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Anxiety vs Anxiety Disorder: When should I seek Help?

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The Difference Between “Anxiety” and Generalised Anxiety Disorder (GAD)

  • Anxiety is a ubiquitous or common emotion that everyone will feel from time to time. This is a normal human response to stress and when the stressful issue or event is over, the anxiety will go away. Anxiety can be felt i) cognitively, ie worries or fearful thoughts, ii) emotionally, ie nervousness, kan cheong, iii) physically eg heart racing, tremors, butterflies in the tummy.

    In normal anxiety, the anxiety is transient, and the individual feels in control. While he or she may be transiently affected, the anxiety is never debilitating and will not cause him or her significant dysfunctions at work or in his or her social life.

  • Generalised Anxiety Disorder is not just simple anxiety but is a bona fide psychiatric /medical condition. Symptoms of GAD are:

    • excessive worry and symptoms of physiological arousal including restlessness, insomnia, and muscle tension. 
    • The patient must have excessive and difficult to control anxiety about several different events or activities
    • In addition to worry, patients must have at least three of the six physiological arousal symptoms:
      • Restlessness or feeling “keyed up” or on edge
      • Being easily fatigued
      • Difficulty concentrating or mind going blank
      • Irritability
      • Muscle tension
      • Sleep disturbance
    • In anxiety disorders, removing the stressor or trigger doesn’t always reduce the anxiety.

  • What is a normal level of anxiety to have? Can anxiety be good for us?
    • Anxiety is a normal response to stress,  and isn’t always a bad thing. 
    • Anxiety and stress follow an inverted U model with our functioning or task performance.
    • Some anxiety or stress is useful in pushing us into better performance but when there is too much of anxiety, we break down. This is known as the Yerkes-Dodson law.
      Anxiety | Psychology Tools
    • However, when anxiety becomes uncontrollable or excessive to the point where it affects our quality of life, an anxiety disorder may have been triggered.

    The Difference Between “Anxiety” and Generalised Anxiety Disorder (GAD)

    • What can cause anxiety? What are the causes of GAD?
      • Humans have evolved to react to danger with the fight or flight response and anxiety is part and parcel of the flight response. 
      • Our mind is constantly looking out for danger as ancient men were hunters and was required to do so to survive. When there is a dangerous situation, men become stressed up and this invokes hormones in our body to be released preparing us to fight or to flight (escape). 
      • It is of note that the danger can be real or imagined.
      • In the modern world while we are not in danger of being attacked or eaten up by a beast, we have associated stress with intense situations in our lives of which we cannot cope with.
      • Common stressors in life which induces anxiety are:
        • Stress at work
        • Stress from school
        • Stress in a personal relationship such as marriage
        • Financial stress
        • Stress from global occurrences or political issues
        • Stress from unpredictable or uncertain world events, like a pandemic
        • Stress from an emotional trauma such as the death of a loved one
        • Stress from a serious medical illness
      • Like most psychiatric conditions, the causes of GAD are unknown. Today what is largely accepted is that anxiety disorders  represent a disruption of monoamine neurotransmitters, namely serotonin, in our brain. It is likely a condition triggered by many factors. Like the Swiss cheese model, when all the holes or factors aligned, severe anxiety which spirals out of control, ie GAD occurs. Risk factors of GAD consist of biological, psychological and social ones and include
        • Genetics or Family history of anxiety
        • Recent or prolonged exposure to stressful situations, including personal or family illnesses and work stress
        • Excessive use of caffeine or tobacco, which can make existing anxiety worse 
        • Childhood abuse or bullying
        • Certain health conditions such as thyroid problems or heart arrhythmias 

    • How might both present in my life differently?
      • Normal anxiety and anxiety disorders lie on a spectrum and are not categorical. 
      • Anxiety, symptoms are listed in first question. eg:
        • If you wake up one morning and you know you have a math test later that day, it’s normal to be nervous or anxious about the test.
        • Your heart might pound, and your stomach might churn, and you might be thinking a lot about the test and your possible result. Once the test is over, you’re likely more relaxed, and physically back to normal.
        • Then anxiety is transient and although a nuisance, it does not affect your usual functioning significantly.
      • GAD
        • You have been worried excessively about a myriad of issues for the last six months. For example you may worry about losing your job, getting infected with COVID-19 or your children failing their exams.
        • You feel nervous and tensed in the day and you find it harder and harder to control the anxiety and worries. 
        • You find it hard to fall asleep at night and have been easily tired.
        • You have been getting more irritable and would lose your temper at your children.
        • Your anxiety has also made it hard for you to make work decisions and you cannot concentrate on your work. 
        • (Symptoms of GAD are listed above)

    Getting Your Anxiety Better: Tips and Treatment

    • What are some ways to lower levels of anxiety?
      • Having time away from the stressful environment or event is the best way. Unfortunately, stress is everywhere in our small yet competitive island. 
      • Adequate rest and sleep on a day-to-day basis, and in doing so allow our body and mind to take a break from the stress of the day is of utmost importance. 
      • It is also important to have hobbies and exercise to take our mind off stress and the anxiety.
      • Limit the use of caffeine and cigarettes.
      • Cognitively, it is important to moderate our excessive high expectations and need of control. We often quote the serenity prayer: “to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference”
    • What are the treatments for GAD?
      • Medication treatment include using serotonin reuptake inhibitors (like fluoxetine, sertraline, venlafaxine, etc) These help to enhance the serotonin in our synapse which helps the brain to recover from an anxiety disorder. We can use anxiolytic medications like lorazepam or alprazolam in the short term judiciously to provide for immediate relief for severe anxiety.
      • Psychological interventions like Cognitive Behavioural Therapy and Mindfulness Therapy are very effective in the treatment of GAD.
      • Social interventions can include providing some rest from work in the form of medical leave or asking for a lower workload for the afflicted individual. Beefing and garnering support from patient’s family and loved ones can help improve things.

    Anxiety and Anxiety Disorder in Singapore

    The Singapore Mental Health Survey 2016 showed an increase in the prevalence of GAD, from 0.9% in 2010 to 1.6% in 2016:

    • What could be some reasons for this increase? 
      • In Asian cultures, anxiety is often manifested as poor sleep and physical ailments such as headaches and stomachs, and much less as feelings of anxiety. The increase may signify a shift towards a more Western recognition and presentation of our emotions.
      • Anxiety Disorders can often be misconstrued. Many relate abnormal anxiety only to being confronted with huge problems in life, and may feel that they cannot be having an Anxiety Disorder since life is good. However, GAD is essentially overblown worries or anxiety feelings, and it is exactly because you have nothing to worry about and yet you are worried which defines it as a disorder. As such, an improvement in mental health literacy and a better understanding of Anxiety Disorder from public mental health education may have helped more identify that they have an anxiety problem.
      • There may be less stigmatization about mental health issues and responders to the survey may have been more likely to answer truthfully.
      • The survery in 2016 showed that the increase in the prevalence of GAD in Singapore was observed only in the youngest age group of 18–34 years and not among those of the older age. There are some suspicion that the proliferation of social media and unhealthy social media use habits can be related to the increase in prevalence of GAD, given that many studies have pointed to correlation between social media use and adverse mental health outcomes.

    • Have Singaporeans become more anxious in the last 10-12 years? What’s the expert take on this?
      • Yes, there has been a trend. We do not have actual data but there are some observable trends in people seeking help in my practice. Anxiety towards exams and schoolwork appears to have been increasing as reflected on people enquiring for help for themselves or their children. The number of people seeking help as they are anxious and cannot cope at and around periods where there are major exams have observably increased.
      • More people have stepped forward to seek help with regards to their anxiety which often are exacerbated by job stress have also increased. This is encouraging as many are picked up by work place programmes and encouraged by their workplace to seek help. Traditionally, men tends to only seek help when their anxiety are severe but have been doing so in the earlier stages of anxiety disorders in recent years. 

    When Men Cry: Understanding Common Psychopathology in Men.

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    1) What are the most common mental health issues affecting men, and do you have statistics for the percentage of Singaporean men who are affected by these issues? 

    Common mental health issues for men include Depression, Generalised Anxiety Disorders (GAD), Obsessive Compulsive Disorders (OCD) and Alcohol Use Disorder. 

    Overall about one in 16 men will experience at least one of this condition in his lifetime. 
    The lifetime prevalence of depression in men is 4.3%.
    The lifetime prevalence of GAD is 1.6%.
    That of OCD is 3.6%.
    That of alcohol use disorder is 4.1%.

    2) What causes these mental health issues? 

    The actual causes are not known but these mental health issues are related to genetics, childhood trauma, environmental stress, negative personality resulting in negative outlooks, and use of substances and alcohol. These factors can result in aberrations in the neurotransmitters in our brain resulting in mental illnesses.   

    3) What are some signs and symptoms of these issues? 

    Depression is characterised by i) depressed mood nearly every day, ii) loss of interest or pleasure in most activities, iii) significant weight loss or weight gain, iv) poor sleep or over sleeping, v) agitation / irritability / restlessness or feeling slowed down vi) feeling tired easily or loss of energy vii) feeling worthless or having excessive guilt, viii) poor concentration, difficulty thinking or forgetfulness and ix) suicidal thoughts, plans or attempts.

    GAD is characterised by i) constantly worrying or obsessing about small or large concerns ii) feeling restless, keyed up or on the edge iii)fatigue and easily getting tired iv) difficulty concentrating or mind “going blank” v) irritability and feeling frustrated vi) Muscle tension or muscle aches and vii) trouble sleeping.

    OCD is characterized by obsessive thoughts and compulsive behaviours. Obsessive thoughts are experienced by the individual as intrusive and distressing. Common obsessive thoughts include i) fear of contamination by germs or dirt, ii) intrusive thoughts about symmetry and orderliness and iii) obsessive thoughts of checking things.

    As a result of the obsessive thoughts, the individual feels that he has to perform a certain act (compulsive behaviours) to undo the obsessions. These include excessive washing and cleaning and/or checking and counting. The compulsions are often performed in a ritualistic manner over a “magical” number of times.

    Alcohol use disorders are unhealthy patterns of use of alcohol resulting in harm including binge drinking and addiction to alcohol.

    4) Why do so many men avoid seeking professional help for their mental health issues? What is the stigma surrounding this? 

    Our society expects a man to be strong and to deal with his own problems himself. As a result, Singaporean men often put up a brave front in the face of adversities. This means that men are less likely to acknowledge their emotional problems and will not seek help if they have psychological difficulties as they are afraid that they may be seen as weak.

    Many worry that their employers will come to know that they suffer from psychological illnesses and their careers will be affected. And as men are often expected to be the main breadwinner, they are even more afraid of jeopardizing their job.

    5) How can such mental health issues affect men if they’re left untreated or undiagnosed?

    Often family members would tell the patient suffering from mental illness to just “get out of it” or to “will it away”.

    However, psychiatric illnesses are genuine medical illnesses. One cannot simply will it away and will require help and treatment. If left untreated, mental illness can cause problems in relationships and at work.

    When unwell, men can be irritable leading to quarrels with spouse, partner and children. Work can be compromised when they have no motivation. poor concentration or are fixated on the difficulties arising from the symptoms.

    To relieve their symptoms, men may turn to alcohol, drugs, pornography and gambling.

    Most significantly, we know that men are less likely to express or talk about their symptoms but are very much more likely than women to complete suicide.

    6) How can men preserve and protect their mental health on a daily basis? Can you talk about good health habits like stress management, a healthy diet, sleep, exercise, opening up to others, etc?

    Start with simple practices like keeping to a good routine. Make sure you have adequate rest, sleep enough, have time for meals and toilet breaks. 

    Either have long easy walks daily, or more intense exercising three times a week for at least 30 mins if physically permitting. 

    Once you have the basic routines, ensure you look into me time, hobbies and spending time with your spouse.

    These and managing your amount of work and hence work stress will help with stress management.

    Particularly important for men, be mindful of alcohol use and not be seduced by substance use to numb yourself. 

    Don’t be afraid of showing your emotions and in fact crying can be cathartic.  Also, don’t be afraid to talk to your loved ones about your difficulties, be it stress with work or your symptoms. 

    7) Many men feel lonely and isolated – how can they overcome these, especially if they are unmarried, have no close family nearby or live alone? 

    Being isolated increases the risk of mental illnesses and even suicide. 

    Even if you are unmarried and have no close family nearby, maintain good friendships and engage with the community. You can participate in volunteering, join an interest group or play group sports regularly.

    With social media and video conferencing, you can also keep close to your family via technology.

    Having a pet like a dog has been shown to be protective for isolated individuals.

    Life can still be fulfilling without anyone with you if you engage in meaningful activities and hobbies.