High anxiety

Elena wakes up with a start. It's 4.45am, the same time as last night, the same time as the night before. Her heart is beating fast; she's bathed in a cold sweat and her stomach is tied in a knot. The first time this happened, a couple of years ago, shortly after her father died, she was convinced she was having a heart attack. After her husband, who had been sleeping soundly at her side, had driven her to the local hospital, she was given a tranquilizer and told she had suffered a panic attack as a result of generalized anxiety disorder, or GAD. For a year after, she went to a psychologist, who confirmed the diagnosis.

Since then, the 42-year-old mother of two is learning to live with her condition. A model daughter and responsible elder sister, a perfectionist at school and work, and a doting mother, Elena has always been a worrier. But the death of her father triggered what she calls "an emotional breakdown," and she simply lost control. She says there are still periods when she finds it hard to keep going. They are typically set off by a piece of bad news, or pressure at work. That's when she'll wake up for no reason in the middle of the night.

Up to 20 percent suffer from anxiety, says WHO. Two- thirds are women

Almost half of Spaniards with a job say they are afraid of losing it

"A certain level of stress is good for performance: you are more alert"

"Everybody, even those with good jobs, now sees adversity everywhere"

According to the World Health Organization, up to 20 percent of the population suffers from anxiety, with women making up two-thirds.

Little wonder. We live in times of high anxiety, with the media constantly telling us that our economies are about to collapse, our financial systems are unsustainable and our governments are barely able to deal with the myriad problems attacking us.

In short, we're afraid, collectively and individually. A study published last year by the Pfizer Foundation on the impact of the economic crisis concluded that almost half of Spaniards with a job say they are afraid of losing it, while 80 percent say things are unlikely to improve in the near future.

Anxiety is a natural response to danger, part of the so-called fight or flight mechanism that allowed us to survive as a species upon confronting saber-toothed tigers.

"The problem starts when there are no tigers around, but we're still anxious," says psychiatrist Alberto Fernández-Liria, head of mental health at the main hospital in the Madrid dormitory town of Alcalá de Henares. "Or when the tiger is a kitten, like having to go out, meet people, deal with day-to-day problems. We don't live in the jungle any more, and so we have to change our strategies. Normal anxiety becomes pathological when it paralyzes us, when it produces more problems than it solves."

Fernández-Liria says that it is important not to tell patients like Elena who come to his unit that "there is nothing wrong with you," or "it's all in your head."

"Of course there is something wrong: they have a rapid heart rate, cramps that can be very painful, they can't breathe, and they think they are about to die. We have to explain to them that the body is getting ready for flight because it thinks that there is danger. Telling people what is going on helps calm them down; after that comes the therapy, which is not so easy. The aim is to help the patient find a new mechanism, and to learn to prioritize. It's not about not being anxious, as managing anxiety," he says.

Enrique Echeburúa, a professor of clinical psychology at the University of the Basque Country, says it is helpful to see anxiety as a malfunctioning of our perception of danger, and one that is widespread.

"Up to 80 percent of us are worriers. We think that everything is hanging by a thread; that something bad is going to happen at any time, and that if they don't worry about things, they are being irresponsible. Worriers make great parents and professionals, they are always vigilant, ready for any situation. And as long as they can handle it, and they don't make everybody else's life a misery, they get along. But others have breakdowns. The limit between normal and pathological is different for all of us," he says.

Three weeks ago, EL PAÍS received the following letter from 33-year-old Fernando: "I would like to call attention to those, like myself, who don't understand why those suffering from the pandemic of the 21st century (anxiety, stress, panic attacks) consume drugs such as diazepam and other tranquilizers. This problem needs to be addressed. I suffer watching my wife, the mother of my three children, drugged, on the verge of tears, and feeling like she is a burden. I just want people to know that family and friends are there to help everybody suffering from this."

Fernando's wife, Blanca, is aged 31, and has been admitted to a Madrid hospital. "They are trying to reduce her medication, because she has uncontrolled anxiety, she is absolutely dependent on drugs, and is a danger to herself," says Fernando.

Outwardly, Blanca and Fernando seem the ideal couple. Young, well educated, with good, if demanding jobs, they are bringing up three young children. But for the last three years, since Blanca began to get panic attacks, their life has been hell. Blanca was unable even to go out, and blamed her paralysis on a heavy work load, domestic pressures, and money problems. "We bought an expensive property, then we had twins, our costs soared, and although we are better off than many people, we can hardly make ends meet," says Fernando.

Blanca went to see her GP, and was given tranquilizers to reduce her anxiety, and was given time off work. Two years later, Fernando was growing impatient. "I didn't understand. I have a lot of stress as well. I just saw her holed up at home and I thought she was just being weak. I used to tell her to buck her ideas up or she would lose her job. I feel really bad now about my ignorant attitude," he says.

For a time, Blanca's condition seemed to improve, and she even lowered her drugs dose, finally returning to work. But at the beginning of this summer she was once again showing the classic symptoms of stress, not sleeping properly, palpitations, and unable to concentrate. Again her GP prescribed tranquilizers, and again she took too many. The family went on holiday, and a few weeks after Blanca returned to work, her boss called Fernando to tell him that Blanca had fainted in the office and been taken to hospital. Blanca admitted to Fernando that she had taken an overdose. "She said that she hadn't tried to commit suicide, but that she felt so much pain inside," he says.

Since then, despite his efforts to reduce her drugs use, she has taken four more overdoses. Finally, her psychiatrist recommended that she undergo a detox.

"When she gets out, they say that she will go to see a psychologist to find out what the root of the problem is," says a puzzled Fernando. "Shouldn't they have done that from the start instead of just prescribing tranquilizers?"

The first port of call for most people suffering from anxiety, like Blanca, is their GP. The Spanish Family Medicine Society estimates that one in three patients who visit their local doctor do so for mental health problems. They may not even show outward signs of unhappiness. They have headaches, backache, stomach pains, rashes, infections, loss of appetite or other eating disorders. They are permanently tired and feel lethargic. Most doctors will recognize these symptoms as psycho-somatic: physical manifestations of psychological problems. "The organism is reacting to the constant activation of anxiety mechanisms, and the body complains," says Antonio Cano Vindel, a professor of psychology and president of the Spanish Society for the Study of Anxiety and Stress (SEAS). He concurs with the increasingly widely held view that these secondary symptoms of anxiety can not only reduce the quality of our lives, but lead to an early death.

The right response from a GP can make a huge difference in dealing with stress early on, says Antoni Bulbena, a professor of psychiatry, and the director of the psychiatry unit at Barcelona's Hospital del Mar. He has written a guide for GPs on how to deal with patients suffering from anxiety, and that the best approach is a blend of psychology, drugs, and therapy. "Medication is useful in acute cases; in the same way that psychotherapy can help in certain cases. Every patient is different, but in the end the aim is to find out what is wrong, and to help patients understand what is happening to them and to provide them with tools to help deal with their situation," he says.

GPs are aware they have come under fire for a perceived over-willingness to prescribe drugs to patients coming to them suffering from anxiety.

"It's easy to say what needs to be done in terms of combining psychotherapy with drugs treatment, but we have five minutes to deal with each patient, and the national health service's mental health waiting list is very long, except in emergency cases, and patients want a solution now," says one GP, adding that prescribing drugs is the simplest and cheapest solution: a private therapist costs around 90 euros a session.

Consumption of tranquilizers has doubled over the last decade. Some 16 percent of Spaniards have taken some kind of psycho pharmaceutical over the last year, according to SEAS. The government's National Drug Plan, which aims to tackle overdependence on both legal and illegal drugs, says that of the 900,000 people who take some kind of sleeping tablet, up to 700,000 are women. Hormonal factors, long working hours combined with household responsibilities, and a greater willingness to seek help explain the figures.

Health experts disagree, however, over the use and effectiveness of drugs. Psychiatrists like Bulbena say there are far more of us suffering from untreated anxiety than those abusing their medication. Other experts warn of the dangers of self-medication and overdependence on drugs. Others, such as psychologists Cano Vindel and Juan José Legarda, believe that we are feeding addiction by prescribing medication to deal with stress, and that a broader debate is needed to recognize the extent to which our societies are unhealthy.

Legarda is the director of Tavad, a Madrid-based center specializing in addiction - all addictions, not just illegal substances and alcohol, but tranquilizers, particularly diazepam and its variants, addiction to which is particularly common among young women. "It is legal, it is prescribed by GPs, and initially it is effective," he says. "But once its effectiveness begins to wear off, if the dose isn't correctly handled, the anxiety simply reappears. And so the patient takes more pills to relieve the anxiety, and they then need more and more, and eventually patients reach a point where the anxiety is being produced by the need for the drug.

"Most of us are unhappy most of the time. The key is knowing how to handle that unhappiness. Some people just bash on, but there are others who look for other ways to calm themselves: food, drugs, alcohol, and some of us end up being addicted to them."

Pablo has driven 300 kilometers to Madrid from his home in a small provincial town to attend his weekly session at Tavad. He is three months into a year-long course that will cost him 5,000 euros, and that includes hospital treatment, as well as drugs and psychotherapy to rid him of his dependence on alcohol. Pablo is 34, and runs a small company. He is married, and has a three-year-old daughter. "I've been a worrier all my life," he says.

He talks non-stop, fiddling with his hands, and biting his nails. His problems really started when his father died six years ago, and he had to take over the family business. He suffered several panic attacks, ending up in hospital on a number of occasions. He decided against using the tranquilizers he was prescribed, saying he was concerned about the side effects. Instead, he started drinking.

"I've always been a social drinker. Alcohol is part of my life: I sell it, I serve it, I buy drinks for others, and they buy drinks for me. But I began drinking more and more as a way of dealing with pressure, as a way of relaxing. Then I started having problems with my wife, and I suddenly saw where I was heading if I didn't put a stop to it, and that is why I am here. I have seen a lot of friends and colleagues end up in a bad way," he explains.

As well as teaching him how to handle his drinking, the clinic also addresses the issue of how to deal with the stress that is behind his drinking. "I don't want to and cannot change my life, among other reasons because I have people who depend on me. Neither can I change the way that I am. So it is a question of dealing with things. It's like having a very close friend who is a pain in the ass but whom you are just going to have to get on with."

Fashion designer Ana Locking, aged 41, has found her own particular way to deal with stress. At her Madrid shop, a pantheon of minimalism, she shows off her latest collection. A full-length dress appears to be a bright, cheerful, Liberty-style print she calls Under Beauty, made up of leaves and flowers. But as the eye runs down the garment, a menagerie of beetles, bugs and insects can be made out eating away at the roots and stems. "My collections are what you might call autobiographical," she admits.

"Underneath the glamour of the fashion world, or of life, there is nothing but decay, chaos and pain. This profession is not the best for dealing with anxiety. It is very demanding: success, fame, and you have to come up with four or five collections a season. Which is why designers like John Galliano, Marc Jacobs and Alexander McQueen have suffered so terribly along the way."

Eleven years ago, Ana had a breakdown. She was working 16-hour days after setting up her own brand of fashion jewelry. The collection was a success, but as she puts it, "my body just broke in two." She says she suffered a panic attack while driving. "I thought I was going to die there and then." She spent a year on medication, and then a year and a half seeing a psychologist. "I still need to have a tranquilizer in my bag, because I am afraid of losing control. But what really helped me was the psychotherapy. It taught me about myself, to understand that there are good days and bad days and that I need to be able to control my mind and my body, and that when things go wrong at work it's not the end of the world. I am stronger now."

Locking says she has friends who are addicted to tranquilizers such as valium, supposedly to help them deal with the pressures of fashion shows, business trips and life in general.

And while high-pressure careers like hers inevitably produce stress, unemployment is an even bigger cause of mental health problems. The jobless have a higher rate of stress-related illnesses than those in work: 2.2 percent, according to the World Health Organization.

We all know people who seem to thrive on pressure to perform: friends who drink four cups of coffee in a row, or are hooked on Coca-Cola or Red Bull. Carlos Tejero, the spokesman for the Spanish Society of Neurology, explains why: "A certain level of stress is good for performance. We see this when we carry out a CAT scan and then subject them to pressure. We see that certain areas of the brain, such as those dealing with association, increase synchronicity between neuron connections: they are more alert. The problem comes when the stress level is too high, or when the subject fails to channel a response correctly. We don't really know what goes on in the brains of the pathologically anxious," he says.

Insecurity, uncertainty, and instability have always been key factors in producing creativity. Spanish writer and thinker Victoria Camps says: "Although mood is an individual question, rather than social, we can say that right now we are immersed in anxiety. We are all suffering from anxiety. Everybody, even those with a good education and with good jobs, now sees adversity everywhere. Politicians, if they are responsible people, are also affected by this widespread malaise. But we should see this as an opportunity. We have to change things. We have to change this feeling of paralysis into action. And we have to do it collectively."

Until we do, doctors' waiting rooms will continue to be full of people suffering from anxiety. "All the minor psychological disorders are to do with anxiety; the rest are just nonsense, like feeling glum about returning to work after the holidays," says Antonio Espino, head of mental health services in the Madrid dormitory town of Majadahonda.

The medical profession has had qualified success in dealing with our society's tendency toward anxiety. "In the United Kingdom they have attempted to measure the success of therapy. Around 65 percent of patients say that they have improved after drugs and therapy, with just 30 percent requiring further treatment. It's not brilliant," admits Fernández-Liria, who tells his patients: "Your body is telling you to run, so run." Exercise, meditation, hobbies, social activities, even self-help books, can all contribute to dealing with a problem that eventually affects us all, he says. "Depressive people are depressing, and the anxious make us anxious, but they need our support."