List of disorders, treatment options, social worker role, practice suggestions, recent literature
Three sections follow:
1. Background Material that provides the context for the topic
2. Suggestions for Practice
3. A list of References
Feedback welcome!
Background Material
Introduction
Up to one-third of women and one-fifth of men will experience anxiety at some point in their lives. While feeling anxious is one way the body keeps people safe from danger, when people become overly worried much of the time and if it affects daily life, it may be an anxiety disorder. An anxiety disorder impacts on a person’s life in a way that makes it hard to go about daily activities and carry out personal responsibilities. Anxiety is the most common mental health condition in Australia. (Better Health Channel, 2024; Black Dog Institute, 2024).
Types of Anxiety
The following material is based on information from Black Dog Institute (2024). A similar outline can be found at Better Health Channel (2024), a website supported by the Victorian Government’s Department of Health (Australia).
Severe anxiety is a feature of a group of mental health disorders including:
generalised anxiety disorder
social phobia
panic disorder
specific phobia
separation anxiety disorder
agoraphobia
While post-traumatic stress disorder (PTSD) and obsessive compulsive disorder (OCD) may have a significant anxiety component, they are no longer grouped with the above anxiety disorders. PTSD is included in the trauma and stress-related disorders category and OCD is included in the obsessive-compulsive and related disorders group.
Generalised anxiety disorder
Signs and symptoms of generalised anxiety disorder
People may have GAD if they experience worry (e.g. work, school, finances, health issues, and relationships) most of the time for more than six months and if the worry makes them feel more than three of the following symptoms:
restlessness, feeling ‘on edge’
getting tired easily
problems concentrating or mind going blank
sleep problems (can’t get to sleep, waking often)
irritability
tense muscles, such as sore arms, back, clenched jaw.
People with GAD should see their GP, who may suggest a number of treatments such as cognitive behavioural therapy (CBT), digital health tools, medication and lifestyle changes.
Social Phobia
Social anxiety disorder, or social phobia, is more than the shyness or passing feelings of nerves and tension that people feel before giving a speech or performing in front of others. Over 10% of Australians will experience social phobia in their lifetime, and it can be treated.
Signs and symptoms of social phobia
People may have social phobia if, over the past six months, on one or more social situations they have felt:
intense fear of being judged by others
fearful they will be judged negatively leading to rejection or offending people
worried that they will show signs of being anxious and this will be embarrassing
a level of fear that is out of proportion to the actual threat or context of the situation
fear and anxiety that causes significant distress, preventing them from living their everyday life.
Physical symptoms of social phobia may include:
shaking or trembling
sweating
dry mouth
racing heart
stuttering, unable to get the words out clearly
stomach aches, diarrhea.
Situations that can ‘trigger’ social phobia symptoms:
having to meet new people and people in authority
being criticised
being the focus of people’s attention
having to speak or perform in public
being watched doing something
being made to feel embarrassed
making phone calls in front of people or to people you don’t know.
People with social phobias often realise that their fears are irrational. However, they are not able to control these symptoms until they get help.
Factors that may influence the development of social phobia include:
personality (often shy, quiet and thoughtful people who can be perceived as being aloof and unfriendly)
genetics (family history)
past events of being humiliated, such as bullying or being criticised in public or at school
family or personal conflicts
sexual abuse.
People should talk to their GP or a mental health professional like a counsellor, psychologist or psychiatrist, so they discuss treatments such as cognitive behavioural therapy (CBT), e-mental health tools (or e-therapies), medication and lifestyle changes.
Panic disorder
Many people experience a panic attack at some stage during their lives. A panic disorder happens when people have recurring panic attacks. These are unexpected feelings of overwhelming and intense fear and distress. A panic attack can happen when people are in a calm or anxious state.
Signs and symptoms
heart palpitations/pounding heartbeat
trembling or shaking
sweating
chest pain
difficulty breathing/shortness of breath
feeling like you’re choking
fear of dying
nausea
dizziness
feeling like you’re detached from yourself
numbness or tingling.
People should get help from their GP for panic attacks if:
they have been worried for more than a month about having another panic attack
they have changed their behaviour to avoid having more panic attacks, such as not exercising or going out.
Specific Phobias
Specific phobias occur when people feel strong fear or anxiety towards a specific object or situation and try to avoid the perceived threat at all costs, even when they may realise there’s no real danger. They feel powerless to control the fear. This excessive fear can affect daily routines and place a strain on work, school, self-esteem and relationships. Some common phobias involve extreme fear of flying, needles, blood, germs, insects or spiders, dentists and lifts or closed spaces.
Signs and symptoms
One of the most disabling symptoms of a phobia is a panic attack. Panic attacks can involve:
racing heartbeat
shortness of breath
shaking or trembling
sweating
difficulty speaking
feeling like one will vomit.
People who think they have a specific phobia should talk to their GP. There are many treatments for phobias, like cognitive behaviour therapy (CBT). Exposure therapy is often effective at changing the response to the situation or feared object by very gradually exposing people to their phobias over time.
Pregnancy and postnatal anxiety
Anxiety can sometimes occur on its own, or together with depression during pregnancy and the postnatal (time after birth) period. About one in seven childbearing women show symptoms of an anxiety disorder. It is a common medical problem during pregnancy and in the postnatal period.
Women are more likely to show increased levels of anxiety when they’ve:
had previous pregnancy, labour or delivery complications
had a history with miscarriage
experienced the death of, or serious medical problems, with their baby.
Also, a history of a specific phobia, generalised anxiety disorder (GAD), separation anxiety or obsessive compulsive disorder (OCD) increases the risk of anxiety symptoms in pregnancy and after birth.
Other risk factors for developing anxiety during pregnancy or postnatally:
family history of mental health issues
personality type – e.g. perfectionist, shy or nervous
delivery complications
lack of support from family
stressful life events like divorce, death in the family, moving house
difficulties with baby’s sleeping, feeding or crying.
Sometimes pregnant women who are anxious might think things will get better once the baby arrives. This is often not the case. They should seek help as soon as they can.
Other types of anxiety
People with anxiety can experience symptoms of more than one type of anxiety. It’s always best to see a health professional to get a proper diagnosis.
Post-traumatic stress disorder (PTSD) PSTD is sometimes discussed as a type of anxiety.
Substance/medication-induced anxiety disorder Substance or medication-induced anxiety disorder is marked by panic attacks or extreme anxiety triggered by either taking (or ceasing to take) drugs or medications, or drinking alcohol.
Anxiety disorder due to a medical condition If anxiety is caused directly by a physical illness or condition, a medical professional needs to carefully evaluate the condition to diagnose this type of anxiety. Some medical conditions that may lead to anxiety include:
thyroid problems (hyperthyroidism, hypothyroidism)
heart problems
asthma
some neurological conditions.
Separation anxiety disorder Separation anxiety disorder is an inappropriate and persistent fear about being separated from people the person is attached to. It’s a type of anxiety disorder that can begin either in childhood or adulthood. In children, separation anxiety disorder is so severe it starts to interfere with daily functioning of children and their parents.
Selective mutism Selective mutism is an anxiety disorder in children where there’s an inability to speak in certain social settings, like at school. The child, however, is able to talk in other settings where they feel comfortable, such as at home. It has a marked impact on the daily functioning of the child. Sometimes they can have another type of anxiety such as social phobia at the same time.
Treatment
Unless indicated otherwise, the following material is based on information from Black Dog Institute (2024).
There are three broad categories of treatment for anxiety, these include:
psychological treatments (talking therapies)
physical treatments (medications)
self-help and alternative therapies.
Psychological therapies are the most effective way to treat and prevent the recurrence of most types of anxiety. However, depending on the type of anxiety, self-help and alternative therapies can be helpful. They can be used alone or combined with physical and psychological treatments. A thorough assessment by a doctor is needed to decide on the best combination of treatments for a person.
Psychological treatments
Psychological treatments can be one-on-one, group-based or online interactions. There are a wide range of psychological treatments for anxiety, including:
cognitive behaviour therapy (CBT) [Research shows CBT is the most effective treatment for anxiety]
exposure therapy (behaviour therapy) [There is good evidence suggesting exposure therapies are effective for post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), and specific phobias.]
interpersonal therapy (IPT)
mindfulness-based cognitive therapy
positive psychology
psychotherapies
counselling
narrative therapy.
Many of these treatments are discussed on this website – see the ‘contents’ tab. They are also outlined in summary form on the Black Dog Institute website: https://www.blackdoginstitute.org.au |
Psychological therapies have been found to be most effective treatment for anxiety and relapse prevention over the long term. Sometimes, however, medication, working together with psychological therapies, can be helpful. Some of the above treatments can be accessed online. These online treatments are often referred to as e-mental health programs and can be as effective as in-person treatments.
e-Mental Health programs
e-Mental health programs can be accessed on the internet using a smartphone, tablet or computer. The programs can help people experiencing mild-to-moderate depression or anxiety. e-Mental health treatments are based on face-to-face therapy, positive psychology and behavioural activation. These therapies mainly focus on reframing thoughts and changing behaviour. Some e-mental health tools, such as myCompass (https://www.mycompass.org.au/), have been found to be as effective in treating mild-to-moderate depression as face-to-face therapies.
Features of e-Mental health programs:
are available throughout Australia (wherever there is an internet connection)
are anonymous
can mostly be accessed without a referral
can be used in conjunction with the work you are doing with your GP, psychologist or counsellor
are self-paced
are free, or have a minimal cost.
e-Mental health treatment programs recommended by Black Dog Institute include:
myCompass (https://www.mycompass.org.au/) is an interactive self-help service that has proven to be effective in helping people experiencing mild-to-moderate depression and anxiety. myCompass is based on CBT, interpersonal psychotherapy, problem-solving therapy, positive psychology, and behavioural activation.
THISWAYUP (https://thiswayup.org.au/) offers proven online courses for depression, and anxiety that use CBT principles.
MoodGYM (https://www.moodgym.com.au/) is a free self-help program to teach CBT skills to people vulnerable to depression and anxiety.
Physical treatments (medication)
A doctor should undertake a thorough health check before deciding whether medication is a good option for a person. If medication is prescribed as part of treatment, the doctor should explain the reason for choosing the medication they have prescribed and discuss the risks and benefits, side effects, and how regularly to return for check-ups. The doctor can also advise what treatments can work together with the medication, such as psychotherapy, lifestyle changes (e.g. exercise) and other support options. Not all anxiety needs medication as many people respond well to lifestyle changes and psychological treatments.
Anti-anxiety medications, such as benzodiazepines, can:
be addictive
become ineffective over time
have other side effects like headaches, dizziness and memory loss.
Anti-anxiety medications are not recommended for long-term use.
Antidepressants were initially developed for treatment of depression, but some antidepressants can also have a role in treating anxiety. If anxiety and depression occur together, antidepressants may be prescribed. Selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) are medications sometimes used in treating anxiety.
Beta blockers are more commonly used for heart and blood pressure issues. They are sometimes used to treat social phobia and anxiety around performance, such as speaking in public. Beta blockers may work by slowing a person’s heart rate when they’re experiencing the ‘fight or flight’ feelings associated with performance. Evidence suggests they are not an effective long-term solution for anxiety issues.
Self-help and alternative therapies
Depending on the type and severity of anxiety, self-help or alternative therapies could be used alone or in conjunction with psychological treatments or medication. Self-help and complementary therapies that may be useful for anxiety include:
exercise
good nutrition
omega-3
meditation
de-arousal strategies
yoga
massage therapy
relaxation and breathing techniques
alcohol and drug avoidance
acupuncture
These therapies are outlined in detail at https://www.blackdoginstitute.org.au/resources-support/anxiety/treatment/. Severe anxiety may not respond to self-help and alternative therapies alone. These can be valuable adjuncts to psychological and physical treatments.
Therapist Aid (2018a) has a worksheet on coping skills that may be useful.
Social Work Role
Social Workers are uniquely positioned to address anxiety in their clients, employing a holistic approach that considers the individual’s environment, history, and personal strengths. Their role involves:
Assessment and Identification: Carefully evaluating clients to identify anxiety, its triggers, and its manifestations.
Strategy Development: Crafting personalized intervention plans that incorporate evidence-based therapies tailored to the client’s specific needs. These evidence-based therapies often include Cognitive-Behavioural Therapy, Mindfulness-Based Stress Reduction and Acceptance and Commitment therapy.
While using these and other therapies social workers should:
Adopt a personalised approach, recognising each client will be different. For example,
Children might need more play-based or creative activities designed to help them express their feelings and understand anxiety.
Adolescents may benefit from a combination of talk therapy and digital tools that offer a sense of autonomy.
Adults might find traditional therapy sessions more useful.
Elderly clients could require approaches that accommodate physical limitations or cognitive changes.
Adapt therapies to align with the culture of clients
Endeavour to ensure clients have access to therapies, which may include enabling access to digital platforms (Mitchell, 2024).
Practice Approach
In assisting clients to overcome anxiety social workers should operate out of their usual practice principles.
Build a strong relationship with the client through active listening, validation, and addressing challenges.
Tailor therapy to meet client’s unique needs and preferences through conducting a thorough assessment, engaging clients in planning to accommodate their preferences, and adapting therapy as needed.
Establish SMART goals aligned to the client’s values and wishes and include an expected timeline of progress.
Stay informed about latest research in anxiety management.
Regularly evaluate progress with the client.
Adapt the approach when necessary (Mitchell, 2024).
A search of Google Scholar resulted in five recently published articles dealing with approaches to anxiety.
1. CBT, MBSR, ACT and exposure therapy
Mitchell (2024) has specific suggestions around anxiety management strategies for social workers. Mitchell suggests that, to “combat anxiety effectively, Social Workers can draw from a repertoire of cutting-edge therapies, each offering unique benefits:
Cognitive-Behavioral Therapy (CBT): Aims to change negative thought patterns and behaviors contributing to anxiety.
Mindfulness-Based Stress Reduction (MBSR): Utilizes mindfulness meditation and yoga to enhance present-moment awareness and reduce stress.
Acceptance and Commitment Therapy (ACT): Encourages clients to accept their thoughts and feelings while committing to actions aligned with their values.”
These topics are discussed in detail elsewhere on this website – use the “contents” tab to find them. Mitchell (2024) offers a precis of each (below) and also offers Exposure Therapy as a fourth option.
Cognitive-Behavioral Therapy (CBT)
CBT stands as a cornerstone in the treatment of anxiety, prized for its evidence-based approach and adaptability to various anxiety disorders.
Core Principles: CBT operates on the premise that negative thoughts and patterns of behavior contribute to the development and maintenance of anxiety. By identifying, challenging, and altering these thoughts and behaviors, individuals can significantly reduce anxiety levels.
Application in Social Work:
Identifying specific negative thought patterns and behaviors affecting the client.
Utilizing techniques such as cognitive restructuring to challenge and change these patterns.
Implementing behavioral experiments to test the validity of certain beliefs and fears.
Therapist Aid (2018b) has a worksheet on managing cognitive distortions that may be useful.
Mindfulness-Based Stress Reduction (MBSR)
MBSR is a therapeutic approach that combines mindfulness meditation and yoga to cultivate awareness of the present moment, aiming to reduce stress and anxiety.
Key Features:
Emphasizes the importance of mindfulness in everyday life.
Teaches clients to observe their thoughts and feelings without judgment.
Social Work Practice:
Incorporating mindfulness exercises into sessions to help clients become more aware of their anxiety triggers.
Guiding clients in the practice of mindful breathing and meditation to manage acute anxiety symptoms.
Therapist Aid (2018c) has information around grounding techniques that may be useful.
Acceptance and Commitment Therapy (ACT)
ACT encourages individuals to accept their thoughts and feelings rather than fighting them, committing to actions that align with their values despite the presence of anxiety.
Essential Concepts:
Utilizes acceptance and mindfulness strategies alongside commitment and behavior change strategies.
Focuses on values and committed action to help clients live a meaningful life in the face of anxiety.
Utilization in Social Work:
Facilitating the exploration of personal values and how anxiety interferes with living according to these values.
Developing mindfulness skills to help clients engage with the present moment more fully.
Therapist Aid (2021) has a worksheet to help people cope with uncomfortable thoughts and feelings by creating distance form these thoughts. This helps reduce the power these thoughts can exert over a person.
Exposure Therapy
A component often used within the framework of CBT, exposure therapy involves the gradual, controlled exposure to anxiety-provoking situations or objects, reducing fear over time.
Principles:
Based on the concept of habituation, the process by which repeated exposure to a feared stimulus decreases the emotional response over time.
Application:
Carefully planning exposure exercises tailored to the client’s specific fears.
Providing a supportive environment to guide clients through exposure tasks, ensuring a gradual approach to prevent overwhelming anxiety.
See also Therapist Aid (2022)—What is exposure therapy?.
2. Online CBT vs offline CBT with young people
Howes et al. (2023) conducted a rapid review and meta-analysis on the effectiveness of online Cognitive Behavioural Therapy with anxious and depressed young people between the ages of 10 and 25. They found “online CBT seems as effective as offline CBT in alleviating anxiety and depressive symptoms among middle-class, non-Hispanic white, cisgender women in high income countries. (However) men were alarmingly underrepresented in trials ... In addition, the experiences of important minoritised group members have not yet been systematically analysed, nor have data reporting on rates amongst transgender people as well as racialised, ethnic, or cultural minority group members, and people who live in poverty.” Links to some online programs are included in the Background Material section above.
3. Treatment options for children and adolescents
The American Academy of Child and Adolescent Psychiatry published four recommendations around the assessment and treatment of children and adolescents with anxiety disorders (Walter et al., 2020).
Cognitive-behavioral therapy (CBT) can be offered to patients 6 to 18 years old with social anxiety, generalized anxiety, separation anxiety, specific phobia, or panic disorder.
Selective serotonergic reuptake inhibitors (SSRIs) can be offered to patients 6 to 18 years old with social anxiety, generalized anxiety, separation anxiety, or panic disorder.
Combination treatment (CBT and an SSRI) could be offered preferentially over CBT alone or an SSRI alone to patients 6 to 18 years old with social anxiety, generalized anxiety, separation anxiety, or panic disorder.
As an additional treatment rather than a first choice option, serotonin norepinephrine reuptake inhibitors (SNRIs) could be offered to patients 6 to 18 years old with social anxiety, generalized anxiety, separation anxiety, or panic disorder.
4. Eco-anxiety – climate change
Baudon and Jachens (2021) conducted a review of interventions for the treatment of eco-anxiety ( i.e. the emotional and mental states associated with heightened awareness of climate change and distress in the face of its implications for the future). Those who suffer from eco-anxiety experience a constellation of emotions including fear, anger, exhaustion, powerlessness, feelings of loss, helplessness, and even phobia and despair. The authors suggest five approaches may help support those experiencing eco-anxiety. The five approaches are:
Fostering clients’ inner resilience by creating strong scaffolding around clients’ inner experience to ensure emotions can be safely accessed, felt and expressed
Shifting from catastrophizing towards a less black-and-white picture.
Discussing and relativising the social and systemic dimensions of climate change.
Fostering optimism and hope.
Grief-focused interventions.
Differentiating between clients’ distress related to their history and distress related to eco-anxiety.
Interventions focused on creative expression and the arts.
Interventions focused on dreams.
Helping clients find social connection and emotional support by joining established groups and organisations.
Encouraging clients to connect to, grow, and enact action plans through individual and collective action.
Practitioner’s self-exploration and self-education, especially around grief awareness
Connecting clients with nature as a space of reflection, resourcing, and inspiration
5. Maternal anxiety during pregnancy and the post-partum period
The existence of anxiety during pregnancy and post-natal was mentioned in the Background Material above. Araji et al. (2020) provide an overview of this topic. They suggest anxiety and depression during pregnancy have been reported to affect between 20 – 40% of pregnant women. The general causes of worry during pregnancy can revolve around: fetal wellbeing, maternal illnesses, social and financial support and mortality. If these worries persist for a prolonged period, they can lead to functional impairment across multiple areas of the mother’s life. The authors suggest:
High risk pregnancy and labour are two major physiological risk factors associated with anxiety during pregnancy.
Even if a patient had smooth antepartum progress, severe anxiety or fear may develop during labour or childbirth. Labour is unpredictable and can occur at any time point, lending to worry about going into labour at an undesirable time (e.g., night, at work, holiday), which may negatively affect access to a desired physician or method of delivery.
During the post-partum period, the number of demands and responsibilities increase, which may also increase worry and distress, e.g. difficulty with breastfeeding, inadequate social support, financial difficulties, maternal health, and child wellbeing. However, the most important predictor of progression of anxiety during pregnancy to the 6-week post-partum period was found to be the severity of anxiety experienced during pregnancy.
Several self-report questionnaires have been found to be valid and reliable for assessing anxiety during pregnancy and the early post-partum period:
Beck Anxiety Inventory (BAI)
Cambridge Worry Scale (CWS)
Hospital Anxiety and Depression Scale (HADS-A)
Penn State Worry Questionnaire
Perinatal Anxiety Screening Scale (PASS)
Pregnancy Anxiety Scale
Pregnancy Anxiety Scale
Prenatal Distress Questionnaire (PDQ)
Pregnancy Related Anxiety Questionnaire (PRAQ)
Pregnancy Related Thoughts
Pregnancy Specific Anxiety Scale
State-Trait Anxiety Index (STAI)
Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ)
Managing anxiety in pregnancy and post-partum can involve:
Home visits focused on strengthening maternal interactions, promoting nurturing behavior, and promoting child wellbeing, although effectiveness depends a great deal on the engagement of the mother.
Traditional CBT—psycho-education, cognitive restructuring, problem-solving, exposures, relaxation/coping strategies, and behavioral experiments.
SSRIs—these are relatively effective although avoiding these medications in pregnancy or at least tapering them in the third trimester is recommended.
References
Araji, S., Griffin, A., Dixon, L., Spencer, S. K., Peavie, C., Wallace, K. (2020). An overview of maternal anxiety during pregnancy and the post-partum period. Journal of Mental Health and Clinical Psychology, 4(4), 47-56. doi: 10.29245/2578-2959/2020/4.1221
Baudon, P., & Jachens, L. (2021). A scoping review of interventions for the treatment of eco-anxiety. International Journal of Environmental Research and Public Health, 18, 9639. https://doi.org/10.3390/ijerph18189636
Better Health Channel (2024). Managing and treating anxiety. Victoria State Government, Department of Health. https://www.betterhealth.vic.gov.au/conditionsandtreatments/anxiety
Black Dog Institute. (2024). Anxiety. https://www.blackdoginstitute.org.au/resources-support/anxiety/
Howes S. T., Gorey, K. M., & Charron, C. M. (2023). Relative effectiveness of online Cognitive Behavioural Therapy with anxious or depressed young people: Rapid review and meta-analysis. Australian Social Work, 76(4), 547-561. https://doi.org/10.1080/0312407X.2021.2001832
Mitchell, M. (2024, March 9). Anxiety management therapies for social workers. Agents of Change. https://agentsofchangeprep.com/blog/anxiety-management-therapies-for-social-workers/
Therapist Aid. (2018a). Coping skills. https://www.therapistaid.com/therapy-worksheet/coping-skills-anxiety
Therapist Aid. (2018b). Decatastrophizing. https://www.therapistaid.com/therapy-worksheet/decatastrophizing
Therapist Aid. (2018c). Grounding techniques. https://www.therapistaid.com/therapy-worksheet/grounding-techniques
Therapist Aid. (2021). Leaves on a stream: Mindfulness exercise. https://www.therapistaid.com/therapy-worksheet/leaves-on-a-stream-worksheet
Therapist Aid. (2022). What is exposure therapy? https://www.therapistaid.com/worksheets/exposure-therapy-info-sheet
Walter, H. J., Keable, H., & Ripperger-Suhler, J. (2020). Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 59(10), 1107-1124. https://doi.org/10.1016/j.jaac.2020.05.005
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