Most people feel anxious from time to time. However, anxiety can become abnormal if it interferes with your day-to-day activities. Anxiety is a symptom of various anxiety disorders. They can often be treated. Treatments include various talking treatments and medication.
What is anxiety?
When you are anxious you feel fearful and tense. In addition you may also have one or more unpleasant physical symptoms - for example, you might have:
- A fast heart rate.
- The sensation of having a 'thumping heart' (palpitations).
- A feeling of sickness (nausea).
- Shaking (tremor).
- Dry mouth.
- Chest pain.
- Fast breathing.
The physical symptoms are partly caused by the brain which sends lots of messages down nerves to various parts of the body when you are anxious. The nerve messages tend to make the heart, lungs and other parts of the body work faster. In addition, you release stress hormones, such as adrenaline (epinephrine), into the bloodstream when you are anxious. These can also act on the heart, muscles and other parts of the body to cause symptoms.
Anxiety is normal in stressful situations and can even be helpful. For example, most people will be anxious when threatened by an aggressive person, or before an important race. The burst of adrenaline (epinephrine) and nerve impulses which we have in response to stressful situations can encourage a 'fight or flight' response.
Anxiety is abnormal if it:
- Is out of proportion to the stressful situation; or
- Persists when a stressful situation has gone, or the stress is minor; or
- Appears for no apparent reason when there is no stressful situation.
What are anxiety disorders?
There are various conditions (disorders) where anxiety is a main symptom.
You may have an anxiety disorder if anxiety symptoms interfere with your normal day-to-day activities, or if worry about developing anxiety symptoms affects your life. About 1 in 20 people have an anxiety disorder at any one time.
The following is a brief overview of the main anxiety disorders. Some people have features of more than one type of disorder.
Anxiety can be one of a number of symptoms as a reaction to stressful situations. There are three common types of reaction disorders:
Acute reaction to stress (sometimes called acute stress reaction)
This sudden reaction - typically due to an unexpected life crisis - features anxiety, low mood, irritability and other symptoms. It usually settles quickly and sometimes occurs before the event takes place (this is known as situational anxiety). See separate leaflet called Acute Stress Reaction.
This is similar to the above but symptoms develop days or weeks after a stressful situation such as a divorce or house move, as a reaction or adjustment to the problem. Symptoms are similar to acute reaction to stress but may include depression. The symptoms tend to improve over a few weeks or so.
Post-traumatic stress disorder
Post-traumatic stress disorder (PTSD) may follow a severe trauma such as a serious assault or a life-threatening accident. The main symptoms of PTSD are recurrent flashbacks about the trauma, avoidance of anything that can trigger thoughts of the trauma, emotional numbness, pessimism about the future and an increased state of irritability and arousal (for example, poor sleep, difficulty in concentrating). See separate leaflet called Post-traumatic Stress Disorder.
Phobic anxiety disorders
A phobia is strong fear or dread of a thing or event. The fear is out of proportion to the reality of the situation. Coming near to or into contact with the feared situation causes anxiety. Sometimes even thinking of the feared situation causes anxiety. Therefore, you end up avoiding the feared situation, which can restrict your life and may cause distress.
Social anxiety disorder
Social anxiety disorder (also known as social phobia) is possibly the most common phobia. With social anxiety disorder you become very anxious about what other people may think of you, or how they may judge you. Therefore, you fear meeting people, or 'performing' in front of other people, especially strangers. You fear that you will act in an embarrassing way and that other people will think that you are stupid, inadequate, weak, foolish, crazy, etc. You avoid such situations as much as possible. If you go to the feared situation you become very anxious and distressed. Discover more about social anxiety disorder.
This too is common. Many people think that agoraphobia means a fear of public places and open spaces. But this is just part of it. If you have agoraphobia you tend to have a number of fears of various places and situations. So, for example, you may have a fear of:
- Entering shops, crowds and public places.
- Travelling in trains, buses, or planes.
- Being on a bridge or in a lift.
- Being in a cinema, restaurant, etc, where there is no easy exit.
But they all stem from one underlying fear. That is, a fear of being in a place where help will not be available, or where you feel it may be difficult to escape to a safe place (usually to your home). When you are in a feared place you become very anxious and distressed and have an intense desire to get out. To avoid this anxiety many people with agoraphobia stay inside their home for most or all of the time. See separate leaflet called Agoraphobia.
Other specific phobias
- Fear of confined spaces or of being trapped (claustrophobia).
- Fear of certain animals.
- Fear of injections.
- Fear of being sick (vomiting).
- Fear of being alone.
- Fear of choking.
But there are many more. See separate leaflet called Phobias.
Other anxiety disorders
- Panic disorder.
- Generalised anxiety disorder (GAD).
- Mixed anxiety and depressive disorder.
- Obsessive-compulsive disorder (OCD).
Anxiety treatment - for disorders and phobias
The main aim of anxiety treatment is to help you to reduce symptoms so that anxiety no longer affects your day-to-day life.
The treatment options depend on what condition you have and how severely you are affected. They may include one or more of the following:
Understanding the cause of symptoms and talking things over with a friend, family member or health professional may help. In particular, some people worry that the physical symptoms of anxiety, such as a 'thumping heart' (palpitations), are due to a physical illness. This can make anxiety worse. Understanding that you have an anxiety disorder is unlikely to cure it but it often helps.
This may help some people with certain conditions. For example, counselling which focuses on problem-solving skills may help if you have GAD.
Anxiety management courses
These may be an option for some conditions, if courses are available in your area. The courses may include: learning how to relax, problem-solving skills, coping strategies and group support.
Cognitive behavioural therapy (CBT) for anxiety
This therapy, if available in your area, can work well for persisting anxiety disorders and phobias:
CBT is a type of therapy that deals with your current thought processes and/or behaviours and aims to change them, which may help you to manage your anxiety. See separate leaflet called Cognitive Behavioural Therapy (CBT).
There are various national groups which can help by giving information, advice and support. They, or your doctor or practice nurse, may also be able to put you in touch with a local group for face-to-face support.
You can also get leaflets, books, CDs, DVDs, MP3s, etc, on relaxation and combating stress. They teach simple deep-breathing techniques and other measures to relieve stress, help you to relax and possibly ease anxiety symptoms. See separate leaflets called Stress and Tips on How to Avoid It and Anxiety - Self-help Guides.
Selective serotonin reuptake inhibitors (SSRIs) are the group of antidepressants commonly used for anxiety disorders.
SSRIs often used for anxiety are:
These are commonly used to treat depression but also help to reduce the symptoms of anxiety even if you are not depressed. They work by interfering with brain chemicals (neurotransmitters) such as serotonin which may be involved in causing anxiety symptoms. Antidepressants are not tranquillisers and are not usually addictive.
Benzodiazepines such as diazepam used to be the most commonly prescribed anxiety treatment. They were known as the minor tranquilisers but they do have some serious known side-effects. They often work well to ease symptoms. The problem is they are addictive and can lose their effect if you take them for more than a few weeks. They may also make you drowsy. Now they are not used much for persistent anxiety conditions. A short course of up to two weeks may be an option for anxiety which is very severe and short-term, or now and then to help you over a bad spell if you have persistent anxiety symptoms.
Buspirone is sometimes prescribed to treat GAD. It is an anti-anxiety medicine but different to the benzodiazepines and is not thought to be addictive. It is not clear how it works. It is thought to affect serotonin, a brain chemical which may be involved in causing anxiety symptoms.
A beta-blocker - for example, propranolol - can ease some of the physical symptoms such as trembling and a 'thumping heart' (palpitations). Beta-blocker medicines do not directly affect the mental symptoms such as worry. However, some people relax more easily if their physical symptoms are eased. These tend to work best in short-lived (acute) anxiety. For example, if you become more anxious before performing in a concert then a beta-blocker may help to ease 'the shakes'.
In some cases a combination of anxiety treatments such as cognitive therapy and an antidepressant may work better than either treatment alone.
Alcohol and anxiety
Although alcohol may ease symptoms in the short term, don't be fooled that drinking helps to cure social anxiety. In the long run, it does not. Drinking alcohol to 'calm nerves' can lead to problem drinking and may make problems with social anxiety and depression worse in the long term. See a doctor if you are drinking alcohol (or taking street drugs) to ease anxiety.
What is social anxiety disorder?
Social anxiety disorder is sometimes called social phobia. Social anxiety disorder is not just shyness; it is more severe than this. With social anxiety disorder you become very anxious about what other people may think of you, or how they may judge you. As a result you have great difficulty in social situations, which can affect your day-to-day life.
- A marked fear or dread of social situations. You fear that you will act in an embarrassing or humiliating way and that other people will think you are stupid, inadequate, foolish, etc:
- In some cases the fear is only for certain situations where you will be looked at by others, even if they are known to you. For example, you become very anxious if you have to 'perform' in some way, such as giving a talk or presentation, taking part in a discussion at work or school, etc. However, you are OK in informal social gatherings.
- In other cases the fear occurs for most social situations where you may meet strangers. This can even include eating in public places, as you fear you may act in an embarrassing way.
- You may have weeks of anxiety prior to a social event or an event where you have to 'perform'.
- You avoid such situations as much as possible.
- If you go to the feared situation:
- You become very anxious and distressed.
- You may develop some physical symptoms of anxiety. These may include:
- A fast heart rate.
- The sensation of having a 'thumping heart' (palpitations).
- Shaking (tremor).
- Feeling sick (nausea).
- Chest pain.
- Stomach pains.
- A 'knot in the stomach'.
- Fast breathing.
- Blushing easily.
- You may have an intense desire to get away from the situation.
- You may even have a panic attack. Read more about panic attack and panic disorder.
- However, you will usually know that your fear and anxiety are excessive and unreasonable.
Social anxiety disorder can greatly affect your life. You may not do as well at school or work as you might have done, as you tend to avoid any group work, discussions, etc. You may find it hard to obtain, or keep, a job. This may be because you feel unable to cope with the social aspects needed for many jobs, such as meeting with people. You may become socially isolated and find it difficult to make friends.
Who has social anxiety disorder?
It is one of the most common mental health conditions. As many as 1 in 10 adults have social anxiety disorder to some degree. It usually develops in the teenage years and is usually a lifelong problem unless treated. Just over twice as many women as men are affected.
What causes social anxiety disorder?
The cause is probably a combination of bad experiences as a child and your genetic 'makeup' which makes you more prone to this condition. In one study about half of affected people said their phobia began after one memorable embarrassing experience. The other half said it had been present for 'as long as they could remember'.
How is it diagnosed?
You must have three features to be diagnosed with social anxiety disorder:
- Your symptoms must not be the result of some other mental health condition (for example, a delusion).
- You feel anxious entirely or mostly in social situations.
- One of your main symptoms will be the avoidance of social situations.
As well as discussing your problems your doctor or practice nurse may use a short questionnaire to obtain extra information on how severely you are affected.
What are the treatment options for social anxiety disorder?
Cognitive and behavioural therapies
Cognitive behavioural therapy (CBT) is a type of therapy that deals with your current thought processes and/or behaviours and aims to change them by creating strategies to overcome negative thought patterns, which may help you to manage your social anxiety. See separate leaflet called Cognitive Behavioural Therapy (CBT) for more details.
You can obtain leaflets, books, CDs, DVDs or MP3s, etc, on how to relax and how to combat anxiety. They teach simple deep-breathing techniques and other measures to relieve stress and anxiety.
Medicines for social anxiety
Although mainly prescribed for the treatment of depression, they can also lessen the symptoms of anxiety. They interfere with brain chemicals (also called neurotransmitters) such as serotonin, which are thought to cause anxiety symptoms. There are lots of different antidepressants, but selective serotonin reuptake inhibitors (SSRIs) seem best for anxiety disorders. Escitalopram and sertraline are two SSRIs commonly prescribed..
Benzodiazepines such as diazepam used to be the most commonly prescribed medicines for anxiety. They were known as the minor tranquilisers but they do have some serious known side-effects. They often work well to ease symptoms. The problem is they are addictive and can lose their effect if you take them for more than a few weeks. They may also make you drowsy. Now they are not used much for persistent anxiety conditions. A short course of up to two weeks may be an option for:
- Anxiety which is very severe and short-term; or
- 'Now and then' treatment to help you over a bad spell if you have persistent anxiety symptoms.
A beta-blocker (for example, propranolol) can ease some of the physical symptoms such as trembling and the sensation of having a 'thumping heart' (palpitations). They do not directly affect the mental symptoms such as worry. However, some people relax more easily if their physical symptoms are eased. These tend to work best in short-lived (acute) anxiety. For example, if you become more anxious before performing in a concert then a beta-blocker may help to ease 'the shakes'.
In some cases a combination of treatments such as cognitive therapy and an antidepressant may work better than either treatment alone.
Social anxiety and alcohol
Although alcohol may ease symptoms in the short term, don't be fooled that drinking helps to cure social anxiety. In the long run, it does not. Drinking alcohol to 'calm nerves' can lead to problem drinking and may make problems with social anxiety (and the depression that often accompanies it) worse in the long term. See a doctor if you are drinking alcohol (or taking street drugs) to ease social anxiety.
What is the outlook for social anxiety disorder?
Not much is known about the natural progress of the condition. However, with treatment there is a good chance that symptoms can be greatly improved. Without treatment, social phobia can be associated with depression in later life.
What is a panic attack?
A panic attack is a severe attack of anxiety and fear which occurs suddenly, often without warning, and for no apparent reason. In addition to the anxiety, various other symptoms may also occur during a panic attack.
Panic attack symptoms
- A 'thumping heart' (palpitations).
- Sweating and trembling.
- Dry mouth.
- Hot flushes or chills.
- Feeling short of breath, sometimes with choking sensations.
- Chest pains.
- Feeling sick (nauseated), dizzy, or faint.
- Fear of dying or going crazy.
- Numbness or pins and needles.
- Feelings of unreality, or being detached from yourself.
The physical symptoms that occur with panic attacks do not mean there is a physical problem with the heart, chest, etc. The symptoms mainly occur because of an overdrive of nervous impulses from the brain to various parts of the body during a panic attack. This overdrive of nervous impulses can lead to the body producing hormones which include adrenaline (epinephrine). This is sometimes referred to as a 'fight or flight' response. This kind of reaction is normal in people when they feel they are in danger. During a panic attack the body can react in the same way.
During a panic attack you tend to over-breathe (hyperventilate). If you over-breathe you blow out too much carbon dioxide, which changes the acidity in the blood. This can then cause more symptoms (such as confusion and cramps) and make a 'thumping heart', dizziness and pins and needles worse. This can make the attack seem even more frightening and make you over-breathe even more, and so on. Over-breathing may make you feel very light-headed and even lose consciousness for a brief period. However, losing consciousness when over-breathing is very uncommon.
A panic attack usually lasts 5-10 minutes; however, sometimes panic attacks come in waves for up to two hours.
What is panic disorder?
At least 1 in 10 people have occasional panic attacks. If you have panic disorder it means that you have repeated panic attacks. The frequency of attacks can vary. About 1 in 50 people have panic disorder.
In panic disorder, there may be an initial event which causes panic but then the attacks after that are not always predictable. If you have panic disorder, you also have ongoing worry about having further attacks and/or worry about the symptoms that you have during attacks. For example, you may worry that the 'thumping heart' (palpitations) or chest pains that you have with panic attacks are due to a serious heart problem. Some people worry that they may die during a panic attack.
What causes panic attacks?
Panic attacks usually occur for no apparent reason. The cause is not clear. Slight abnormalities in the balance of some brain chemicals (neurotransmitters) may play a role. This is probably why medicines used for treatment work well. Anyone can have a panic attack but they also tend to run in some families. Stressful life events such as bereavement may sometimes trigger a panic attack.
Panic disorder, agoraphobia and other fears
Some people with panic disorder worry about having a panic attack in a public place where it is difficult to get out of, or where help may not be available, or where it can be embarrassing. This may cause them to develop agoraphobia. About 1 in 3 people with panic disorder also develop agoraphobia. See separate leaflet called Agoraphobia for more details.
If you have agoraphobia you have a number of fears of various places and situations. So, for example, you may be afraid to:
- Be in an open place.
- Enter shops, crowds and public places.
- Travel in trains, buses, or planes.
- Be on a bridge or in a lift.
- Be in a cinema, restaurant, etc, where there is no easy exit.
- Be anywhere far from your home - many people with agoraphobia stay inside their home for most or all of the time.
You may also develop other irrational fears. For example, you may think that exercise or certain foods cause the panic attacks. Because of this you may fear (develop a phobia for) certain foods, or avoid exercise, etc.
Dealing with a panic attack
To ease a panic attack, or to prevent one from becoming worse, breathe as slowly and as deeply as you can. Really focus on your breathing. Learning and using relaxation techniques may help. Many people find that deep-breathing exercises are useful. This means taking a long, slow breath in, and very slowly breathing out. If you do this a few times, and concentrate fully on breathing, you may find it quite relaxing.
Some people find that moving from chest breathing to tummy (abdominal) breathing can be helpful. Sitting quietly, try putting one hand on your chest and the other on your tummy. You should aim to breathe quietly by moving your tummy with your chest moving very little. This encourages the lower chest muscle (diaphragm) to work efficiently and may help you avoid over-breathing.
What is the treatment for panic attacks and panic disorder?
No treatment is needed if you just have an occasional panic attack. It may help if you understand about panic attacks. This may reassure you that any physical symptoms you have during a panic attack are not due to a physical disease. It may help to know how to deal with a panic attack.
Treatment can help if you have repeated attacks (panic disorder). The main aim of treatment is to reduce the number and severity of panic attacks.
Cognitive behavioural therapy (CBT) for panic disorder
CBT is a type of specialist talking treatment. It is probably the most effective treatment. Studies show that it works well for over half of people with panic disorder (and agoraphobia). CBT is a type of therapy that deals with your current thought processes and/or behaviours and aims to change them through creating strategies to deal with negative patterns, which may help you to deal with panic attacks and manage panic disorder more effectively.
Medicines for panic disorder
Antidepressants work well to prevent panic attacks in more than half of cases, even if you are not depressed. Symptoms of panic are thought to be associated with the production of brain chemicals (neurotransmitters) such as serotonin, and antidepressants are believed to interfere with the way these chemicals work. Escitalopram and sertraline are commonly used for panic disorder. They belong to the group of antidepressants known as selective serotonin reuptake inhibitors (SSRIs). If SSRIs do not work, other types of antidepressants such as imipramine or clomipramine are sometimes used.
If it works, it is usual to take an antidepressant for panic disorder for at least a year. At the end of a course of treatment, you should not stop an antidepressant suddenly; rather, you should reduce the dose gradually under the supervision of a doctor. In about half of people who are successfully treated, there is a return of panic attacks when treatment is stopped. An option then is to take an antidepressant long-term. The attacks are less likely to return once you stop antidepressants if you have had a CBT course.
A combination of CBT and antidepressants may work better than either treatment alone.
What is generalised anxiety disorder?
If you have generalised anxiety disorder (GAD) you have a lot of anxiety (feeling fearful, worried and tense) on most days. The condition persists long-term. Some of the physical symptoms of anxiety may come and go. Your anxiety tends to be about various stresses at home or work, often about quite minor things. Sometimes you do not know why you are anxious.
It can be difficult to tell the difference between normal mild anxiety in someone with an anxious personality and someone with GAD. As a rule, symptoms of GAD cause you distress and affect your day-to-day activities. In addition, you will usually have some of the following symptoms:
- Feeling restless, on edge, irritable, muscle tension, or keyed up a lot of the time.
- Tiring easily.
- Difficulty concentrating and your mind going blank quite often.
- Poor sleep (insomnia). Usually it is difficulty in getting off to sleep.
You do not have GAD if your anxiety is about one specific thing. For example, if your anxiety is usually caused by fear of one thing then you are more likely to have a phobia.
Who develops generalised anxiety disorder?
GAD develops in about 1 in 50 people at some stage in life. Twice as many women as men are affected. It usually first develops in your 20s but is frequently being recognised in older people.
What causes generalised anxiety disorder?
The cause is not clear. The condition often develops for no apparent reason. Various factors may play a part. For example:
- Your genetic 'makeup' may be important (the material inherited from your parents which controls various aspects of your body). Some people have a tendency to have an anxious personality, which can run in families.
- Childhood traumas such as abuse or death of a parent, may make you more prone to anxiety when you become older.
- A major stress in life may trigger the condition. For example, a family crisis or a major civilian trauma such as a toxic chemical spill. But the symptoms then persist when any trigger has gone. Common minor stresses in life, which you may otherwise have easily coped with, may then keep the symptoms going once the condition has been triggered.
Some people who have other mental health problems such as depression or schizophrenia may also develop GAD.
How is generalised anxiety disorder diagnosed?
If the typical symptoms develop and persist then a doctor can usually be confident that you have GAD. Current guidelines from the International Classification of Diseases tenth edition (ICD-10) suggest the diagnosis should be made if you have had your symptoms for six months but it is sometimes difficult to tell if you have GAD, panic disorder, depression, or a mixture of these conditions.
Some of the physical symptoms of anxiety can be caused by physical problems which can be confused with anxiety. So, sometimes other conditions may need to be ruled out. For example:
- Drinking a lot of caffeine (in tea, coffee and cola).
- The side-effect of some prescribed medicines. For example, selective serotonin reuptake inhibitor (SSRI) antidepressants.
- An overactive thyroid gland.
- Taking some street drugs.
- Certain heart conditions which cause the sensation of having a 'thumping heart' (palpitations) - uncommon.
- Low blood sugar level (rare).
- Tumours which make too much adrenaline (epinephrine) and other similar hormones (very rare).
What are the treatment options?
TALKING TREATMENTS AND OTHER TREATMENTS NOT USING MEDICATION
Cognitive behavioural therapy (CBT) and GAD
Cognitive behavioural therapy is a type of therapy that deals with your current thought processes and/or behaviours and aims to change them through creating strategies to deal with negative patterns, which may help you to manage generalised anxiety disorder more effectively.
In particular, counselling that focuses on problem-solving skills may help some people.
Anxiety management courses
These may be an option if they are available in your area. Some people prefer to be in a group course rather than have individual therapy or counselling. The courses may include learning how to relax, problem-solving skills, coping strategies and group support.
You can get leaflets, books, CDs, DVDs and downloads on relaxation and combating stress. They teach simple deep-breathing techniques and other measures to relieve stress and help you to relax. They may ease anxiety symptoms. There are also websites offering online self-help advice, treatment and support on the internet. See separate leaflet called Stress and Tips on How to Avoid It.
MEDICATION FOR GENERALISED ANXIETY DISORDER
Antidepressants are not only useful for depression but also for GAD. Studies suggest that over half the people with GAD are helped by antidepressants. It's thought that they work by interfering with the way chemicals such as serotonin work within the brain. Antidepressants are particularly beneficial if you have the type of GAD in which anxiety is mixed with depression. SSRI antidepressants are commonly used and escitalopram and paroxetine are both licensed for this condition.
Benzodiazepines, such as diazepam, used to be the most commonly prescribed medicines for anxiety. They usually work well to ease symptoms. The problem is, they are addictive and can lose their effect if you take them for more than a few weeks. They may also make you drowsy. Therefore, they are not used much now for persistent anxiety conditions such as GAD. A short course of up to 2-4 weeks may be an option now and then to help you over a particularly bad spell.
Buspirone is another option to treat GAD. It is an anti-anxiety medicine but different to the benzodiazepines. It is not clear how it works but it is known to affect serotonin, a brain chemical which may be involved in causing anxiety symptoms. It causes less drowsiness than benzodiazepines.
Pregabalin is a medicine used for several conditions (principally epilepsy). It has been found useful in GAD. It tends to be considered for GAD if the other treatments mentioned above have been unhelpful.
Beta-blockers, such as propranolol, tend to work better in short-lived (acute) anxiety rather than in GAD and so are not usually considered appropriate treatment here.
A combination of treatments
CBT plus an antidepressant medicine may work better in some cases than either treatment alone.
What is the outlook for generalised anxiety disorder?
Although GAD gets better in some people, in others it tends to come and go. Some people need to take medicines for a long time but are otherwise able to lead perfectly normal lives.
Symptoms may flare up and become worse for a while during periods of major life stresses. For example, if you lose your job or split up with your partner.
People with GAD are more likely than average to smoke heavily, drink too much alcohol and take street drugs. Each of these things may ease anxiety symptoms in the short term. However, addiction to nicotine, alcohol or drugs makes things worse in the long term and can greatly affect your general health and well-being.
Further reading & references
- Social anxiety disorder: recognition assessment and treatment; NICE Clinical Guideline (May 2013)
- Anxiety disorders; NICE Quality Standards, Feb 2014
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Laurence Knott
Dr John Cox