Anxiety disorders

You settle one thing that needs settling before you can rest, and when you settle it, another arrives to take its place.

Anxiety is the body and mind treating an uncertain situation as a dangerous one. The alarm system that should switch on in the face of a real threat begins firing at possibilities: the message you have not heard back on, the sensation in your chest, the meeting tomorrow, the thing that might go wrong and probably will not. It can appear as panic, as constant worry, or as dread on waking. It often appears alongside good functioning. Many people carry considerable anxiety while performing well at demanding work, and arrange the rest of their lives quietly around what they are trying not to feel.

Why it holds on

Anxiety is maintained less by the fear itself than by what you do to manage the fear. This is the part that matters clinically, and it is the part that most reassurance misses.

Avoidance usually begins as sensible caution. You sit near the exit. You leave early, or you do not go. You over-prepare. You keep someone available in case. You check the symptom, the reply, the lock. You ask for reassurance and feel steadier for an hour, and then the doubt returns wearing a slightly different question. Each of these is an attempt to feel safe, and each one works in the short term, which is exactly why it is so hard to give up. The problem is what it teaches. Every time you avoid the feared situation, or escape it, or get through it only by leaning on a safety behaviour, you deny yourself the chance to learn that you could have coped without it. The fear is never tested, so it never updates. The world of things that feel manageable slowly narrows.

The specific disorders differ in their content but share this machinery. Panic disorder turns ordinary bodily sensations, a fast heartbeat, breathlessness, dizziness, into signs of imminent catastrophe, and the frightened response amplifies the very sensations that started it. Health anxiety pulls you into scanning your body, searching online and seeking certainty that never holds. Social anxiety keeps attention fixed on how you are coming across, and fills the hours afterwards with replaying what you said. Generalised anxiety turns rest itself into another place where worry is waiting.

How I work with anxiety

NICE recommends cognitive behavioural therapy as the first treatment to be offered to adults with social anxiety disorder, and as a main treatment option for generalised anxiety disorder and for panic disorder. The work is active and structured rather than open-ended conversation. We look together at what your body does, what your mind predicts will happen, what you do to feel safer, and how those three keep each other going.

Much of the useful work is done by testing predictions rather than discussing them. That means approaching, in a graded and deliberate way, the situations you have been avoiding, and dropping the safety behaviours one at a time so that you can find out what actually happens. For panic, it means learning that the sensations you fear are not dangerous. For worry, it means changing your relationship to the worry itself rather than trying to answer every question it raises. It is uncomfortable at first, and the pace matters.

Therapy is not a substitute for medical assessment or treatment, and I do not diagnose or prescribe. Where medication or a physical health question is part of the picture, your GP or medical clinician remains responsible for that, while the therapy stays focused on the patterns keeping anxiety in place. Sessions are fifty minutes, online, and usually weekly to begin with.

Anxiety disorders are core CBT territory, and my twenty-five years working as a Consultant Cognitive Behavioural Psychotherapist have kept me close to them. Fifteen of those years have been in the City of London with professionals in banks and law firms, which means I see a great deal of high-functioning anxiety: people who perform well in public while organising their lives around what they are trying not to feel. I work online with adults and adolescents.