We all can feel anxious from time to time about various issues or incidents in our lives. Feeling anxious about having to speak in front of a group is quite normal for most people. Worrying about whether a certain person likes or dislikes you is a common source for concern. It is also normal to think about how close you might have come to having had a car accident when you were driving on an icy road.

Some level of anxiety can even be helpful. For example anxiety can help a person study harder for an exam or perform better in sports. Normal anxiety that lasts a short period of time is not necessarily harmful.

However, if anxiety becomes persistent and disrupts our normal functioning in our day to day life, if the response is disproportionate to the severity of a stressor (trigger or cause of anxiety) or if the anxiety occurs even in the absence of a stressor, we may have an anxiety disorder. According to the website of the Canadian Mental Health Association, anxiety disorders are among the most common types of mental health problems affecting 1 out of every 10 Canadians (see www.cmha.ca).

The Centre for Addiction and Mental Health (CAMH) states in their website (see www.camh.ca) that the following list of anxiety symptoms may indicate an anxiety disorder:

1. Cognitive symptoms: anxious thoughts (eg."I'm losing control"), anxious predictions (eg. "I'm going to fumble my words and humiliate myself") and anxious beliefs (eg. "only weak people get anxious").

2. Physical symptoms: excessive physical reactions relative to the context (eg. heart racing and feeling short of breath in response to being at the mall). The physical symptoms of anxiety may be mistaken for symptoms of a physical illness such as a heart attack.

3. Behavioural symptoms: avoidance of a feared situation (eg. driving), avoidance of activities that elicit sensations similar to those experienced when anxious (eg. exercise), subtle avoidance’s (behaviours that aim to distract the person, eg. talking more during periods of anxiety) and safety behaviours (habits to minimize anxiety and feel safer).

The factors that CAMH list as determining whether the anxiety warrants the attention of a mental health professional include: the degree of distress caused by the anxiety, the level of effect that the anxiety has on a person's ability to work or study, socialize or manage tasks, and the context in which the anxiety occurs. Anxiety disorders may cause a person to have feelings that are so uncomfortable that the person avoids certain routines or activities. Some anxiety attacks are so intense that the person is terrified or immobilized.

Types of Anxiety Disorders:

1. Panic Disorder (with or without agoraphobia)

Panic Disorder involves "repeated unexpected panic attacks (eg. heart palpitations, sweating, trembling) followed by at least one month of persistent concern about having another panic attack". These panic attacks occur without warning. The Anxiety Treatment and Research Centre (in Hamilton, Ontario) defines a panic attack as, "a discrete period of intense fear or discomfort, in which at least four from a list of 13 standard symptoms develop abruptly and reach a peak within 10 minutes. The official list of 13 Panic Attack symptoms include: racing or pounding heart, sweating, trembling or shaking, shortness of breath, feeling of choking, chest pain or discomfort, nausea or abdominal distress, feeling dizzy, unsteady or faint, feeling unreal or detached, paresthesias (numbing or tingling), chills or hot flashes, fear of dying, fear of going crazy or losing control." Panic attacks can be accompanied by agoraphobia (the avoidance of specific situations such as public places or places where crowds gather, from which a person might not easily escape).

2. Specific Phobias

Specific phobias involve many types of intense fear reactions of specific objects or situations such as fear of spiders, flying or heights. There are five subtypes of specific phobia: animal type (such as fear of spiders), natural environment type (eg. fear of storms or heights), blood-injection-injury type (eg. fear of seeing blood), situational type (such as fear of elevators or public transportation), and other type (such as fear of vomiting). Symptoms can be sweating, muscle tension and dizziness. Avoidance of the object or situation that is feared is common.

3. Social Anxiety (or Social Phobia)

This is the most common type of anxiety disorder. It is a fear of being embarrassed in social situations. It is not a fear of people... Social anxiety disorder is a fear of humiliation or embarrassment. Symptoms can include blushing, dry mouth and sweating. People with social phobia will often avoid social situations that can cause anxiety. Most people with social anxiety fear or avoid situations from both of these two main categories: performance situations and social interactions. Examples of feared performance situations include: public speaking, talking in meetings or in class, participating in sports or exercise in front of others, performing music or acting on stage, and using public restrooms when others are nearby. Examples of feared social interactions are: going to a party, initiating or maintaining conversations, talking to strangers, expressing personal opinions, being assertive and being in intimate situations.

4. Generalized Anxiety Disorder

This is a general feeling of anxiety most of the time. There is continual excessive anxiety about a number of things (such as work, children, health, money). Also there can often be worrying over minor matters such as "Will I arrive on time?", "What if I can't find a parking spot?", "What if I get lost while driving?" There is no specific source of the fear. The anxiety and worry occurs more days than not, and must last at least six months for a diagnosis to be made. People with GAD tend to report worrying more frequently, about more topics and for longer periods of time than do those without GAD. In addition, people with generalized anxiety disorder often find it more difficult to control their worry. Symptoms can include muscle tension, trembling, shortness of breath, fast heartbeat, dizziness, dry mouth, sleeping problems, and poor concentration.

5. Obsessive Compulsive Disorder (OCD)

This occurs as a result of unwanted thoughts (obsessions) that trigger repetitive actions (compulsive behaviours) that are an attempt to try to reduce or suppress the anxiety caused by the obsessive thoughts. Obsessions are uninvited, intrusive thoughts or urges that can surface over and over again in the mind, such as concerns about contamination or doubts. These thoughts can trigger compulsions such as repeated hand washing or repeated checking. Compulsions are behaviours or "rituals" that a person follows to try to reduce or suppress his or her obsessive thoughts. Other types of compulsive behaviours are counting things and constantly putting things in order,

This disorder can be severe enough to be time consuming or cause marked distress or impairment.

6. Post-Traumatic Stress Disorder

This is anxiety associated with and occurring after a stressful life event, such as sexual assault, war zone experiences, natural disasters, physical assault or severe motor vehicle accidents. PTSD is diagnosed if after experiencing a traumatic event the person experiences symptoms that last at least a month from the following three clusters:

(i)- re-experiencing symptoms in which the person relives the trauma (as in recurrent recollections or flashbacks, or intense bodily reactions when reminded of the trauma).
(ii)-persistent avoidance of things associated with the trauma and a sense of emotional numbing.
(iii)-persistent symptoms of increased arousal (as in outbursts of anger, sleep disturbances, difficulty in concentration or being hyper-alert for danger).

Anxiety Disorder or something else?

It must be remembered that any diagnosis must be done by a physician, psychologist or a qualified mental health specialist, as there are certain medical conditions or medications that can mimic or aggravate anxiety. For example, hyperthyroidism, cardiovascular disorders such as arrhythmia’s, breathing problems or peptic ulcer must be ruled out before giving a diagnosis of an anxiety disorder.

Starting or stopping certain medications suddenly can also mimic some anxiety symptoms. Some medications, such as stimulants, may cause side-effects that look like certain anxiety symptoms.

How are anxiety disorders treated?

a- Lifestyle changes and non-drug strategies

-decrease caffeine intake
-decrease alcohol intake, smoking, or use of illicit drugs
-regular aerobic exercise
-diet modification
-good sleep hygiene (minimize use of sedatives)
-relaxation and breathing techniques

b- Psychotherapy

-exposure and response prevention
-breathing retraining
-supportive counselling
-couples or family therapy
-cognitive behavioural therapy

c- Pharmacotherapy (medications)

-antidepressants including SSRI's like fluoxetine or citalopram, SNRI's like venlafaxine, or tricyclic antidepressants like clomipramine)
-benzodiazepines (eg. lorazepam, clonazepam,)
-anticonvulsants (eg. gabapentin, pregabalin)
-atypical antipsychotics


-are very useful for many anxiety disorders (as well as for depression)
-the newer antidepressants have a slow onset of action (take 2 to 6 weeks to be effective).
-treatment is usually recommended for at least 1 year, with a slow taper in order to avoid withdrawal.
-these drugs have many benefits, but may have side-effects. Talk with your pharmacist.
-these medications should not be taken with alcohol.


-such as lorazepam (Ativan), clonazepam (Rivotril), oxazepam (Serax)
-useful for panic disorder, social anxiety disorder or generalized anxiety disorder
-used for the short term relief of the symptoms of excessive anxiety.
-these drugs work by slowing the activity of the nerves in the brain (i.e. the central nervous system)
-can be addicting
-can interfere with alertness
-should never be taken with alcohol
-can interact with medications such as antihistamines, narcotics and others (see your pharmacist).

Medications in perspective:

-Medications certainly have their role in the treatment of anxiety, but there can be side-effects. Your pharmacist is available to help you manage your treatment and to give advise regarding any side-effects.
-Drugs prescribed by your doctor can be very successful in treating the various anxiety disorders, but non-drug treatments such as psychotherapy (counselling, breathing retraining, desensitization, and cognitive behaviour therapy) are often equivalent to the success rate of medications, but the success with psychotherapy can last longer than with medications alone.
-A combination of psychotherapy along with medications when appropriate can be effective in treatment of anxiety disorders.

The Prevalence of Stigma:

Because stigma is still a problem in the way our society views mental illness, people with an anxiety disorder may be joked about or told that they are over-reacting or hysterical. Stigma, coupled with the feelings of embarrassment that a person who suffers from an anxiety disorder often has, can prevent a mentally ill patient from seeking professional help for a treatable condition.

It is good for us all to reflect on a statement by Bill Clinton, "Mental illness is nothing to be ashamed of but stigma and bias shame us all."

A personal word of encouragement (from Phil Smith):

So much of life must be in balance. If you are a person of faith and are experiencing anxiety you may feel guilty that you have not prayed enough or that you have not trusted God enough. The Bible does have advice about needless worry. There is also a catchy secular song... "Don't worry... be happy". Sometimes we do worry needlessly and should trust God more; however, there are many people who have tried to not worry, have tried their best to resolve issues, have been trusting God, and yet still struggle with anxiety or struggle with another mental health issue.

I firmly believe that we all need to come alongside each other no matter what issue may be crippling us. Two are better than one! Life could be so much more tolerable if more of us (whether we have faith or not) made it easier to share each others burdens. How? .... by being more REAL WITH EACH OTHER... by ACCEPTING each other as we are... by NOT JUDGING AND HURTING EACH OTHER like so many of us do.

If you or someone you care about is suffering from an anxiety disorder or any mental illness, make sure you seek out professional help. Remember, there is someone who cares and you are not alone. Speak to your doctor, see a counsellor, or contact a mental health association, helpline or website (see below). If you have any questions about your medications, talk with your pharmacist.

Philip A. Smith, B.Sc.Phm.

Canadian Mental Health Association (www.cmha.ca)
Mental Health Helpline: 1-866-531-2600
www.mentalhealthhelpline.ca/Home/Email (for e-mailing questions about mental health issues)
If you are in a crisis, go to www.dcontario.org which has contact information for distress centres in Ontario. If you need immediate assistance, go to your nearest hospital or dial 9-1-1.

S. Dyett, Demystifying the Spectrum of Anxiety Disorders, Psychiatric Patient Care, Ontario Pharmacists' Association Seminar, Toronto, Nov.30,2012