‘Deeply unpleasant’: When does anxiety become a problem?

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Explainer

‘Deeply unpleasant’: When does anxiety become a problem?

Anxiety is a normal part of life. But sometimes it can get the better of us. How do you know when to ask for help?

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Over the past two weeks, how often have you felt bothered by any of the following: feeling nervous, anxious or on edge; not being able to stop or control worrying; trouble relaxing; feeling something awful might happen?

These are the types of questions people around Australia are being asked in GP rooms, or in online tests to help them determine if the symptoms and sensations they experience indicate the presence of anxiety – and to help them know if they’re at the point where they may need to seek support.

Record numbers of Australians have been reporting moderate to severe mental distress during COVID restrictions. Beyond Blue has reported that online forums have been very active with people comparing notes and offering peer support. The Australian Bureau of Statistics found that in June, 20 per cent of Australians had experienced high or very high levels of psychological distress in the previous four weeks, a figure similar to March (20 per cent) and November 2020 (20 per cent). Almost one in three (30 per cent) people aged between 18 and 34 reported high or very high levels of psychological distress. In the mix is anxiety.

Anxiety had become a buzzword everywhere from workplaces to schoolyards, Twitter to TikTok, well before the onset of COVID-19. It has been dubbed the defining mental issue of our decade. But what is it?

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What, exactly, is anxiety?

In its most basic form, anxiety is “a very normal human emotion and one which we all feel from time to time”, says Dr Marie Yap, a psychologist and associate professor at Monash University. “Everyone can relate to feelings of being on edge, nervous, scared, fearful, worried.”

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And it has its role: “In a sense, anxiety is very useful day to day ... It alerts us to the need for more resources: there’s something going on here, we need to attend to it, to problem solve. It’s that fight or flight instinct.”

When we talk about anxiety, “we’re actually talking about a number of things”, says psychiatrist Lisa Lampe, an associate professor and deputy head of Newcastle University’s school of medicine and public health.

These include fear, which is a response to imminent threat, and “anxious anticipation”, which is worry or dread about something that may or may not happen and may be bad if it came to pass (which is particularly linked to uncertainty). It also refers to chronic anxiety, which can include fearfulness, recurrent panic attacks and/or constant worry and which feels “extremely unpleasant”.

“Worry is an attempt to try and control things, get the measure of things and get some certainty and be prepared.”

Worry arises as a coping mechanism, allowing us to anticipate everything that could go wrong and to plan for any eventuality, which may feel like it is “inoculating” us from the worst.

“In fact, research suggests worry is a very inefficient problem-solving strategy. It feels as if it is helping, whilst at the same time triggering anxiety,” said Lampe.

“Worry is an attempt to try and control things, get the measure of things and get some certainty and be prepared. Ninety nine times out of 100 [the subject of the worry] doesn’t happen, and the worry can start to become a burden in and of itself because it’s just miserable to be worried all the time,” says Lampe. Many people then “start worrying about being worried”, which can quickly turn into a kind of psychological loop.

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Similarly, Dr Peter Baldwin, clinical psychologist and clinical research fellow at the Black Dog Institute, says feeling anxiety is part of having “a normal human brain”. “Your brain is constantly creating predictions about your environment so it can stay a few milliseconds ahead that could make the difference to an organism in a high-threat situation.

“It is taking everything from past experiences and guessing what’s going to happen next and those guesses are important for our moment-to-moment lives. But they can take over, and you can see them as fact rather than fiction.” He says this can tip into a mindset like Chicken Little, the children’s book character convinced the sky is falling and constantly on high alert.

Apart from potentially saving your life, anxiety has other upsides too, especially when it comes to performing complex tasks under pressure, like doing an exam or landing a plane, says Ian Hickie, NHMRC research fellow and professor of psychiatry at the University of Sydney. Because you need to focus your attention on threats, “it improves your performance, so some degree of anxiety is good”.

So when is anxiety a problem?

Normal anxiety becomes abnormal “when you find yourself aroused and attending [psychologically] but to no external stimulus – you feel threat, but no threat is there,” says Hickie.

Of course, the pandemic is not a figment of our imaginations. The distinction is if a response is out of proportion and is effectively “getting us ready to solve a problem that’s really out of our hands”, says Dr Baldwin, such as the pandemic.

“That’s where all of us are at the moment; the double-whammy of being in a very unpredictable situation, in which our brain would prefer to have a bunch of resources to hand to deal with it, but we can’t affect much change.

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“That mix of unpredictability and not having the resources to cope is a perfect storm for the brain: we’re all getting a crash course in anxiety, regardless of whether we had a history of mental health problems or not. We’re all learning anxiety is really common and normal, except that’s it’s deeply unpleasant.”

“People who are anxious become hyper-vigilant for threat and are constantly on the lookout for signs of danger.”

When we are experiencing more troubling anxiety, areas of the brain used for making sense of our world and interpreting sensory input are working overtime, the experts say, producing hormones such as adrenalin and the stress hormone cortisol. Our heart rate goes up. We breathe faster, and might even become dizzy or nauseous. We sweat. Our muscles tense (and teeth clench, shoulders creep up to our ears, and so on). Some people mistake these changes as serious illness – in turn feeding their anxiety, says Lampe.

“People who are anxious become hyper-vigilant for threat and are constantly on the lookout for signs of danger,” she says, but since the anxious brain can distort our ability to appraise things efficiently, some people “see threat everywhere and are constantly reacting to it with anxiety”.

Prolonged production of cortisol can cause health issues such as the propensity to gain weight, which carries an elevated risk of diabetes or prediabetes.

It can also be exhausting. A clear sign that anxiety is becoming an issue is when worries start to feel overwhelming, says Yap. You might be sensing, “I can usually cope better than this but nowadays less so”. It might affect your appetite, sleep and ability to concentrate and function properly in daily life.

It has reached the stage of mental illness when “it is really getting in the way of people doing what they want to do and causing them a lot of distress; if you can’t go to work or are spending most of your day worrying about the symptoms of anxiety and worrying about what’s going to happen – that’s the point where we’d recommend see a GP”.

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Lampe says anxiety and depression often go hand in hand. “People can get depressed because of their anxiety, but depression can sometimes present with a lot of anxiety. A careful assessment is important in order to identify the treatment priorities. Having both together makes it hard to get better and is definitely a situation where people should reach out for professional help.”

Melanie Faith Dove found herself in an aimless muddle during Melbourne’s 2020 lockdown.

Melanie Faith Dove found herself in an aimless muddle during Melbourne’s 2020 lockdown.Credit:Jason South

What’s it like to be overwhelmed by anxiety?

Photographer Melanie Faith Dove says the anxiety she developed during Melbourne’s long lockdown in 2020 felt “paralysing”.

Having experienced varying degrees of anxiety through life, she found her sleeping, eating and exercising patterns entirely disrupted by anxiety during lockdown. She lost work, drank more alcohol and gained weight. She could still cook, paint and care for her family but lost her sense of life purpose.

“It’s only when it becomes so unmanageable and in your face that you’ve got to stare it down.”

“Sometimes it can manifest in being quite confused in the direction of what I want to do; I’ll start doing one thing then another and end up having so many balls in the air then I am just incredibly overwhelmed ... Then it’s really hard to beat a path out of the irrational, aimless muddle,” she says.

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“People live with low-level anxiety. It’s only when it becomes so unmanageable and in your face that you’ve got to stare it down because there’s no way around it, that’s how you know it’s proper anxiety: when it stops you from functioning and there’s no way out.”

Dove says walking daily, being back able to spend time with her horse who is agisted and who she could not see in lockdown, cutting out alcohol and coffee and eating better brought the anxiety, and the weight, under control and she was able to lift her mood.

Do we risk ‘pathologising’ ourselves?

Anxiety is so common, says Dr Grant Blashki, a GP and lead clinical adviser at Beyond Blue, “that in any year 2 million Australians experience an actual anxiety condition”. However, he cautions people not to be too quick to “pathologise or over-medicalise normal worries, disappointments and losses, which are a part of life”.

“If you’re worried about the lockdowns, then you’re worried, that doesn’t mean you’ve got an anxiety condition,” says Blashki. He has noticed the word “anxiety” entering the vernacular, particularly among young people, and says there is a balance to be achieved “between healthy mental-health literacy and an appreciation that mental health is a common, serious issue and at the same time not over-medicalising normal human experience”.

“There’s not always an absolutely clear line between someone who’s very worried and stressed and someone who’s got an anxiety condition.”

But he says “there’s not always an absolutely clear line between someone who’s very worried and stressed and someone who’s got an anxiety condition; as a GP, the sort of things that really help you differentiate are the severity of worries, the duration and if it’s all-pervasive and really affecting [a person] day to day, in terms of being able to work or manage home duties.”

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The issue many Australians face in the pandemic, and why so many people are wondering if they have full-blown anxiety (many are seeking psychological support for it or depression when they have not needed to previously) is that uncertainty is inherently anxiety-provoking. “If there was ever a situation of uncertainty, it’s now,” says Marie Yap.

Symptoms of anxiety because of COVID-19 worry are very likely to be more common at the moment, and “possibly for people who already have anxiety it may be more severe”. It is unclear, though, if there is an increase in diagnosis of full-blown anxiety disorders such as generalised anxiety disorder or panic disorder.

So, what are some solutions?

Standard ways to help manage feelings of anxiety include getting regular exercise, decreasing stimulants such as coffee and alcohol and trying to keep the sleep-wake cycle regular.

Lisa Lampe says that if anxiety is mild to moderate and has been present for a short time, such as a couple of months, by far the best approach is cognitive behavioral therapy (CBT). This helps people learn to manage their appraisals of things and identify feedback loops that may otherwise keep them stuck in a cycle of anxious responding.

Medication is reserved for people who have persistent moderate to severe anxiety that is causing them significant distress or impairment and has lasted about six months or more, and possibly who have not been improved by CBT. The first line of treatment is antidepressants, which have been found to work effectively for anxiety and to potentially help people change anxious thinking patterns.

“Managing anxiety is one of my favorite roles, because people get better and they get good outcomes.”

Dr Grant Blashki says in his experience, CBT said is very effective. Referrals to psychologists can be provided by GPs. “Managing anxiety is one of my favorite roles, because people get better and they get good outcomes,” he says.

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He urges people who are experiencing distressing symptoms to speak to their GP sooner rather than later, saying research by Beyond Blue in 2017 found 37 per cent of people seeking support for clinical anxiety had waited longer than 12 months, and about one in five waited longer than six years because they did not believe they had a real medical condition or their issues were serious enough. Yet “93 per cent of those who got professional support found it really helpful – that’s why it breaks my heart a little bit”.

Black Dog’s Peter Baldwin agrees that helping people with issues such as managing anxiety “is why professionals such as me get up in the morning”. “Don’t hesitate.”

Many websites run by Australia’s large mental health organisations, including Beyond Blue, offer tools, resources and online support groups. Blashki also recommends the federal government’s Head to Health website, which offers a wide range of helpful information. The Black Dog Institute has a similarly evidence-base resource page, as does the Royal Australian and New Zealand College of Psychiatrists also has a comprehensive website, Your Health In Mind.

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