Yes, anxiety can temporarily get worse before it gets better, and this happens through two distinct paths: starting medication and starting therapy. About 15% of people who begin taking SSRIs experience a noticeable increase in anxiety during the first two weeks of treatment. In therapy, particularly approaches that involve confronting fears directly, short-term spikes in distress are a built-in part of the process. Understanding why this happens, how long it lasts, and what crosses the line from “normal adjustment” to “something’s wrong” can make the difference between pushing through to relief and abandoning a treatment that would have worked.
Why SSRIs Can Increase Anxiety at First
SSRIs work by changing the balance of serotonin activity in your brain, but that shift doesn’t happen cleanly overnight. In the first days and weeks, your brain is adjusting to a new chemical environment, and that adjustment period can produce what’s sometimes called an activating effect: restlessness, jitteriness, heightened nervousness, and trouble sleeping. Your brain is essentially recalibrating, and during that window, some of the same systems that regulate anxiety are being nudged in unfamiliar directions.
In a study of 201 patients starting SSRIs, roughly half reported improvement in anxiety within the first two weeks, about 37% noticed little change either way, and 15% experienced a measurable worsening of their anxiety symptoms. So while the majority of people either improve quickly or hold steady, a meaningful minority feels noticeably worse before the medication begins doing its job. This early worsening typically peaks within the first one to two weeks and fades as the medication reaches its full therapeutic effect, which generally takes four to six weeks.
The activating effect is more common at higher starting doses, which is why many prescribers begin with a lower dose and increase gradually. If you’re in that 15% who feel worse initially, it doesn’t necessarily mean the medication is wrong for you. It means your brain is reacting strongly to the adjustment period.
Why Therapy Feels Harder Before It Feels Easier
If you’re in cognitive behavioral therapy or any approach that involves exposure, the entire method is built on temporarily increasing your discomfort. The logic is straightforward: to teach your brain that something isn’t actually dangerous, you have to face it while anxious and stay with it long enough for the anxiety to naturally decrease. That first encounter with a feared situation, whether it’s a social setting, a crowded store, or a difficult memory, almost always produces a spike in distress that feels like your anxiety is getting worse.
It isn’t getting worse in a clinical sense. Your baseline anxiety level hasn’t increased. What’s changed is that you’re no longer avoiding the things that trigger it, so you’re feeling the full weight of anxiety you were previously managing through avoidance. Over repeated exposures, your brain forms new associations. The feared situation starts to feel less threatening, and the spike gets smaller each time. But that first phase, sometimes lasting several sessions, can feel genuinely terrible.
Research on trauma-focused therapy in adolescents offers an interesting window into what’s happening in the brain during this process. Girls who responded best to therapy had brains that reacted strongly to genuine threats but stayed calm in response to neutral situations. Their fear response was well-calibrated: it fired when appropriate and stayed quiet when it wasn’t needed. Those who struggled more in therapy showed heightened brain reactivity to both threatening and non-threatening situations, suggesting their nervous systems had a harder time distinguishing safety from danger. This distinction matters because it suggests that the ability to eventually learn “this is safe” is central to why therapy works, and that learning process takes time and discomfort.
The Timeline for Feeling Better
For medication, the rough timeline looks like this: side effects, including increased anxiety, tend to peak in week one or two. By weeks three and four, those effects are usually fading. The actual therapeutic benefit, the part where you feel meaningfully less anxious than you did before starting, typically arrives between weeks four and eight. Some people notice improvement sooner, and some medications take longer, but that four-to-eight-week window is the standard expectation.
For therapy, the timeline depends heavily on the type of anxiety and the approach being used. Exposure-based therapy for specific phobias can produce significant improvement in as few as one to five sessions. Generalized anxiety, social anxiety, and panic disorder typically require 12 to 20 sessions, with many people noticing the sharpest discomfort in the early and middle sessions when they’re actively confronting their most difficult triggers. The back half of treatment often feels dramatically easier as the skills become more automatic and the feared situations lose their charge.
If you’re doing both therapy and medication simultaneously, the timelines can overlap in your favor. The medication begins to lower your baseline anxiety right around the time therapy is asking you to do the hardest work.
Normal Adjustment vs. Something Worth Flagging
The tricky part is knowing when a temporary increase in anxiety is part of the process and when it’s a sign that something needs to change. A few markers can help you tell the difference.
Normal adjustment on medication looks like: mild to moderate increases in nervousness, some trouble sleeping, feeling “wired” or jittery, and perhaps some nausea or headaches. These effects are uncomfortable but manageable, and they either hold steady or begin improving after the first week or two.
Signs that warrant a call to your prescriber include: anxiety that is significantly worse than it was before you started the medication and continues escalating past the two-week mark, panic attacks that are new or more frequent than before, severe insomnia that isn’t improving, or any thoughts of self-harm. The FDA recommends close monitoring during the initial weeks of treatment, with particular attention to agitation, irritability, and unusual behavioral changes. This applies especially to children and adolescents, but the principle holds for adults too.
In therapy, normal discomfort looks like: feeling drained after sessions, having a rough day or two after a particularly intense exposure, and occasionally feeling like your anxiety is more “present” because you’re paying closer attention to it. What’s not expected is a sustained increase in your day-to-day functioning problems, persistent new symptoms that weren’t there before, or feeling so overwhelmed that you can’t engage with the exercises between sessions. A good therapist will check in about this regularly, but you shouldn’t wait to be asked if something feels off.
What Helps During the Hard Part
If you’re in the “worse before better” phase, a few practical things can make it more tolerable. On medication, staying on a consistent sleep schedule matters more than usual because SSRIs can disrupt sleep patterns during the adjustment period. Cutting back on caffeine, even temporarily, reduces the jitteriness that stacks on top of the medication’s activating effect. Gentle exercise helps burn off some of the restless energy that comes with the early weeks.
In therapy, the single most important thing is not to skip sessions when the work gets hard. Avoidance is the engine that keeps anxiety running, and dropping out of therapy during the most uncomfortable phase is essentially hitting the reset button on your progress. If a particular exposure felt overwhelming, tell your therapist so they can adjust the pace, but keep showing up.
Tracking your symptoms can also be surprisingly useful during this period. Anxiety has a way of distorting your perception of time and progress. When you’re in the thick of it, it’s easy to feel like things have been getting worse for weeks when the actual data shows a spike followed by gradual improvement. A simple daily rating, even just a number from 1 to 10, gives you something concrete to look back on when your anxious brain is telling you nothing is working.