Anxiety & PTSD

What it's like

From the inside, the different kinds, and the myths that keep it going.

From the inside

• Dread: A sense of danger, panic or doom.
• In the body: A pounding heart, sweating, trembling, an upset stomach, trouble sleeping.
• Can't switch it off: Fear and worry that are hard to control.
• Panic: A surge so intense that people often believe they're having a heart attack.
• After a trauma: Reliving it, avoiding anything that brings it back, and feeling constantly on guard.
• The pull to avoid: Avoiding brings relief now — and keeps the fear going.

Anxiety is the body's alarm, and everyone has one. In an anxiety disorder the fear and worry are intense and excessive, hard to control, distressing, and can last a long time without treatment — getting in the way of family, social, school or working life.

The main kinds

• Generalised anxiety: Persistent, excessive worry about everyday things.
• Panic disorder: Panic attacks that keep coming, and fear of the next one.
• Social anxiety: Intense fear of being humiliated, embarrassed or rejected.
• Agoraphobia: Fear and avoidance of places where panic or helplessness might strike.
• Separation anxiety: Excessive fear of being apart from the people you're closest to.
• Specific phobias: Intense fear of particular things or situations, and avoiding them.
• Selective mutism: Mostly in children: being unable to speak in some settings while speaking freely in others.

What anxiety can feel like

• Trouble concentrating or making decisions.
• Irritability, tension or restlessness.
• Nausea or an upset stomach.
• A pounding heart; sweating, trembling or shaking.
• Trouble sleeping.
• A sense of danger, panic or doom.

A panic attack

A sudden wave of intense fear with a racing heart, sweating, chills, trembling, breathlessness, dizziness, tingling hands, chest pain or nausea. It can last from a few minutes to an hour, and many people having one believe it's a heart attack. A doctor can check that nothing physical is causing it.

PTSD can follow a frightening or distressing event. Its symptoms fall into three groups — reliving the event, avoiding reminders of it, and feeling constantly on guard — and usually begin straight away or within a month.

Anxiety disorders raise the risk of depression, of problems with alcohol and drugs, and of suicidal thoughts.

• Myth: Letting a child avoid what scares them is the kind thing to do. In fact: It brings relief now, but families helping a child avoid their fears is implicated in keeping childhood anxiety going. Treatment works by facing fears, step by step.
• Myth: Everyone who goes through trauma gets PTSD. In fact: About 70% of people experience a potentially traumatic event in their lifetime; only about 5.6% of them develop PTSD.
• Myth: Talking it through straight after a trauma prevents PTSD. In fact: One-off "debriefing" sessions straight after a trauma mostly made no difference in trials, and the studies that followed people longest found some harm. They shouldn't be used routinely.
• Myth: PTSD is for life. In fact: Up to 40% recover within a year. Across 42 studies, 44% no longer had PTSD after an average of 40 months, even without specific treatment.
• Myth: Tranquillisers are the answer. In fact: Benzodiazepines aren't generally recommended for anxiety, because of dependence and little long-term benefit. For PTSD they were ineffective and linked to worse outcomes.

What's happening in the brain

An alarm set too sensitive, brakes that hold less, and a safety lesson that doesn't stick. The model lights each one as you read.

The alarm

Across PTSD, social anxiety and phobias, the amygdala and insula are consistently more active than in people without them. The amygdala sends its alarm down to the hypothalamus and brainstem, which set off the body's defences — a racing heart, sweating, the urge to run or freeze. That's why anxiety is felt in the body, not just thought.

The brakes

In PTSD, areas of the prefrontal cortex and anterior cingulate that help regulate emotion are less active than usual. The alarm goes off, and less comes back down to turn it off.

Learning it's safe — and remembering it

Fear can be unlearned. When a feared thing keeps not leading to harm, the brain lays down a new memory — it's safe now — that competes with the old fear. People with PTSD learned that lesson as well as anyone in an experiment, but recalled it worse the next day, with less activity in the hippocampus and the ventromedial prefrontal cortex.

Context

One proposal puts a failure of context at the heart of PTSD: the hippocampus, prefrontal cortex and thalamus working out which situation you're in, and so what a cue means here. A firework at a party and a blast in a war zone sound alike; telling them apart is context's job. In PTSD the hippocampus is smaller on average.

Why it happens

Who's most at risk, and how families get pulled in.

• 470m people with an anxiety disorder: About 5.8% of the world's population, in 2023.
• 70% face a traumatic event: Most people experience at least one potentially traumatic event in their lifetime.
• 15% PTSD after war: Among people exposed to violent conflict or war, about 15.3% develop PTSD.

Anxiety disorders often start in childhood or adolescence and carry on into adulthood, and girls and women are more likely to have one.

Anxiety pulls families in. Most parents of anxious children take part in their child's anxious behaviour or change family routines around it, and the more they do, the more severe the anxiety tends to be. It comes from love, and it's one of the most useful things to change.

Getting help

Where to start, and what to bring.

A family doctor is the usual first step. They can check that a physical problem isn't causing the symptoms, and refer on for psychological treatment, which can be delivered one-to-one, in groups, online or as guided self-help.

Worth noting down before the appointment

• What happens: The worries, the physical feelings, any panic attacks — when and where.
• What's being avoided: Places, people, school, activities — avoidance often says more than the fear does.
• How long: When it started, and whether anything happened around then.
• How you cope: Including alcohol or drugs, if they've become a way of getting through.

What helps

Facing fears, step by step — and what not to rely on.

• CBT with exposure (Learning, step by planned step, to face what you fear.): In 41 placebo-controlled trials, CBT had moderate effects on anxiety disorders and nearly tripled the odds of getting better; treatments built mainly on exposure tended to work best. It's the treatment the WHO recommends.
• Trauma-focused therapy and EMDR (For PTSD: therapy that works directly with the memory of the trauma.): The first-choice treatments for PTSD, with the strongest evidence.
• Parent-based treatment (For anxious children: working with the parents, not the child.): In a trial of 124 anxious children aged 7–14, a programme that only worked with parents — helping them stop accommodating the anxiety while staying supportive — was as effective as CBT with the child.
• SSRIs (Antidepressants, taken daily.): They can help adults with anxiety disorders, weighed against side effects and personal preference. They take several weeks to work.
• Relaxation and mindfulness (Slow breathing, progressive muscle relaxation, a few minutes of mindfulness a day.): Stress-management skills like these can reduce symptoms — useful alongside treatment rather than instead of it.
• Benzodiazepines (Tranquillisers such as diazepam.): Generally not recommended for anxiety, because of the risk of dependence and little long-term benefit. People can build tolerance and need ever higher doses. For PTSD they were ineffective and linked to worse outcomes — including a higher risk of PTSD when taken soon after a trauma.
• One-off debriefing (A single session to talk through a trauma straight afterwards.): Mostly no benefit in trials, and some harm in the studies with the longest follow-up.

Supporting someone

Support the person, not the avoidance.

• Instead of "There's nothing to be scared of.", try "I can see this is really frightening. I know you can handle it.". Dismissing the fear doesn't make it go, and rescuing someone from it keeps it going. Acknowledging it while showing confidence does neither.
• Instead of "You don't have to go if it's that bad.", try "We'll go together, and you can stay for ten minutes.". Avoiding relieves anxiety now and feeds it later. Small, supported steps toward the feared thing are how exposure works.
• Instead of "Just calm down.", try "Let's breathe slowly together. This will pass.". Slow breathing is one of the techniques the WHO recommends, and panic attacks pass: they can last from a few minutes to an hour.
• Instead of "You need to talk about what happened.", try "I'm here whenever you want to talk — and it's fine if that's not now.". Talking with people you trust helps after a trauma, but only when you're ready.
• Instead of "It's been months. You should be over it.", try "Recovery takes different lengths of time. Would it help to see someone who specialises in this?". Up to 40% recover within a year; for the rest, trauma-focused therapy is the first-choice treatment.

Day to day

• Cut down on alcohol and avoid drugs.
• Exercise regularly — even a little.
• Keep regular times for sleeping and eating.
• Practise slow breathing or progressive muscle relaxation.
• After a trauma, keep up normal routines as far as you can.

When to get help

When worry has become something more.

It's worth seeing a doctor if…

• Worry or fear feels out of proportion and hard to control, most days, for weeks.
• Places, people, school or activities are being avoided because of it.
• There are panic attacks, or life is being arranged around avoiding the next one.
• A child regularly refuses school, can't bear to separate, or has stomach aches with no cause.
• Nightmares, flashbacks, jumpiness or numbness carry on weeks after a trauma.

Watch for

Anxiety disorders raise the risk of depression, of alcohol and drug problems, and of suicidal thoughts. If drinking or drugs have become the way of coping, that's worth saying to a doctor too.

If someone might be in danger

If someone talks about wanting to die or to hurt themselves, take it seriously and get help today. Asking them directly about suicide doesn't put the idea in their head.

Put it into practice

Five real situations. Choose what you'd do, and see why.

• Every school morning your 9-year-old says their stomach hurts and begs to stay home. The doctor has found nothing physically wrong. What's most likely to help? Acknowledge it's hard, show you're confident they can manage, get them to school — and ask about an assessment for anxiety. Anxiety often starts in childhood and really does cause stomach symptoms. Support plus confidence, rather than avoidance, is what parent-based treatment builds.
• At a party, a friend suddenly says their heart is racing, they're shaking, can't breathe and feel like they're dying. They've had this before, and a doctor has checked them over. What do you do? Stay with them somewhere quieter, breathe slowly with them, and remind them it will pass. These are the classic signs of a panic attack, which can last from a few minutes to an hour, and slow breathing helps. If it were a first attack, or you weren't sure, getting medical help would be right.
• A colleague was in a serious car crash last week. HR arranges a one-off session for them to talk through every detail of what happened. Will that help prevent PTSD? Probably not. Better to offer support, let them talk when they're ready, and watch for symptoms that don't fade. Debriefing isn't recommended routinely, while talking to trusted people when ready and keeping up routines are. Most people who go through a trauma don't develop PTSD.
• Six months after an assault, your sister has nightmares, avoids the area where it happened and jumps at every noise. Her doctor has offered tranquillisers. What's most worth asking about? Trauma-focused therapy or EMDR. They're the first-choice treatments for PTSD, while benzodiazepines were ineffective for PTSD and linked to worse outcomes.
• Since a panic attack in a supermarket last month, you've been doing your shopping online and avoiding shops altogether. What's most likely to help in the long run? Planned steps back in: a small shop at a quiet time, then longer, then busier — ideally with CBT. Exposure is the core of CBT for panic, and it works by teaching the brain that the feared thing doesn't happen.