What is anxiety?

Causes and Symptoms

Anxiety is a subjective state of fear, apprehension, or tension. In the face of a
naturally fearful 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. The anxiety
disorders are distinguished from one another by characteristic clusters of
symptoms. The estimated lifetime prevalence of any anxiety disorder is
approximately 15 percent, while the twelve-month prevalence rate is approximately
10 percent. Women are 60 percent more likely than men to experience an anxiety
disorder over their lifetime.

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 that indicates 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.
In the United States, the lifetime prevalence of generalized anxiety disorder is
approximately 5 percent, and women are 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, or a history of physical or emotional
trauma, represent significant risk factors for developing generalized anxiety
disorder.

Panic disorder has a lifetime prevalence of about 5 percent in the United States,
and the female-to-male ratio is 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 (so-called
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; up to one in five
have reported a suicide attempt at some time. 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, snakes, flying in an
airplane, 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 that phobias
are either exaggerations of normal fears or that they develop accidentally,
without any symbolic meaning. For example, fear of elephants may arise if a young
boy at a zoo is accidentally separated from his parents. At the same time that he
realizes he is alone, he notices the elephants. He may then associate elephants
with separation from his parents and fear elephants thereafter. However, there is
no clear consensus on how phobias develop. Some researchers believe that 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,
heart failure, cardiac arrhythmias, cancer, 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. 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.

In addition, several types of psychotherapy can be used. For example, patients
with panic disorder can be educated about the nature of their panic attacks,
reassured that they will not die from it, and taught 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. Other effective therapeutic approaches for the
treatment of anxiety disorders include individual or group psychotherapy and
cognitive-behavioral therapy. Physical activity, particularly aerobic exercise and
yoga, have also been shown to improve anxiety symptoms.

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 primarily 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 with 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 pharmacological and therapeutic
treatments for anxiety are well established, highly effective, and long
lasting.

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