Anxiety

Anatomy or system affected: Heart, nervous system, psychic-emotional system, skin

Definition: Heightened fear or tension that causes psychological and physical distress; the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recognizes several types of anxiety disorders, which can be successfully treated through counseling or with medications.

Causes and Symptoms

Anxiety is a subjective state of fear, apprehension, or tension. In the face of a naturally fearful, stressful, or threatening situation, anxiety is a normal and understandable reaction. When anxiety occurs without obvious provocation or is excessive, however, anxiety may be said to be abnormal or pathological (existing in a disease state). Normal anxiety is useful because it provides an alerting signal and improves physical and mental performance. Excessive anxiety results in a deterioration in performance and in emotional and physical discomfort.

There are several forms of pathological anxiety, known collectively as the anxiety disorders. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders(DSM-5), the anxiety disorders include separation anxiety disorder, selective mutism, specific phobias, social anxiety disorders (formerly known as social phobia), panic disorder, panic attack, agoraphobia, and generalized anxiety disorder as well as substance- or medication-induced anxiety disorder, anxiety disorder due to another medical condition, other specified anxiety disorder, and unspecified anxiety disorder. Anxiety disorders are distinguished from one another by characteristic clusters of symptoms. According to the Anxiety and Depression Association of America (ADAA) in early 2021, forty million adults eighteen and older in the United States are affected by anxiety disorders every year.

In previous editions of the DSM, posttraumatic stress disorder (PTSD) and adjustment disorder with anxious mood were categorized as anxiety disorders, but PTSD and adjustment disorders are now recognized as trauma- and stressor-related disorders. Obsessive-compulsive disorder (OCD) was also categorized as an anxiety disorder in previous editions of the DSM, but the DSM-5 includes OCD in a new chapter, titled "Obsessive-Compulsive and Related Disorders," in light of the growing body of evidence indicating that OCD is distinct from the anxiety disorders and to reflect its relation to other disorders characterized by obsessive preoccupations and repetitive behaviors, such as body dysmorphic disorder, trichotillomania, hoarding disorder, and excoriation.

Generalized anxiety disorder is thought to be a biological form of anxiety disorder in which the individual inherits a habitually high level of tension or anxiety that may occur even when no threatening circumstances are present. Generally, these periods of anxiety occur in cycles that may last weeks to years. Generalized anxiety disorder is diagnosed when persistent anxiety and uncontrollable worries occur consistently for at least six months. According to the ADAA, in the United States, 3.1 percent of the population was affected by generalized anxiety disorder annually in 2021, and women were twice as likely as men to be affected.

Evidence suggests that generalized anxiety disorder may be related to abnormalities in common neurotransmitter receptor complexes found in many brain neurons, possibly resulting from abnormal serotonergic and noradrenergic neurotransmission. Other altered neurotransmitters thought to be involved in generalized anxiety disorder include gamma-aminobutyric acid (GABA) and dopamine. Generalized anxiety disorder has 32 percent heritability, suggesting a possible genetic basis that manifests with environmental influence. Adverse life events, including unemployment, disability, illness, grief, or physical or emotional trauma, represent significant risk factors for developing generalized anxiety disorder. An individual with generalized anxiety disorder has multiple pressing worries—for example, about their finances, relationships, job, health, or future prospects.

In 2021 the ADAA reported that 2.7 percent of the US population was affected by panic disorder each year, and the female-to-male ratio was 2:1. This disorder usually begins in late adolescence or early adulthood. Panic disorder is characterized by recurrent and unexpected attacks of intense fear or panic. Each discrete episode lasts about five to twenty minutes. These episodes are intensely frightening to the individual, who is usually convinced he or she is dying. Because people who suffer from panic attacks are often anxious about having another attack (secondary anxiety), they may avoid situations in which they fear an attack may occur, in which help would be unavailable, or in which they would be embarrassed if an attack occurred. This avoidance behavior may cause restricted activity and can lead to agoraphobia, the fear of leaving a safe zone in or around the home. Thus, agoraphobia (literally, “fear of the marketplace”) is often secondary to panic disorder.

Panic disorder appears to have a biological basis. In those people with panic disorder, panic attacks can often be induced by sodium lactate infusions, hyperventilation, exercise, or hypocalcemia (low blood calcium). Highly sophisticated scans show abnormal metabolic activity in the right parahippocampal region of the brain of individuals with panic disorder. The parahippocampal region, the area surrounding the hippocampus, is involved in emotions and is connected by fiber tracts to the locus ceruleus, a blue spot in the pons portion of the brain stem that is involved in arousal.

In addition to known biological triggers for panic attacks, emotional or psychological events may also cause an attack. To be diagnosed as having panic disorder, however, a person must experience attacks that arise without any apparent cause. The secondary anxiety and avoidance behavior often seen in these individuals result in difficulties in normal functioning. There is an increased incidence of suicide attempts in people with panic disorder. Risk factors for panic disorder include significant life stressors, a history of sexual or physical abuse in childhood, anxious temperament, and cigarette smoking.

A phobia is an abnormal fear of a particular object or situation. Simple phobias are fears of specific, identifiable triggers, such as heights, spiders, snakes, flying in an airplane, dogs, elevators, or the number thirteen. Social anxiety disorder (previously known as social phobia) is an exaggerated fear of being in social settings where the affected person fears he or she will be open to scrutiny by others. This fear may result in phobic avoidance of eating in public, attending church, joining a social club, or participating in other social events. Phobias often have a childhood onset.

In classic psychoanalytic theory, phobias were thought to be fears displaced from one object or situation to another. It was thought that this process of displacement took place unconsciously. Many psychologists now believe phobias are either exaggerations of normal fears or develop accidentally, without any symbolic meaning. For example, fear of elephants may arise if a young boy is accidentally separated from his parents at a zoo. While realizing he is alone, he notices the elephants. He may associate elephants with separation from his parents and fear elephants thereafter. However, there is no clear consensus on how phobias develop. Some researchers believe phobias may be due to a maladaptive activation of an evolutionarily defined fear pathway.

Selective mutism is an anxiety disorder that causes individuals who are normally capable of speaking to become unwilling or unable to speak in anxiety-producing situations. Selective mutism is often related to social anxiety disorder and separation anxiety disorder, and it typically has a childhood onset.

In addition to the anxiety disorders described, abnormal anxiety may be caused by a variety of drugs and medical illnesses. Common drugs involved in substance- or medication-induced anxiety include caffeine, alcohol, stimulants in cold preparations, nicotine, and many illicit drugs, including cocaine and amphetamines. Medical illnesses that may cause anxiety include thyroid disease, cancer, cardiac arrhythmias, heart failure, and schizophrenia.

Treatment and Therapy

When an individual has difficulty with anxiety and seeks professional help, the cause of the anxiety must be determined. Before the etiology can be determined, however, the professional must first determine if the patient has an anxiety disorder. People with anxiety disorders often complain primarily of physical symptoms that result from the anxiety. These symptoms may include motor tension (muscle tension, trembling, and fatigue) and autonomic hyperactivity (shortness of breath, palpitations, cold hands, dizziness, gastrointestinal upset, chills, and frequent urination).

When an anxiety disorder is suspected, effective treatment often depends on an accurate diagnosis of the type of anxiety disorder present. Accurate diagnosis requires both physical and psychological evaluations, as it is very important to rule out nonpsychiatric medical conditions causing anxiety.

Several types of psychotherapy can be used in the treatment of anxiety, including cognitive behavioral therapy (CBT), relaxation response training, mindfulness meditation training, or a combination of approaches. CBT components include exposure to or discussion of anxiety-producing stimuli and one's feelings as well as cognitive strategies to reduce the exaggerated perception of the threat and to manage arousal levels, such as breathing control. Patients with panic disorder can benefit from education about the nature of their panic attacks, assurance that they will not die from it, and coping methods to ride out attacks. This process avoids the development of secondary anxiety, which complicates the panic attack. Patients with phobias can be treated with systematic desensitization, in which they are taught relaxation techniques and are given graded exposure to the feared situation so that their fear lessens or disappears. Effective therapeutic approaches for the treatment of anxiety disorders include individual or group psychotherapy. Physical activity, particularly aerobic exercise and yoga, has been shown to improve anxiety symptoms.

A variety of medications can be prescribed for the treatment of anxiety disorders, including selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, and benzodiazepines.

Perspective and Prospects

Anxiety has been recognized since antiquity and was often attributed to magical or spiritual causes, such as demonic possession. Ancient myths provided explanations for fearful events in people’s lives. Pan, a mythological god of mischief, was thought to cause frightening noises in forests, especially at night; the term “panic” is derived from his name. An understanding of the causes of panic and other anxiety disorders has evolved over the years.

Sigmund Freud (1856–1939) distinguished anxiety from fear. He considered fear to be an expected response to a specific, identifiable trigger, whereas anxiety was a similar emotional state without an identifiable trigger. He postulated that anxiety resulted from unconscious, forbidden wishes that conflicted with what the person believed was acceptable. The anxiety that resulted from this mental conflict was called an “anxiety neurosis” and was thought to result in a variety of psychological and physical symptoms. Psychoanalysis was developed to uncover these hidden conflicts and to allow the anxiety to be released.

Freud’s theories about anxiety are no longer clinically accepted. Many psychiatrists now believe that many instances of anxiety disorders have a biological cause and that they are more neurological diseases than psychological ones. This is particularly true of generalized anxiety disorder and panic disorder. It is recognized that anxiety can also be triggered by drugs (legal and illicit) and a variety of medical illnesses.

Psychological causes of anxiety are also recognized. Unlike Freud’s conflict theory of anxiety, most modern psychiatrists consider personality factors, life experiences, and views of the world to be the relevant psychological factors in the development of anxiety disorders. Although anxiety disorders have a high prevalence compared to other mental disorders, the therapeutic and pharmacological treatments for anxiety are well established, highly effective, and long lasting.

While concerns over mental health in the United States were already high by 2020, the declaration of the global coronavirus disease 2019 (COVID-19) pandemic in March of that year led mental health experts to monitor relevant reports and statistics of psychological and psychiatric disorders and symptoms at an even greater level. The public health crisis led to widespread social and economic upheaval as lockdowns and distancing measures were implemented in an effort to slow and contain the spread of the highly transmissible and deadly coronavirus causing COVID-19. As the pandemic stretched into 2021 with a persistently high rate of cases in many countries, according to a 2021 report from the nonprofit Mental Health America, in September 2020 eight out of ten people who took part in anxiety screening scored with moderate to severe symptoms. In April 2021, the Centers for Disease Control and Prevention reported that between August 2020 and February 2021, 41.5 percent of adults had symptoms of an anxiety or depressive disorder in the previous seven days. Furthermore, a 2021 meta-analytical study published in The Lancet found a global 25.6 percent increase in anxiety disorders since the beginning of the COVID-19 pandemic. Due to the extent and length of the disease threat, analysts also focused on potential correlations between experiencing the pandemic and development or increasing of agoraphobia as much of public interaction, especially in terms of work, education, and entertainment, was greatly reduced. In part to address elevated as well as newly reported cases of anxiety during the pandemic, health care systems also adapted to provide virtual options for assessment and therapy.

As the number of active Covid-19 cases peaked and previous activities have resumed, in 2023 the impacts of the pandemic have continued to linger, particularly among younger segments of the US adult population. Data reported by the US Census Bureau suggests that 50% of Americans ages 18-24 responded having symptoms of anxiety and depression. Although a third of all adults indicated similar conditions, reporting of anxiety and depression was the most prevalent among the youngest population grouping. For example, it more than doubled reports among respondents sixty-five years of age and older (20.1%). Notable is that older members of the population are deemed more at medical risk to Covid-19. Researchers have hypothesized that mental health challenges being experienced by those who reached young adulthood during the pandemic were impacted by social distancing measures such as school closures and remote work.

This increase in Covid-19-related anxiety levels has of course not just been confined to the United States. In 2022, the World Health Organization (WHO) reported that anxiety and depression had increased by 25% on a global basis. Similar to the US Census reporting, social isolation was identified as a primary cause. While the ramifications of the pandemic continue to be assessed, a common call to action has been the need for more attention to the area of mental health monitoring and evaluation.

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