Anxiety

Dr Lisa Beckett

May 2022

What is anxiety?

Anxiety is an uncomfortable inner feeling of fear or imminent disaster. We all experience temporary anxiety when faced with danger. Anxiety is a common normal human reaction to stress, which helps us to stay safe and take action when needed.

Anxiety becomes a problem when we have the same reaction to the extent that it interferes with our lives. When we’re very anxious, we have intense feelings of worry or distress that are not easy to control.

Anxiety is the most common mental health condition in Australia. Up to one-third of women and one-fifth of men will experience anxiety at some point in their lives.

What are the symptoms of anxiety?

The symptoms vary significantly from one person to another and in different situations. They may range from feeling tense and tired to panic attacks.

Physical symptoms can include:
• tiredness or fatigue
• dry mouth, difficulty swallowing
• sleep disturbances and nightmares
• muscle tension/headache
• rapid heart rate and breathing
• sweating
• trembling
• diarrhoea
• flare-up of an illness (e.g. dermatitis, asthma)
• sexual problems

Psychological symptoms can include:
• apprehension: ‘something awful will happen’
• inability to focus
• rumination: obsessing over thoughts or situations
• irritability
• feeling nervous, scared or on edge
• feeling worried you’re going crazy

Because other conditions can have similar symptoms (such as thyroid disorders), it’s important to talk to your GP about what is happening. They can investigate as needed and help support you to find the best treatment.

Types of anxiety

There are different types of anxiety disorders. Most commonly:
- generalised anxiety disorder
- social phobia
- panic disorder
- specific phobia
- separation anxiety disorder
- agoraphobia

What treatments are available?

Treatment for anxiety can be grouped into 3 main types:
- psychological
- medications
- self-help and lifestyle

Self-help and lifestyle treatments for anxiety

There are many techniques and therapies that can be of benefit in anxiety. Examples include:
- exercise
- good nutrition
- meditation
- yoga
- massage therapy
- relaxation and breathing techniques
- alcohol and drug avoidance
- acupuncture

Exercise
Exercise can increase chemicals in the brain such as serotonin and endorphins. These chemicals can improve mood, sleep, libido and appetite.  Regular exercise can help in anxiety by:
- increasing energy
- improving sleep
- acting as a distraction from overthinking
- improving general health
- providing social support if done with others
- giving a sense of achievement and control

Nutrition
While eating well helps our bodies be at their best, it can also help our psychological health. There is some evidence that magnesium, vitamin D, B vitamins, omega-3, and omega-6 can be useful for reducing anxiety. Make sure you talk to your doctor before starting any supplements.

Anxiety can be worsened by stimulants such as caffeine and energy drinks. Too many stimulants leave our body feeling like we’re in an anxious state with an increased heart rate and jitteriness. They are best avoided.

Psychological therapies

Psychological therapies are the most effective way to treat anxiety. They may be effective on their own or used in combination with other treatments. Psychological treatments may be one on one, group based or online.

The aim of psychological therapy is to help us change the way we think and respond. Psychology may give us a better understanding of why we feel the way we do, help us recognise any underlying triggers, change unhelpful thoughts and develop skills to improve our mental health.

There are a number of different forms of psychological therapies including:

Cognitive behavioural therapy (CBT)
CBT involves recognising our thoughts about anxiety and re-framing them to decrease our stress response. The way we think affects how we feel. It is possible to challenge our thoughts and recognise cognitive distortions - unhelpful thought patterns.

CBT can be completed individually in person or online, or in small groups. It works best when guided by a qualified clinician. Sessions are usually completed over several weeks to months.

Exposure therapy
Therapy involving gradual exposure to stressors is often used for PTSD, OCD and phobias. It may be combined with CBT. Exposure therapy involves facing the fear in a slow controlled way, over a long period of time.

Exposure therapy should be guided by a trained clinician.

Mindfulness
Mindfulness has gained in popularity as a tool for mental health. It involves being intentionally aware of what is happening in the present moment, without judgement. Recognising our thoughts, feelings and sensations in the moment, and accepting them without trying to change them.

Anxiety tends to focus on what could go wrong. Many anxious people ruminate on worst case scenarios, and label their emotions and thoughts as ‘bad’. Mindfulness aims to bring you back to the present moment.

There are a number of mindfulness apps and it is a skill that can be practiced alone or with a clinician.

Other forms of therapy
There are many forms of psychological therapy that may be helpful for anxiety including:
- Dialectical Behavioural Therapy (DBT)
- Interpersonal therapy
- Acceptance and Commitment (ACT) therapy
- Emotionally focused therapy
- Trauma focused therapy including EMDR

It is best to be guided by a qualified clinician to determine which suits you best.

Psychological therapies are the most effective way to treat anxiety for most people. They are often combined with medications or medicinal cannabis treatments and self care.

Even if you decide that medications, medicinal cannabis or self help treatments are more suitable for you, it is recommended that you consider psychological therapy as well.

Medications

When psychological and lifestyle therapies are not helping with anxiety, medication can be a good option. All medications have risks and benefits and potential side effects and it’s important to discuss these with your doctor before starting.

There are a few main groups of medications used for anxiety: anti-anxiety medications, antidepressants and beta-blockers.

Anti-anxiety medications
This group of medications includes benzodiazepines such as Valium. While they can be useful for acute symptoms such as panic attacks they are not recommended for long term use. Most commonly they are used short term while waiting for longer term medications to take effect.

Anti-anxiety medications have side effects including headaches, dizziness, memory loss and drowsiness. They can be addictive and you can develop tolerance - requiring higher doses over time to get the same effect.

Antidepressants
While antidepressants were originally developed to treat depression, some are useful in anxiety also. They can be particularly useful when anxiety and depression occur together.

There are a number of classes of antidepressants. The main ones used for anxiety are selective serotonin reuptake inhibitors (SSRIs) and serotonin noradrenaline reuptake inhibitors (SNRIs).

SSRIs
SSRIs are first line medications for anxiety disorders, particularly generalised anxiety disorder. Common SSRIs include citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline. Escitalopram has the most evidence for generalised anxiety disorder but further studies are needed to see how it compares to other SSRIs.

SNRIs
There is good evidence that SNRIs can be effective for generalised anxiety disorder, particularly duloxetine. Other SNRIs include desvenlafaxine and venlafaxine.

Side effects of antidepressants include nausea, restlessness and agitation, sexual dysfunction and weight gain. They often take 2-4 weeks to be fully effective and need to be weaned off if taking a high dose.

Beta-blockers
Beta blockers are usually used to treat blood pressure and heart conditions. Because they slow your heart rate down they can be helpful for feelings of anxiety. Beta blockers are mostly used in situational anxiety such as public speaking.

Medicinal cannabis

When psychological therapies and traditional medications are not effective in treating anxiety, doctors may consider prescribing cannabis.

Can cannabis be used for anxiety?

Yes, for some patients cannabis can be used to help treat anxiety. It may be used alone or in combination with other therapies including psychology or antidepressants.

Cannabis contains more than 100 compounds called cannabinoids. The most well known of these are Δ 9-tetrahydrocannabinol (THC) and cannabidiol (CBD). Our bodies also make their own cannabinoids. Cannabinoids act in the endocannabinoid system and have a wide range of effects. See more here.

CBD is non-psychoactive and acts indirectly on CB2 receptors. Oral CBD is used first line as medicinal cannabis treatment for anxiety. If ineffective, inhaled CBD or oral THC may be trialled.

It is important to appreciate that THC is psychoactive and acts on CB1 receptors. This means it can potentially make anxiety worse and is a known side effect of use. If THC is used it should be started at a low dose and titrated very slowly. Using CBD with THC may help counteract any anxious side effects from THC use.

Can cannabis be prescribed for anxiety in Australia?

Yes it can. Any registered doctor in Australia can prescribe medicinal cannabis with approval from the TGA. You can speak to your GP about how suitable this is for you, or Candor can help you connect to a GP with medicinal cannabis knowledge who can apply for the approvals.

To be eligible you must have been diagnosed with an anxiety disorder and have trialled other treatments such as those outlined above. If other treatments have been ineffective or you had unacceptable side effects then medicinal cannabis may be appropriate for you.

What research is there for anxiety and cannabis?

There have been a number of studies looking at how cannabis can be used to treat anxiety. It has mostly been shown that CBD oil can be effective for anxiety. Studies have shown that post-traumatic stress disorder, generalized anxiety disorder, obsessive-compulsive disorder, and social anxiety disorder may all improve with medicinal cannabis, however these studies were on animal models.

Studies have also shown that females may benefit more from medicinal cannabis use than males when it comes to anxiety and stress.

Further testing is required to gain a comprehensive understanding and optimal treatment plans.

References

Bergamaschi MM, et al. Neuropsychopharmacology 2011;36(6):1219

Crippa JA, et al. J Psychopharmacology 2011;25(1):121–30

Bar-lev Schleider L, et al. Sci Rep 2019;9(1):200

Cutler C, et al. J Affect Disord 2018;235:198⎼205

Stith SS, et al. Frontiers in Pharmacol 2018;9(916):1⎼8

https://www.blackdoginstitute.org.au/resources-support/anxiety/treatment/