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The Nature of Anxiety

Anxiety disorders are the most common mental health conditions in the United States, impacting over 40 million American adults every year. For some people, anxiety disorders are like a subtle background alarm that never shuts off, always keeping them on edge and coloring their daily experiences in ways they try to keep hidden. For others, anxiety can be much more public and debilitating, interfering with their ability to maintain jobs and relationships.

Where Anxiety Comes From

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While many consider anxiety to be a modern problem, it has roots in the most primal human emotions. Not only have people recorded feelings of anxiety in their stories for hundreds of years, it’s not even limited to the human experience. Many animals can exhibit anxious states or even anxious temperaments.

One way to think about anxiety is that it is a maladaptive extension of an adaptive trait. Fear is what motivates people or animals to flee from a threat or fight back. Anxiety is persistent fear that lingers even when there is no immediate danger. People worry about problems that don’t yet exist in the same way prey animals anxiously scan their environments for predators. While animals benefit from this constant vigilance, most people no longer live in circumstances that require it. More significantly, anxiety rarely helps people respond more effectively to danger. More often, it causes them to freeze or have maladaptive reactions that cause further harm.

Biological Causes

Anxiety is driven by a few different systems in the brain. The amygdala, the brain region responsible for emotional arousal, and the hippocampus, the part of the brain responsible for the formation and retrieval of memories, function differently in people who have chronic anxiety. People who have anxiety disorders retrieve fear-laden memories more often and remain in a state of negative emotional arousal longer than other people.

The sympathetic nervous system (SNS) also plays a role in the development of anxiety. The SNS is the network of neurons and nerves that activate the fight-or-flight response. When the SNS is active, blood pressure and pulse rate rise, lung passages expand, and key blood vessels dilate to send more oxygen-rich blood to skeletal muscles. This gives people the extra energy and power they need to fight, run, or otherwise spring into action in response to a threat.

Most of the time, this response fades after danger has been averted or a stressful problem has been solved. However, in people with anxiety disorders, the SNS remains active even in the absence of an immediate stressor. For people with generalized anxiety disorder, elements of the SNS are constantly active at a low but steady level. For people with panic disorder, the full suite of SNS responses can be activated by minor or nonexistent threats. Surging adrenaline and racing heart rates often send people to emergency departments seeking treatment for heart attacks when they are actually experiencing the SNS response to psychological panic.

Environmental Causes

People who have anxiety disorders often grow up in stressful home environments or are born with temperaments that make them more sensitive to stress. Chronic stress trains the brain to recall frightening events more often and to amplify fearful responses, often leading to anxiety. Different kinds of stressors are linked with different anxiety disorders.

People with social anxiety disorder often had negative social experiences early in their lives, such as being bullied or emotionally abused by their parents. People with generalized anxiety often grew up in unpredictable or chaotic home environments or with long-term stressors like parents with chronic illnesses. Similar environmental circumstances can cause panic disorder. Single episodes of severe trauma, like a violent assault or a natural disaster, can trigger post-traumatic stress disorder (PTSD) or acute stress disorder.

The common denominator among environmental causes of anxiety disorders is that they make people feel unsafe.

Anxiety and Other Disorders

Given that anxiety is the most common mental health condition in America, it rarely occurs in isolation. Sometimes, it can follow from other primary mental health disorders like mood or personality disorders, while in other cases it can aggravate or trigger secondary mental health conditions like depression. The chronic stress that comes with anxiety disorders can also cause or worsen a wide range of medical conditions.

Mood Disorders

It’s not unusual for people with anxiety to also have a mood disorder. Co-occurring anxiety and depressive disorders are especially common. In fact, half of people who seek treatment for depression also have an anxiety disorder. Research also shows that people with anxiety disorders have a very high likelihood of developing depression in the following year.

While either disorder can come first, people with anxiety disorders have many risk factors for depression. The constant state of alert that comes with being anxious can deplete energy and affect the balance of chemicals in the brain in a way that makes people more vulnerable to mood disorders. In addition, the constant worry that often comes with anxiety disorders can lead to rumination on fearful or hopeless themes that can trigger or aggravate depressive thoughts.

Personality Disorders

Anxious depression is especially common in people who have comorbid personality disorders. Research shows that people with anxiety disorders have higher rates of personality disorders than the general population, especially Cluster C personality disorders. This makes sense, as avoidant, dependent, and obsessive-compulsive personality disorders are often called the “anxious cluster” of personality disorders and are linked with anxious temperaments.

It can be difficult to distinguish the symptoms of these personality disorders from anxiety disorders. It’s hard to tell obsessive-compulsive personality disorder (OCPD) and obsessive-compulsive disorder (OCD) apart, while avoidant personality disorder resembles social anxiety disorder and dependent personality disorder is similar to separation anxiety disorder.

There are a few ways to tell these different kinds of disorders apart. The symptoms of anxiety disorders are usually more acute but are often easier to treat than symptoms of personality disorders. The symptoms of personality disorders are subtler but also more ingrained, to the extent they’re often called “traits” rather than symptoms. People identify with them more and are less likely to see them as indicative of a disorder.

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Anxiety disorders also commonly co-occur with borderline personality disorder (BPD). A national survey showed that nearly 60 percent of people with borderline personality disorder have a comorbid anxiety disorder. Having borderline personality disorder significantly increases a person’s risk of self-harm and suicide and having a secondary anxiety disorder even further increases this risk.

Medical Disorders

Many health problems can be caused or aggravated by chronic stress. People who have anxiety disorders are constantly on alert in ways that increase the circulation of the stress hormone cortisol. Research shows that when people have chronically elevated levels of cortisol, their immune systems don’t work as well and they get sick more often. Cortisol also inhibits insulin production, increasing the risk of diabetes and other problems with blood sugar.

Anxiety, chronic stress, and elevated cortisol increase the risk of high blood pressure and heart disease. They are also implicated in many gastrointestinal problems including gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS). High rates of stress and anxiety can also contribute to chronic headaches, including severe and debilitating migraines.

Types of Anxiety Disorders

The primary reference guide used to diagnose anxiety disorders is the Diagnostic and Statistical Manual of Mental Disorders (DSM), currently in its fifth edition (DSM-5). The following anxiety disorder descriptions and criteria are all taken from the DSM-5.

Separation Anxiety Disorder

People with separation anxiety disorder fear being separated from people to whom they are emotionally or otherwise attached. To be diagnosed with separation anxiety disorder, a person must have three or more of eight symptoms of anxious distress caused by separation or fear of separation. These include obsessive worries about separation, refusal to leave home, physical symptoms like nausea, and nightmares about being left alone. These symptoms should be persistent, lasting at least one month in children and six months or more in adults.

Selective Mutism

The DSM defines selective mutism as “consistent failure to speak in specific social situations in which there is an expectation for speaking despite speaking in other situations.” This episodic silence should occur for at least one month, interfere with school or work performance, not be due to a lack of fluency in a given language, and not be better explained by another disorder like schizophrenia or autism spectrum disorder.

Specific Phobia

According to the DSM, a specific phobia is “marked fear or anxiety about a specific object or situation.” People with specific phobias avoid the subject of their phobia altogether or endure exposure to it with extreme distress. The fear they feel is out of proportion to the actual threat posed by what they fear. For example, a person with a spider phobia will react with the same degree of fear regardless of whether a particular spider is poisonous or close enough to bite. Phobias are persistent and are usually only diagnosed if they last for six months or longer.

Social Phobia (Social Anxiety Disorder)

People are diagnosed with social phobia or social anxiety disorder when they experience a characteristic pattern of fear of or anxiety about social situations that is out of proportion to the actual potential consequences of social judgment. People with social anxiety fear being scrutinized and rejected by others, especially for making mistakes or exposing personal weaknesses. They either avoid situations that risk humiliation or endure them with extreme anxiety. They may eventually start staying home and avoiding social encounters altogether.

People who experience these symptoms in the context of speaking or performing in public are given a more specific diagnosis of performance-only social anxiety disorder. It should be noted that this is not the same as simple anxiety about speaking in public, which is the most common fear in America. Performance-only SAD is a full psychiatric disorder with significant social and personal impacts. People with this condition don’t just get jitters before speaking but are likely to avoid it altogether, even if it means missing important social or professional opportunities.

Panic Disorder

Panic disorder is the clinical term for recurrent panic attacks, which the DSM defines as “abrupt surges of intense fear or intense discomfort that reach a peak within minutes.” To be diagnosed with a panic attack, a person must experience at least four of the following:

Heart palpitations or increased heart rate
Increased sweating
Trembling or shaking
Shortness of breath or sensations of smothering or choking
Chest pain or discomfort
Nausea or stomach pain
Feeling dizzy, light-headed, or faint
Chills or hot flashes
Numbness or tingling sensations
Derealization (feelings that the world is unreal)
Depersonalization (extreme detachment from the sense of self)
Fear of losing control or “going crazy”
Fear of dying

A person with panic disorder fears additional panic attacks and their potential consequences. They often make maladaptive behavioral changes to avoid panic. For example, they might withdraw socially or regularly pursue unnecessary medical evaluation or intervention.

Agoraphobia

Agoraphobia is the fear of being outdoors. People who have agoraphobia typically experience fear in response to one or more of the following five situations:

Using public transportation
Being in open spaces like parking lots or on bridges
Being in enclosed spaces like shops or movie theaters
Standing in line or otherwise being enclosed by a crowd
Being away from home alone

A person with agoraphobia will avoid these situations out of fear that they will be unable to escape if there is danger or get help if they start to panic. They will usually either avoid these situations, engage in them only when with they are with a close companion, or endure them with great distress. This fear must be out of proportion to the real risk these situations pose and must persist for six months or more.

Generalized Anxiety Disorder

Generalized anxiety disorder is defined by the DSM as “excessive anxiety and worry occurring more days than not for at least six months about a number of events or activities.” This worry must be difficult to control and associated with three or more of the following symptoms:

Feeling restless or “on edge”
Being easily fatigued
Having difficulty concentrating
Feeling irritable
Experiencing muscle tension
Having sleep disturbances

These symptoms must cause clinically significant distress or functional impairment and not be better explained by the effects of a substance or a medical condition.

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Substance-Induced Anxiety Disorder

The DSM uses the same criteria for substance-induced anxiety disorders whether they occur in response to recreational drug use or to taking medications prescribed by a physician. To be diagnosed with a substance-induced anxiety disorder, a person must experience symptoms of anxiety or panic attacks while they are under the influence of a substance or experiencing its withdrawal effects. The substance or medication must be capable of causing these symptoms.

These symptoms should not be better explained by an anxiety disorder that is not substance-induced. If symptoms persist for one month or more after the active intoxication or withdrawal period, they are more likely to signal an underlying anxiety disorder than substance-induced anxiety. A diagnosis of substance-induced anxiety disorder is often used only for purposes of clarification, as these disorders rarely require a long course of treatment. Usually, they only require a period of supervision until symptoms dissipate on their own.

Anxiety Due to a General Medical Condition

The criteria for this diagnosis are similar to the criteria for substance-induced anxiety disorders. To be diagnosed with anxiety due to a general medical condition, a person must have panic attacks or anxiety and a medical condition that can cause these symptoms. Anxiety should not be better explained by another disorder or occur solely in the course of an episode of delirium.

Obsessive-Compulsive Disorder

To be diagnosed with OCD, a person must experience obsessions, or “recurrent and persistent thoughts, urges, or images that are experienced… as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.” People with OCD try to ignore or suppress these obsessions or neutralize them with compulsions.

The DSM defines compulsions as “repetitive behaviors or mental acts the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.” They are “aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.” Obsessions and compulsions are time consuming, distressing, and demanding of mental or physical resources, often causing significant functional impairments.

Disorders related to OCD that also feature anxiety-driven symptoms and behaviors include body dysmorphic disorder, in which a person engages in obsessions or compulsions related to a distorted body image. Hoarding, hair-pulling, and skin picking disorders are also listed in the DSM as OCD- related disorders, as well as substance-induced OCD and OCD due to a medical condition.

Post-Traumatic Stress Disorder

To be diagnosed with PTSD, a person must have been exposed to “actual or threatened death, serious injury or sexual violence” either directly, as a witness, or as a third party who was told or shown details or images of a traumatic event. They must have one or more symptoms from each of the following categories:

Intrusive symptoms
Avoidance symptoms
Cognitive and mood symptoms
Alterations in arousal and reactivity

Intrusive symptoms include flashbacks, nightmares, and unwanted memories. Avoidance symptoms include avoiding certain environments or activities to prevent triggering traumatic memories. Cognitive and mood symptoms include dissociation, irrational guilt, and blunted emotions. Arousal symptoms include hypervigilance and an exaggerated startle response.

Other disorders listed as trauma-and-stressor-related disorders in the DSM-5 include acute stress disorder, a slightly milder version of PTSD that requires a person to have suffered a trauma and to have at least five symptoms from any of the above four listed categories.

Anxiety Disorder Not Otherwise Specified

This term derives from the DSM-IV and has been separated into “Other Specified Anxiety Disorder” and “Unspecified Anxiety Disorder” in DSM-5. Any of these three disorders can be diagnosed when someone has a pattern of recurrent anxiety symptoms that do not fit criteria for any other anxiety disorders listed in the DSM.

Anxiety and Substance Abuse

Research shows that about 15 percent of people with anxiety disorders have co-occurring substance use disorders. There are two different pathways to these dual disorders. Chronic substance use can cause changes in brain chemistry and chronic life stressors that contribute to the development of anxiety disorders. Conversely, people can start using substances to try to alleviate anxiety, then use them in greater amounts or over greater periods of time than intended, leading to addiction or other problems related to substance use.

Nearly all substances that people use recreationally can cause anxiety, either immediately or over time. Stimulants work by activating the sympathetic nervous system, which is already overactive in people with anxiety disorders. Excessive use of stimulants can cause panic attacks, paranoia, and even psychosis, even when people do not already have an underlying thought or anxiety disorder. Many substance-induced anxiety disorders and emergency room visits follow from stimulant use. While many people initially experience it as calming, marijuana can also cause similar episodes of paranoia and panic in sensitive individuals.

Opioids and alcohol are both often used for their soothing properties, though they can also make people feel disinhibited and more outgoing and social. In fact, alcohol’s ability to disrupt self-aware and self-critical thought is one of its most appealing qualities for people with anxiety disorders. Unfortunately, the price people pay for the calming effects of these substances is long-term discomfort.

As the brain adapts to regular alcohol or opioid use, it produces less of its own natural pain-killing and anxiety-reducing chemicals. This means that as tolerance develops and these substances lose their power to make people feel better, the brain also produces fewer endorphins and less serotonin, slowly losing its capacity to manage discomfort. This can cause hyperalgesia, or increased sensitivity to pain and stress. Long-term alcohol and opioid use often causes people to feel more uncomfortable than they did before they started using substances.

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Anxiety Treatment

There are many different approaches to the treatment of anxiety. Medication can be useful but is not necessary to successfully treat anxiety disorders. Cognitive symptoms that drive anxiety like worry and catastrophic thinking can be addressed with psychotherapy. Physical stress can be managed through complementary therapies and lifestyle changes.

Medication for Anxiety

Sedatives are some of the best-known anti-anxiety medications, especially benzodiazepines like alprazolam (Xanax), clonazepam (Klonopin), lorazepam (Ativan), and diazepam (Valium). These powerful sedatives effectively neutralize the activity of the sympathetic nervous system and slow the firing of neurons in the brain, causing symptoms of anxiety to quickly dissipate.

However, benzodiazepines are highly addictive and carry severe risks of overdose and dangerous interactions with other medications. When combined with alcohol or other drugs, they can trigger blackouts, or episodes of dissociative amnesia during which people are more prone to accidental injury and high-risk behavior with negative legal or social consequences.

Selective serotonin reuptake inhibitors (SSRIs) may be a better option for people with co-occurring substance use disorders or other individual factors that make benzodiazepines risky to take. These medications were originally formulated to treat depression but have also been proven to effectively treat a wide range of anxiety disorders. These five SSRIs are frequently prescribed for anxiety:

Paroxetine (Paxil)
Citalopram (Celexa)
Escitalopram (Lexapro)
Sertraline (Zoloft)
Fluoxetine (Prozac)

These medications increase the availability of serotonin, helping the brain rebuild connections and create new nerve cells in key regions. This can help people with anxious temperaments recover a fundamental sense of calm. Several studies have shown that paroxetine is an especially effective medication for many anxiety disorders, including social anxiety disorder.

Psychotherapy for Anxiety

Psychotherapy involves talking to a therapist about psychological problems or symptoms with the goal of gaining insight into their origin or developing strategies to alleviate them. Research suggests that a strong therapeutic relationship is more important than the type of therapy a person receives.

However, some approaches may be more useful for people with anxiety disorders. Cognitive behavioral therapy (CBT) is one of the most widely researched and evidence-based therapeutic interventions for anxiety, depression, and many other mental health conditions. It is effective because it targets cognitive symptoms like worry, helping people immediately identify and counter irrational or distorted thought patterns that promote or prolong anxiety.

Many other therapeutic methods can be effective in treating anxiety. Traditional Freudian or Jungian depth therapy can help people explore the deep roots of their anxiety, like childhood experiences that made them feel unsafe. Exposure therapy is a traditional intervention for specific phobias, helping people overcome their fears by slowly exposing them to approximations of what they fear until they can confront the real thing.

Some therapeutic interventions are especially useful for people with histories of trauma. Dialectical behavioral therapy (DBT) is a variation of CBT specifically developed for people with trauma-related and personality disorders. Its nonjudgmental approach can help people engage in therapy more readily and learn how to regulate their emotional responses. Eye movement desensitization and reprocessing therapy (EMDR) is an increasingly popular intervention for trauma-related disorders that can help people explore traumatic memories safely and reprogram the way they respond to them.

Complementary Therapies for Anxiety

Given that it arises from primal responses to fear, many simple and natural interventions that calm the body and mind can help reduce anxiety. Aerobic exercise capitalizes on the activation of the sympathetic nervous system, channeling excess energy into healthy activity that promotes the release of natural stress-alleviating endorphins. Even gentle exercise like slow-paced stretching or yoga can promote the release of naturally calming neurochemicals. Focusing on immediate bodily sensations and the present moment can help counter anxious rumination. Grounding techniques like taking an inventory of objects in a particular room or doing a body scan can have a similar effect, as can meditation and mindfulness practices.

Dietary changes can also help reduce anxiety. Limiting even mild stimulants like caffeine can reduce sympathetic nervous system activity. Foods that reduce inflammation like yogurt and other fermented foods can also help reduce anxiety and related gastrointestinal problems. Walking in nature may be an especially effective way to induce calm and a sense of wonder. Art therapy and unstructured creative endeavors can channel or soothe anxiety. Interacting with animals, especially pets, can help people feel grounded, loved, and safe.

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Conclusion

Anxiety is a maladaptive mutation of the fear response that keeps people in a state of heightened stress and discomfort even after the threat has passed. It is driven by activation of the sympathetic nervous system and regions of the brain responsible for emotional arousal and memory. Chronic anxiety can take the form of many distinct anxiety disorders including generalized anxiety disorder, panic disorder, social anxiety, PTSD, and OCD.

People with anxiety disorders often have additional behavioral health disorders including depression, personality disorders, and substance use disorders. Substance use can provide immediate relief of anxiety but ultimately makes it worse by altering the balance of natural brain chemicals. Fortunately, anxiety can respond to many different interventions including medication, psychotherapy, and lifestyle changes like diet, meditation, and exercise.

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