Too little serotonin might also have the same effect. Some medications for anxiety may help anxiety by boosting GABA and serotonin.

^2.11

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The list here includes most of the main options for anxiety but does not say what works and doesn't. Many may be used in combination. Most herbal and alternative therapies have not really been tested in the same rigorous way that medicines have. Obviously, these web pages are about choice and medication and so we will concentrate on medicines.

Our aim is to try to help people who are taking medicines (or should be) get the right medicine, dose and take it regularly for as long as is best. Any medicines should usually be part of the overall treatment, although some people are quite happy to just stick with medicines or talking treatments. If your medicines are right, then everything else can fall into place. If the medicines are wrong, then they may make the symptoms worse and self-help will not be as useful.

Self help

• Relaxation (e.g. using relaxation tapes, books and breathing exercises, in groups) and massage (about as effective as each other). It's a good idea to practice relaxation regularly, not just try to use it in an emergency or crisis

• Taking any medicines properly e.g. regularly and reliably if it is meant to be regular; or use it just when required if it is to help just when you need it

• Eating healthily and taking exercise (“exercise to energise”) or being active, to help boost your feeling of well-being

• Putting help from others into practice

• Making sure you don't drink too much caffeine e.g. cola-drinks, tea, coffee etc. Too much caffeine will make your symptoms worse and more difficult to cope with.

Help from others

• Talking therapies e.g. psychotherapy and cognitive behavioural therapy (CBT) – these may be better saved if self-help or medicines haven’t worked or if the symptoms are particularly bad

• Reassurances e.g. self-help groups, support, help with the problems, talking to someone else about your anxieties  

• Alternative therapies such as aromatherapy, hypnosis or hypnotherapy, homeopathy (treating like with like) can be used with (but not instead of) conventional treatments. Acupuncture is used a lot in many countries and may help anxiety, stress and insomnia. The evidence for these treatments is not very good. All of these can be used in conjunction with other therapies. If they work then that is fine and we wouldn’t knock them. Click here for a balanced review of complementary and alternative therapies from the Royal College of Psychiatrists (e.g. Ginkgo, Sage, vitamins, other herbals etc, and some useful links).

Medicines

• Medicines can help in two ways. Firstly, to help in the short-term to help a crisis. Secondly in the long-term (i.e. the anxiety just won’t go away) to help you get on with your life.

^{Updated 10.11}

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If you are prescribed a medicine, then there may be many reasons why that one has been chosen. These might include:

• side effects (which ones are important to you)
• local policies or agreements (such as what your GP surgery uses or agreements in your area)
• national policies (e.g. NICE, SIGN - see last question)
• familiarity (it may be better for prescribers to use medicines they are familiar with)
• relative costs for similar medicines (if two medicines are very similar, why waste money on the more expensive one?)
• personal preference (either yours or your prescriber)
• how bad your symptoms are
• any medicine you might have done well with in the past (as it's more likely to work again)

The main medicine treatment options are listed below. They are divided in "Main medicines" and "Others".

For convenience, the "Main medicines” are those medicines that are officially "approved" to treat the condition or symptoms (www.bnf.org/bnf/) and which are listed in the British National Formulary (BNF). To be listed in the BNF there needs to be good evidence that the medicine works and that the manufacturers have applied for a license (a long and costly exercise). "Others" are those medicines where there is some evidence that they help, but either not enough for a license or that no license has been applied for. These should usually only be used where other standard treatments have failed.

Main medicines:

• Benzodiazepines from the well-known Valium and Librium group (such as alprazolam, chlordiazepoxide (formerly Librium®), diazepam (formerly Valium®), lorazepam and oxazepam)
• Beta-blockers (such as propranolol and oxprenolol), to help reduce the increased heart rate and shaking that can occur in anxiety
• Buspirone (Buspar®), a unique drug affecting serotonin  
• SSRIs (such as escitalopram [Cipralex®] 10-20mg a day, paroxetine 20mg a day) - the other SSRIs are probably just as effective but their manufacturers haven't applied for a license
• Pregabalin (Lyrica®) - usually around 300mg a day, and also used as an antiepileptic and for pain  
• Serotonin and noradrenaline boosting medicines such as venlafaxine (usually 75mg a day, but sometimes may be better at higher doses) and duloxetine (around 60mg a day)  

Others:

• Other SSRIs (such as citalopram, fluvoxamine, fluoxetine, sertraline)

Having problems getting to sleep can be a symptom of anxiety. Some medicines can make you a bit drowsy and so help you go to sleep. They don't, however, actually help improve the quality of your sleep.

• Antipsychotics  (such as pericyazine, quetiapine, risperidone, olanzapine) which can be helpful to aid sleep by making you sleepy or less anxious. Quetiapine, at a dose of 150mg a day, is the only one of these that we know helps other symptoms of anxiety as well (LaLonde 2011).
• Mirtazapine (Zispin®) which can make you feel very sleepy
• Tricyclics (such as amitriptyline, imipramine, lofepramine)
• Trazodone

To help you make a choice between these, click here for a handy chart comparing the different medicines for anxiety. It has the names, doses, how they work, the main side effects, how long to take it for and how to stop.

Sometimes the symptoms of anxiety can become very severe. This can result in the person becoming very distressed and/or too difficult to cope with and might need to be admitted to hospital. This might then become what is called an "acute psychiatric emergency" or crisis. The treatments for this may need to include some other medicines just to calm the person down and prevent harm to that person, or others. If this happens, follow the link to some information that might help explain what might be going on.

^{Updated 11.11}

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You should think carefully about taking any chemical that affects your body, including your brain. So think carefully before your next cup of tea or coffee!

For an appeal for everyone to have a sense of balance about the pros and cons of medicines and the pros and cons talking therapies please click here for our take on it.

^{Updated 11.11}

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Download a handy summary chart (PDF format) comparing the main medications for anxiety e.g. names, how they work, doses, how long they take to work, some side effects, how long to take and how to stop.

^{Updated 11.11}

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This will depend on how bad the anxiety is, and which medicine or medicines you are taking: 

• For the SSRIs and other serotonin boosters (e.g. tricyclics, mirtazapine, trazodone, duloxetine, venlafaxine) and buspirone - if these are working, then carrying on for at least 6 months will reduce the chances of you getting ill again. It seems that the risk of getting anxious again after stopping is quite high so it's a good idea to have some talking therapies as well as they might give a longer-lasting effect

• Pregabalin - we don't know for sure yet, but probably the same as the medicines mentioned above

• Benzodiazepines - this is an individual choice. There is the risk of having difficulty stopping but also the risk of becoming ill again. Benzodiazepines are often said to be "addictive" but not everyone agrees, as the "withdrawal" symptoms are very similar to the original symptoms of anxiety so it might just be the symptoms coming back. A few people do rely on them, but if the medicine helps you get on with your life then it may be worth it.

• Beta-blockers and antipsychotics - these start to work quite quickly on the main symptoms of anxiety but they wear off quite quickly too so it will be up to you how long you take them for

^{Updated 11.11}

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Before going onto another medicine, it is worth trying to get the best out of the first one. There is a risk that switching medicines too quickly means you don't get the best out of one medicine. Then perhaps you start to search for the "magic bullet", expecting the drugs to work quicker and having less patience. There are of course no "magic bullets". Most symptoms have started to happen over a few weeks, months or years, not a few days, so it is perhaps unfair to expect them to go away over a few days. The symptoms are more likely to go gradually over a few weeks or months. If side effects are the main problem with a medicine, try to cope with these by e.g. changing times, splitting the dose and managing any side effects.

The best thing to do is set out your aims of success of any treatment in advance and be realistic. If you decide to stop, then that's your decision, but make sure you consider the chances of becoming unwell again (and consequences of that to yourself and the people close to you).

• Benzodiazepines - these are usually fairly quick to work i.e. you should feel a bit better in a few days or so, but this effect may build up as you find the right dose for you. You should probably try them for about a month or so before deciding if they suit you.
• Beta-blockers - these help the physical symptoms of anxiety e.g. racing heart and tremor, so the effect is fairly quick e.g. a few days, although the effect may build over several weeks.
• Buspirone - you need to build up (usually slowly) to a dose of 10mg three times a day, then stick with this for 4-5 weeks before it starts to work. If you only use it when you need it, it won't work. So, give the buspirone time to work.
• SSRIs, venlafaxine, mirtazapine, tricyclics, duloxetine and trazodone - it is worth knowing that your symptoms may get worse before they get better. So, it is best to start at a lower dose (e.g. paroxetine 10mg, escitalopram 5mg, citalopram 10mg) for a week or so, then build to the normal dose (e.g. paroxetine 20-40mg, escitalopram 5-10mg, citalopram 20-40mg), and then give it at least 4 weeks before making a decision. 
• Pregabalin - we don't really know for sure yet (not very helpful but honest!). However, it seems that if you are starting to improve after 2 weeks, it is very likely that you will carry on improving after that. If you haven't improved after 2 weeks, then the message is to stick with it for another couple of weeks because you may well still improve (Baldwin 2012).
• Antipsychotics - the effect is mainly via a calming and sedative effect so you should get an effect in a few days.

^{Updated 1.12}

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There are no easy answers to this and it is a very individual choice. Generally one medicine should always be the aim but combinations (often called "polypharmacy") sometimes help. It is rarely of any use to combine drugs with similar ways of working. Below are some of the combinations that are used with the reasons. This is not a complete list but you might want to talk to your prescriber about any combinations not on this list you may be prescribed.

Generally one medicine is the aim. However, many medicines for GAD have different ways of working. So, sometimes combining e.g. one of the antidepressant drugs with one of the others is reasonable. Since the SSRI-type medicines can make anxiety a bit worse before getting better, having a benzodiazepine for a couple of weeks can help enormously. But, you shouldn't need them longer-term once the SSRI kicks in.

Some of the main combinations are:

^{Updated 9.11}

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If you want to read up a bit more on the best treatments, there are many guidelines that you can look at. Probably the most important of these for England and Wales are those produced by NICE (the National Institute for Health and Clinical Excellence). NICE is an independent body that is asked to produce advice about preventing and treating illnesses and promoting good health. Scotland and Northern Ireland have similar bodies.

Each set of NICE Guidelines is written by an independent and carefully chosen group of specialists and experts (including service users and carers). They carefully review the available evidence and base their guidelines on this.

There are two main types of NICE guidance:

• "Technology appraisal". These look at an "intervention" (i.e. a medicine, a surgical operation etc) and decide if they think the evidence is good enough to make this intervention a standard and/or if it is cost-effective compared to other treatments

• "Clinical guidelines", which look at a particular condition (e.g. hypertension, lung cancer, depression, Parkinson's disease, bipolar disorder etc) and give guidelines covering medicines, services, support etc.

The guidelines are well intentioned and give generally sound guidance (although these are sometimes controversial). They are, however, only "guidelines", so are not rigid instructions.

When NICE issues a guideline, it produces a full set, and all of these are available on the NICE website:

• Full guideline (very long and detailed, often several hundred pages, for anorak healthcare professionals only)

• Official guideline (usually 10-30 pages, the summary version for healthcare professionals)

• Quick reference guideline for healthcare professionals (usually only a couple of pages)

• User-friendly summary for service users, carers and the general public

These should then be reviewed, usually about 4-5 years or sooner if more information becomes available.

As a general rule, you should start with treatments recommended by NICE as these are the ones with most evidence that they work. However, if these do not help you, it may be useful to try other treatments.

• NICE (click here for the Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults guidelines). There is also a guideline for Common mental health disorders, Identification and pathways to care, and this includes anxiety.

• Scottish Intercollegiate Guidelines Network (SIGN)

• Northern Ireland

There are plenty of other guidelines and so-called "consensus statements" (where a group of experts and specialists pool their ideas, based on their own experiences as well as what the published papers say, rather than just what the published studies say). These will have been produced for healthcare professionals by such bodies as BAP (British Association for Psychopharmacology).

^{Updated 11.11}

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Use the resources below to find out more information about anxiety. Please note that this is not an exhaustive list. We welcome your feedback on resources that you think should be listed here.

If you want a more in-depth read, you could do no better than visit the BAP (British Association for Psychopharmacology) public web pages, where there are some fairly scientific articles, including about anxiety disorders so click here to get there.

Mental Health Ireland has a great links page on this extensive site

Your Mental Health Ireland, with a young person’s page as well

Information about local mental health trusts is available on the NHS Choices website.

^{Updated 11.11}

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