Anxiety: When Worry Becomes an Illness
Anxiety is the body's alarm system doing its job at the wrong time. It becomes an illness rather than an ordinary emotion when it is out of proportion to what is happening, when it persists for weeks or months, and when it starts to shrink what a person can do — work, study, travel, sleep, meeting people. It very often shows up first as physical symptoms: a pounding heart, tightness in the chest, breathlessness, dizziness, trembling, sweating, stomach upset and tingling in the hands, which is why many people here see a cardiologist or a gastroenterologist before anyone mentions anxiety. Those symptoms are genuine, not imagined, and they are produced by adrenaline rather than by weakness of character or of faith. A panic attack peaks within about ten minutes and is terrifying, but it is not dangerous in itself, though a first episode of chest pain or breathlessness must always be assessed properly before it is put down to anxiety. Treatment works: talking therapy, particularly cognitive behavioural therapy, has the strongest evidence, and antidepressant medicines from the SSRI and SNRI groups are effective when a doctor judges them appropriate. Alprazolam and diazepam, which are widely bought without prescription in Pakistan, calm anxiety within an hour and cause dependence within weeks; they are not a treatment for anxiety, and after long use they must never be stopped suddenly.
Health writers · Aslam Clinic
What anxiety is
Every human being has an alarm system. Faced with something threatening, the body releases adrenaline: the heart speeds up, breathing quickens, blood is pushed to the muscles, the gut shuts down, the senses sharpen. It is an excellent system for escaping danger, and a certain amount of it before an exam or a difficult conversation improves performance rather than harming it.
Anxiety becomes a disorder when that alarm fires without a matching threat, or keeps firing long after the threat has gone. Three things separate an illness from an ordinary emotion, and all three have to be present: the anxiety is out of proportion to the situation, it is persistent rather than passing, and it interferes with life — sleep, work, study, relationships, or the places you are still willing to go. A month of dread before a viva is not a disorder. Six months of waking at four in the morning with a pounding heart, avoiding the motorway, and refusing invitations is.
It takes several recognised forms. Generalised anxiety is constant, wide-ranging worry about many things at once. Panic disorder is repeated sudden surges of terror with severe physical symptoms, plus the fear of the next one. Social anxiety is intense fear of being judged, which is far more than shyness. Phobias are focused on one thing — needles, heights, travel. Health anxiety is the persistent conviction of serious illness that a normal test reassures only briefly. Obsessive-compulsive disorder and post-traumatic stress are related but separate conditions with their own treatments.
Why it so often feels like a physical illness
In Pakistan, anxiety very commonly reaches a clinic as a physical complaint. People describe dil ghabrana, a fluttering or sinking in the chest, heat rising in the head, weakness in the legs, gas and churning in the stomach, or aching all over. That is not a lesser or a false version of anxiety; it is how the body expresses it, and the words a person uses are shaped by the language and the culture they think in.
Adrenaline explains nearly all of it. A fast heart produces and . Rapid shallow breathing lowers carbon dioxide in the blood, which causes the tingling around the mouth and in the fingers, light-headedness and a feeling of not being able to fill the lungs — the more you try to breathe deeply, the worse that particular symptom gets. Tense muscles produce headache, jaw pain and a sore chest wall that hurts to press. The gut slows or empties, producing nausea or urgent loose motions. Every one of these is a real bodily event with a real mechanism.
It is also why people often see two or three specialists first, and why an entirely normal and echo do not stop the symptoms. Tests are worth doing once, properly, and then worth trusting.
Things that look like anxiety but are not
Before settling on anxiety, a doctor considers the conditions that imitate it. This is not an exhaustive list, and it is the reason a proper assessment is worth having rather than a self-diagnosis from a search engine.
| Possible cause | What points towards it | Usual test |
|---|---|---|
| Overactive | Weight loss with a good appetite, heat intolerance, tremor, loose motions, a fast pulse at rest | and thyroid hormone levels |
| Anxiety mixed with low mood, fatigue, weight gain, cold intolerance, dry skin | ||
| Heart rhythm disturbance | Palpitations that start and stop abruptly, fainting, a racing pulse without fear beforehand | , sometimes a 24-hour recording |
| Low blood sugar | Shaking, sweating and hunger relieved within minutes by eating, usually in someone on diabetes treatment | at the time of symptoms |
| Breathlessness on exertion, tiredness, pallor, heavy periods | ||
| Wheeze, cough at night, breathlessness triggered by dust, smoke or exercise | and response to an | |
| Caffeine and energy drinks | Symptoms worst in the hours after coffee, strong tea or an energy drink | Trial of stopping them for two weeks |
| Medicines | Symptoms began after starting salbutamol, a , a decongestant or thyroid hormone | Medication review with the prescriber |
| Withdrawal | Anxiety, sweating and tremor a day or two after stopping alcohol or long-term sedative tablets | History; this needs medical supervision |
How it is assessed
There is no blood test for anxiety. A doctor listens to the story, asks about the physical symptoms, sleep, mood, alcohol and drug use, and about thoughts of self-harm — that last question is routine, is asked of everyone, and is not an accusation. A short questionnaire called the GAD-7 is often used. It is worth understanding what it does: it measures how severe symptoms have been over the past fortnight and tracks whether treatment is working. It does not make the diagnosis, and a high score on a bad week does not label anyone for life. Basic blood tests are usually done once, to rule out the mimics above.
What treatment actually involves
Talking therapy comes first for most people. Cognitive behavioural therapy has the strongest evidence of any treatment for anxiety, and its benefit tends to last after the sessions end, which is not true of medicine stopped abruptly. It is practical rather than mystical: you learn to notice the thought that starts the spiral, test it against evidence, stop the safety behaviours that keep the fear alive, and approach avoided situations in graded steps. Courses typically run eight to sixteen sessions. Where a trained therapist is not available locally, structured self-help workbooks and reputable online CBT programmes have real evidence behind them, and some clinics offer therapy by video.
Medicine is genuinely useful for moderate and severe anxiety. The usual first choice is an antidepressant from the SSRI group, or an SNRI, both of which treat anxiety as well as depression. Three things about them are worth knowing in advance, because not knowing them is why people give up. They take two to six weeks to work. They commonly make anxiety, nausea or restlessness slightly worse for the first week or two before they help. And they must be stopped gradually under supervision rather than suddenly, because abrupt withdrawal causes dizziness, electric-shock sensations and a rebound in symptoms that is often mistaken for the illness returning. Which drug, what dose and how long are a prescriber's decisions, made with you.
Beta blockers are sometimes prescribed for the physical symptoms of performance anxiety — a trembling hand, a racing heart before speaking in public. They blunt the adrenaline response and do not treat the underlying condition, and they are not suitable for everyone, particularly people with asthma.
Alprazolam, diazepam and the trap they set
This deserves plain speech, because in Pakistan these tablets are handed over the counter without a prescription and are taken by a great many people for years. Benzodiazepines — alprazolam, diazepam, lorazepam, clonazepam and their relatives — genuinely do reduce anxiety, within an hour, which is exactly why they are so easy to keep taking. Tolerance develops within weeks, so the same tablet does less and the dose creeps up. Dependence follows, and the anxiety felt between doses is then partly withdrawal rather than the original illness. They impair memory, concentration and driving, they interact dangerously with alcohol and with opioid painkillers, and in older people they cause falls and confusion.
What you can do yourself
- Slow the out-breath, do not deepen the in-breath. Breathe in for about four seconds and out for six or seven, through the nose, for a few minutes. Deep gulping breaths make hyperventilation symptoms worse; a long slow exhale settles them.
- Ride out a panic attack rather than fighting it. Name it — this is panic, it peaks in ten minutes, it has never harmed me. Sit down, slow the exhale, and let it pass. Running out of the shop teaches the brain that the shop was the danger.
- Stop avoiding, in small steps. Avoidance is the fuel. Whatever you have stopped doing, plan a smaller version of it and do that, then a slightly larger one. This is the active ingredient of therapy and it works outside a clinic too.
- Cut caffeine and energy drinks entirely for two weeks and see what changes. Strong tea, coffee, cola and energy drinks all count, and many people are astonished by the difference.
- Move your body most days. Thirty minutes of brisk walking has a measurable effect on anxiety. It is not a substitute for treatment in severe illness, and it is not nothing either.
- Protect sleep. A fixed waking time, no screen in bed, no napping late, and no phone within reach at night. Poor sleep and anxiety feed each other in both directions.
- Give worry a time and a place. Fifteen minutes in the early evening with a notebook, writing down what is worrying you and what, if anything, can be done tomorrow. Worry outside that window gets postponed to it rather than argued with.
- Keep hold of people. Isolation makes anxiety worse. Family, friends, congregational prayer and community work all help, and for many people here prayer and dhikr are genuinely steadying. None of that is in competition with treatment; use both.
- Be careful with what you are told is a cure. No herbal preparation, tonic, injection or spiritual treatment has been shown to treat an anxiety disorder. Draw comfort where you find it, and do not let anyone charge you for stopping your medicine.
Living with it
Anxiety tends to run a fluctuating course: better for long stretches, worse under pressure, sometimes returning years later during a hard period. That is not failure, and it is not evidence that treatment did not work. Most people who complete a course of therapy or a properly conducted course of medicine reach or something close to it, and the skills learned in therapy remain available the next time. The is good, and it is better the earlier treatment starts, mainly because avoidance has had less time to narrow the person's world.
When to see a doctor
Go to hospital the same day if you are thinking about ending your life, if someone has harmed themselves, or if chest pain or breathlessness is new and severe. Book an appointment if anxiety has lasted more than a few weeks, if it is stopping you working, studying, sleeping or leaving the house, if you are drinking or using tablets to cope, if you have started avoiding things you used to do easily, or if you have been taking alprazolam or a similar tablet regularly for more than a few weeks. Bring a list of everything you take, including anything bought without a prescription. Anxiety and low mood travel together more often than not, so it is worth reading about depression as well.
Common questions
Still not sure what to do?
Reading about a symptom only goes so far. A doctor who can ask you questions and examine you will get further in ten minutes than any article can.
