In 1907, ‘Declan’, a 35-year-old plumber was admitted to Richmond District Lunatic Asylum (later St Brendan’s Hospital) in Grangegorman, Dublin. Declan’s father told the admitting doctor that “we have often seen him wash his hands ten times in half a hour, dry each time, then wash water tap and pipe down to trap”. While Declan had a number of other problems too, and care must be taken when applying the diagnostic categories of today to cases in the past, Declan’s symptoms appear to suggest obsessive-compulsive disorder (OCD), a condition in which worry and anxiety are key features.

Anxiety disorders are not new. Conditions such as generalised anxiety, panic attacks, social anxiety and phobias feature in the history of psychiatry from its earliest times, and appear frequently in the archives of Ireland’s mental institutions in the 19th and early 20th centuries.¹ Today, OCD is no longer considered to be an anxiety disorder in most classification systems, but its management still resembles that of anxiety disorders, based on a combination of psychotherapy and pharmacotherapy. Similarly, post-traumatic stress disorder (PTSD) was previously considered to be an anxiety disorder, but is now classified elsewhere, although its features and management still resemble most classical anxiety disorders. Depression, too, often presents primarily with anxiety, even if the person also fulfils criteria for depression. 

As a result, anxiety is essentially everywhere. This has always been the case. Virtually every generation in human history believes itself to be vastly more anxious than previous ones, and our current generation is no different. In truth, humans have always been anxious.

Today, anxiety disorders in children and adults are considered to include selective mutism, separation anxiety, specific phobia, social anxiety disorder, agoraphobia, panic disorder and generalised anxiety disorder.² Selective mutism is a consistent failure to speak despite language competence, which impacts on education or social communication. Separation anxiety is persistent, unrealistic anxiety or fear about separation from an attachment figure (such as a parent) or fear about something bad happening to them. These two conditions are seen most commonly in children and can require specialist input from child and adolescent mental health services.

In children or adults, a phobia involves excessive anxiety or fear of a defined situation or object, with consequent avoidance. Social anxiety disorder is a marked, excessive, unreasonable fear of scrutiny or adverse judgement by others, while agoraphobia involves similar anxiety about leaving home, entering certain public spaces, transportation or crowds. Panic disorder is characterised by recurring, unexpected episodes of severe anxiety, usually with both psychological and physical symptoms. Generalised anxiety disorder involves continuous worry about everyday issues and events.

While many of these symptoms are quite common in the general population, and most anxiety disorders are successfully treated in primary care, referral to secondary care is indicated when the anxiety is complex or treatment-refractory, when it results in very marked functional impairment or when there appears to be high risk of harm.³

Treating anxiety disorders

Psychological therapies and psychotropic medications are both first-line treatments for many anxiety disorders. Cognitive behaviour therapy (CBT) is the most commonly used psychological treatment and the one best supported by evidence. CBT focuses on cognitive strategies (ie. strategies related to thinking habits and patterns) and behavioural strategies (ie. strategies related to actions and behavioural habits) that can re-frame anxious thoughts, enhance coping strategies, reduce symptoms and promote recovery.⁴ Usually, the therapist will meet the patient once per week as the patient and therapist identify errors or unhelpful thinking patterns that deepen or prolong the patient’s condition. The patient and therapist develop ways to address these habits and errors and incrementally improve symptoms.

CBT is usually a time-limited therapy that lasts for eight to 20 sessions, but this is flexible. The treatment can be delivered individually or in groups, can occur online and can be adapted to the specific needs of each individual. There is compelling evidence that CBT is effective in the management of multiple anxiety disorders and, for some patients with mild or moderate depression, the benefits of CBT can exceed those of antidepressants. The chief difficulty lies in accessing CBT, because provision is uneven and private CBT can be expensive. There is growing evidence to support online CBT, once it is properly delivered, so this might be a more accessible option for many people.

Medication is another first-line treatment for certain anxiety disorders. Various classes of selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs) are useful in social anxiety disorder, panic disorder, agoraphobia and generalised anxiety disorder.² The Maudsley Prescribing Guidelines in Psychiatry recommend starting SSRIs at half the usual starting dose for generalised anxiety disorder or panic disorder and titrating to the normal antidepressant dosage range appropriately, while remaining mindful of the possibility of an initial worsening of anxiety.⁵ They suggest that standard antidepressant starting doses are generally tolerated in social phobia. As is usual with antidepressants, the guidelines recommend monitoring for side-effects and suicidal ideation, and note that discontinuation effects can occur if these medications are stopped abruptly. Patients need to be advised of these possibilities, as well as the likely considerable benefits of these medications once they are used appropriately.

Benzodiazepines should be avoided if possible and limited to extreme situations. They should be kept to the lowest dose feasible and prescribed for the shortest period manageable, not exceeding a few weeks. While these medications might have certain uses in very specific cases, the risks and harms generally exceed the short-term benefits in anxiety disorders. Propranolol can be prescribed for anxiety in Ireland and can help with certain symptoms in carefully selected patients, provided there is appropriate monitoring. The roles of various other medications, such as pregabalin, are outlined in detail in treatment algorithms in the Maudsley Prescribing Guidelines in Psychiatry.⁵

Finally, it appears that combination therapy works well, using both antidepressants and psychological therapies at the same time. One meta-analysis of adults with depression or anxiety disorder found that the effects of combined pharmacotherapy and psychotherapy compared with placebo were approximately twice as large as those of pharmacotherapy alone compared with placebo.⁶ In addition, the effects of pharmacotherapy and those of psychotherapy seemed to be largely independent of one another, and both contributed equally to the benefits of combined treatment.

Mindfulness-based therapies

In addition to traditional psychological therapies (such as CBT), approaches that are rooted in mindfulness have gained significant attention in recent years. Reangsing et al describe mindfulness as “a process that leads to a mental state defined by non-judgmental awareness of one’s experiences, thoughts, physiological states, consciousness and environment, while fostering openness, curiosity and acceptance”.⁷ Mindfulness-based interventions allow for “self-regulation of the body and mind through body scan, sitting meditation and mindfulness movement such as yoga or other mindfulness exercise […] With this practice, individuals become more aware and can self-regulate their thoughts, emotions and behaviours related to anxiety”.

While the term “mindfulness” is now overused and at times misused, mindfulness remains a powerful psychological technique provided it is practised with care, commitment and consistency. Growing evidence supports specific programmes of mindfulness for a range of mental illnesses and psychological problems, including certain cases of depression and anxiety disorders. The best evidence relates to eight-week courses of mindfulness-based stress reduction and mindfulness-based cognitive therapy. In Ireland, the Mindfulness Centre in Dublin offers a range of these and other courses, both in person and online, delivered by teachers who are fully trained and accredited. Its website also has plenty of free material: guided meditations, recordings and other helpful resources (www.mindfulness.ie).

Mindfulness does not appeal to everyone, so other activities like yoga or walking can offer benefits. Adjustments to lifestyle are often central to managing anxiety in the longer term and finding ways to diminish its impact in a person’s life. In addition, patients can start to misuse alcohol, other drugs or medications such as benzodiazepines in an effort to manage their anxiety. It can be helpful to name this with patients, provide support for stepping away from these habits and validate other activities that can serve similar functions in a healthy way, eg. swimming, gardening or going to the cinema.

For the most part, anxiety conditions are managed in a step-wise fashion with combinations of treatment approaches that can change over time. Treatments usually alleviate anxiety to a significant or substantial degree, and reduce the problems it causes in people’s lives. For some people, however, ongoing management is needed, so lifestyle changes are essential to sustain progress. These include regular exercise, a healthy diet, sleep hygiene and appropriate social activities.³ Unstructured social contact can be a particular challenge in anxiety, so activities such as Park Run can offer a relatively accessible way to exercise and meet people while walking or running (www.parkrun.ie). 

Discharged, recovered

Back at the Richmond District Lunatic Asylum in Dublin in 1907, Declan spent three months in the institution with his symptoms of anxiety and OCD. His other problems included alcohol misuse, likely owing to anxiety. Declan’s treatment in the asylum is not recorded, but probably included a relatively healthy diet, activities such as gardening or maintaining the building and simple institutionalisation, rather than more focused therapy. Despite the lack of specific treatment for his anxiety, and notwithstanding the perils of institutional life, Declan was “discharged, recovered” after three months in the Richmond. There is no record of him having any further problems.