Dear Doctor: A Doctor Answers Your Questions
Return to the main Dear Doctor page
Living with Anxiety
Dear Doctor
I've suffered from numerous bouts of depression but now consider myself recovered and lead a full and happy life, helped greatly by anti depressants and counselling. I continue on medication but find that, though not depressed, I feel panic and anxiety when I wake up each morning in spite of the fact that I avoid caffeine. This lasts several hours. Why does this happen and is there anything I can do to lessen the sensation of worry?
It is very good to hear that, after the trouble you have had with depression, you’re now doing so well and leading a full & happy life. You ask why you experience a good deal of anxiety each morning, and what you can do about it. Of course it’s difficult to answer your questions in much specific detail without having considerably more information about your situation. I can though make some fairly general points that hopefully will be of help.
Firstly I do think it’s well worthwhile to tackle the anxiety in quite a determined way, rather than just going on suffering it. This is for two reasons. The first is obvious – the quality and enjoyment of your life is likely to be appreciably better when you are no longer suffering in this way each morning. The second reason is maybe a bit less obvious – residual symptoms after recovery from depression are a risk factor for relapse or recurrence. It’s a bit like putting out a bonfire. It’s not really good enough to mostly put it out, but leave it smouldering. It makes it too likely that you’ll come back later to find it’s flared up again. Even if the anxiety isn’t ‘residual’ in the sense that you had symptoms rather like this before you ever became depressed, anxiety is still a risk factor for depressive recurrence.
Anxiety, of course, is rather a broad term covering a variety of sub-types such as panic disorder, agoraphobia, generalized anxiety disorder, social anxiety disorder, health anxiety and so on. The dividing lines separating the different sub-types aren’t that rigid and it’s common to be affected by more than one form of anxiety. You mention both panic and worry. There are good books giving information on self-help for panic. I like the cognitive therapy orientated “Overcoming” series. Examples are “Overcoming Panic” by Derrick Silove & Vijaya Manicavasagar and “Overcoming Anxiety” by Helen Kennerley. Severe worry and tension are more typically signs of generalized anxiety disorder. Robert Leahy’s “The Worry Cure” is a useful and fairly recently published self-help book that tackles this kind of problem. For a more general overview on helping all kinds of anxiety see Edmund Bourne’s “The Anxiety & Phobia Workbook”
You say you are still taking an antidepressant. Usually antidepressants help anxiety as well as depression. Occasionally though, the antidepressant itself may be aggravating feelings of tension and anxiety. If you think this might be the case for you, discuss it with your doctor. It may be possible to experiment a bit with dose to test this out. Shifting to a different antidepressant is also always an option. Think too about other possible physical causes of the anxiety. Some people find that alcohol can aggravate anxiety. Others find that autumn and winter make them feel more tense (see the DAS website for details of Seasonal Affective Disorder www.dascot.org/sad.html).
It’s particularly important to consider ways that you can help the anxiety psychologically. Professor David Barlow is a world expert on anxiety disorders. He highlights three areas that it’s likely to be especially helpful to work on. One area is avoidance. Avoidance typically involves not doing things that are actually pretty safe but seem very scary to the person with anxiety. Examples are not going to the supermarket in agoraphobia or not speaking out in a group in social anxiety disorder. Avoidance can also involve fear of certain physical sensations. Examples are feeling breathless or having one’s heart racing in panic disorder. Avoidance can involve emotions, such as being terrified of tears or anger. Avoidance can even focus on thoughts with worry about worry in generalized anxiety disorder or fear of trauma memories in post traumatic stress disorder. Avoidance at times can be quite subtle and hard to detect. In general avoidance of something one feels anxious about makes one feel better in the short run, but keeps the anxiety problem going in the long run – a bit like having a drink for an alcoholic. It’s usually a good idea to confront avoidance in a step by step way, starting with easier challenges and gradually working up to harder ones.
A second area David Barlow highlights as important to tackle is catastrophic, pessimistic thinking. Interestingly this is often tied up with avoidance. Confronting the avoidance as an “experiment” to challenge the catastrophic thinking can be particularly helpful. Exploring healthier ways of seeing things rather than catastrophising is central to cognitive therapy (see the “Overcoming” books mentioned earlier). Sometimes it can also be useful to ask oneself whether negative ways of seeing things link back to earlier periods of one’s life. See, for example, James Pennebaker’s book “Writing to Heal” New Harbinger Publications (2004). Barlow’s third area of focus in treating anxiety disorders is to enhance health and wellbeing. This might involve learning relaxation skills or exercising more. It might involve reducing alcohol, caffeine or smoking. It might involve working to improve one’s relationships or one’s job situation. Stephen Hayes’ book “Get out of your Mind and into your Life” New Harbinger Publications 2004 is a classic on the importance of focusing on one’s values and wellbeing even if one does have a number of very difficult symptoms.
There are also some great websites providing good information about anxiety. Examples include:
Scotland’s Five Areas site at www.fiveareas.com
UK Royal College of Psychiatrists site at www.rcpsych.ac.uk/mentalhealthinformation.aspx
US National Institute of Mental Health’s site at www.nimh.nih.gov/healthinformation/anxietymenu.cfm
Self-help cognitive therapy FearFighter at www.fearfighter.com/index.htm or www.livinglifetothefull.co.uk
US Anxiety Disorders Association of America at www.adaa.org/
So many of us suffer are affected by anxiety of one kind or another. In fact getting anxious occasionally is normal and can, at times, serve a useful function. Excessive, inappropriate or continuous anxiety is, however, horrid to live with. I hope the ideas I’ve mentioned are helpful and that if you chase up any of the books or websites I’ve mentioned, you will find them useful as well.
Dr James Hawkins
Books Recommended by Dr Hawkins
(Details of these books and links to Amazon can be found at www.dascot.org/books.htm#anxiety)
Overcoming Panic Derrick Silove & Vijaya Manicavasagar (Constable and Robinson 1997)
Overcoming Anxiety by Helen Kennerley (Constable and Robinson 1997)
The Worry Cure Robert Leahy (Piatkus Books, 1996)
The Anxiety & Phobia Workbook by Edmund Bourne (New Harbinger Publications,U.S. May 2005)
Writing to Heal James Pennebaker New Harbinger Publications 2004
Get out of your Mind and into your Life Stephen Hayes New Harbinger Publications 2004