Anxiety is a multisystem response to a perceived threat or danger. It reflects a combination of biochemical changes in the body, the patient's personal history and memory, and the social situation. As far as we know, anxiety is a uniquely human experience. Other animals clearly know fear, but human anxiety involves an ability, to use memory and imagination to move backward and forward in time, that animals do not appear to have. The anxiety that occurs in posttraumatic syndromes indicates that human memory is a much more complicated mental function than animal memory. Moreover, a large portion of human anxiety is produced by anticipation of future events. Without a sense of personal continuity over time, people would not have the "raw materials" of anxiety.
It is important to distinguish between anxiety as a feeling or experience, and an anxiety disorder as a psychiatric diagnosis. A person may feel anxious without having an anxiety disorder. In addition, a person facing a clear and present danger or a realistic fear is not usually considered to be in a state of anxiety. In addition, anxiety frequently occurs as a symptom in other categories of psychiatric disturbance.
Although anxiety is a commonplace experience that everyone has from time to time, it is difficult to describe concretely because it has so many different potential causes and degrees of intensity. Doctors sometimes categorize anxiety as an emotion or an affect depending on whether it is being described by the person having it (emotion) or by an outside observer (affect). The word emotion is generally used for the biochemical changes and feeling state that underlie a person's internal sense of anxiety. Affect is used to describe the person's emotional state from an observer's perspective. If a doctor says that a patient has an anxious affect, he or she means that the patient appears nervous or anxious, or responds to others in an anxious way (for example, the individual is shaky, tremulous, etc.).
— An observed emotional expression or response. In some situations, anxiety would be considered an inappropriate affect.
— A type of medication that helps to relieve anxiety.
Autonomic nervous system (ANS)
— The part of the nervous system that supplies nerve endings in the blood vessels, heart, intestines, glands, and smooth muscles, and governs their involuntary functioning. The autonomic nervous system is responsible for the biochemical changes involved in experiences of anxiety.
— A ductless gland, such as the pituitary, thyroid, or adrenal gland, that secretes its products directly into the blood or lymph.
— A state or condition of muscular and emotional tension produced by hormones released during the fight-or-flight reaction.
— A portion of the brain that regulates the autonomic nervous system, the release of hormones from the pituitary gland, sleep cycles, and body temperature.
— A group of structures in the brain that includes the hypothalamus, amygdala, and hippocampus. The limbic system plays an important part in regulation of human moods and emotions. Many psychiatric disorders are related to malfunctioning of the limbic system.
— In psychoanalytic theory, a psychological defense against anxiety in which the patient displaces anxious feelings onto an external object, activity, or situation.
Although anxiety is related to fear, it is not the same thing. Fear is a direct, focused response to a specific event or object, and the person is consciously aware of it. Most people will feel fear if someone points a loaded gun at them or if they see a tornado forming on the horizon. They also will recognize that they are afraid. Anxiety, on the other hand, is often unfocused, vague, and hard to pin down to a specific cause. In this form it is called free-floating anxiety. Sometimes anxiety being experienced in the present may stem from an event or person that produced pain and fear in the past, but the anxious individual is not consciously aware of the original source of the feeling. It is anxiety's aspect of remoteness that makes it hard for people to compare their experiences of it. Whereas most people will be fearful in physically dangerous situations, and can agree that fear is an appropriate response in the presence of danger, anxiety is often triggered by objects or events that are unique and specific to an individual. An individual might be anxious because of a unique meaning or memory being stimulated by present circumstances, not because of some immediate danger. Another individual looking at the anxious person from the outside may be truly puzzled as to the reason for the person's anxiety.
Causes and symptoms
Anxiety can have a number of different causes. It is a multidimensional response to stimuli in the person's environment, or a response to an internal stimulus (for example, a hypochondriac's reaction to a stomach rumbling) resulting from a combination of general biological and individual psychological processes.
In some cases, anxiety is produced by physical responses to stress
, or by certain disease processes or medications.
THE AUTONOMIC NERVOUS SYSTEM (ANS). The nervous system of human beings is "hard-wired" to respond to dangers or threats. These responses are not subject to conscious control, and are the same in humans as in lower animals. They represent an evolutionary adaptation to the animal predators and other dangers with which all animals, including primitive humans, had to cope. The most familiar reaction of this type is the so-called "fight-or-flight" response. This response is the human organism's automatic "red alert" in a life-threatening situation. It is a state of physiological and emotional hyperarousal marked by high muscle tension and strong feelings of fear or anger. When a person has a fight-or-flight reaction, the level of stress hormones in their blood rises. They become more alert and attentive, their eyes dilate, their heartbeat increases, their breathing rate increases, and their digestion slows down, allowing more energy to be available to the muscles.
This emergency reaction is regulated by a part of the nervous system called the autonomic nervous system, or ANS. The ANS is controlled by the hypothalamus, a specialized part of the brainstem that is among a group of structures called the limbic system. The limbic system controls human emotions through its connections to glands and muscles; it also connects to the ANS and "higher" brain centers, such as parts of the cerebral cortex. One problem with this arrangement is that the limbic system cannot tell the difference between a realistic physical threat and an anxiety-producing thought or idea. The hypothalamus may trigger the release of stress hormones by the pituitary gland, even when there is no external and objective danger. A second problem is caused by the biochemical side effects of too many "false alarms" in the ANS. When a person responds to a real danger, his or her body gets rid of the stress hormones by running away or by fighting. In modern life, however, people often have fight-or-flight reactions in situations in which they can neither run away nor lash out physically. As a result, their bodies have to absorb all the biochemical changes of hyperarousal, rather than release them. These biochemical changes can produce anxious feelings, as well as muscle tension and other physical symptoms associated with anxiety. They may even produce permanent changes in the brain, if the process occurs repeatedly. Moreover, chronic physical disorders, such as coronary artery disease, may be worsened by anxiety, as chronic hyperarousal puts undue stress on the heart, stomach, and other organs.
DISEASES AND DISORDERS. Anxiety can be a symptom of certain medical conditions. Some of these diseases are disorders of the endocrine system, such as Cushing's syndrome (overproduction of cortisol by the adrenal cortex), and include over- or underactivity of the thyroid gland. Other medical conditions that can produce anxiety include respiratory distress syndrome
, mitral valve prolapse, porphyria, and chest pain
caused by inadequate blood supply to the heart (angina pectoris).
A study released in 2004 showed that people who had experienced traumatic bone injuries may have unrecognized anxiety in the form of post-traumatic stress disorder
. This disorder can result from witnessing or experiencing an event involving serious injury, or threatened death
(or experiencing the death or threatened death of another.)
MEDICATIONS AND SUBSTANCE USE. Numerous medications may cause anxiety-like symptoms as a side effect. They include birth control pills; some thyroid or asthma
drugs; some psychotropic agents; occasionally, local anesthetics; corticosteroids; antihypertensive drugs; and nonsteroidal anti-inflammatory drugs (like flurbiprofen and ibuprofen).
Although people do not usually think of caffeine
as a drug, it can cause anxiety-like symptoms when consumed in sufficient quantity. Patients who consume caffeine rich foods and beverages, such as chocolate, cocoa, coffee, tea, or carbonated soft drinks (especially cola beverages), can sometimes lower their anxiety symptoms simply by reducing their intake of these substances.
Withdrawal from certain prescription drugs, primarily beta blockers and corticosteroids, can cause anxiety. Withdrawal from drugs of abuse, including LSD, cocaine, alcohol, and opiates, can also cause anxiety.
Some aspects of anxiety appear to be unavoidable byproducts of the human developmental process. Humans are unique among animals in that they spend an unusually long period of early life in a relatively helpless condition, and a sense of helplessness can lead to anxiety. The extended period of human dependency on adults means that people may remember, and learn to anticipate, frightening or upsetting experiences long before they are capable enough to feel a sense of mastery over their environment. In addition, the fact that anxiety disorders often run in families indicates that children can learn unhealthy attitudes and behaviors from parents, as well as healthy ones. Also, recurrent disorders in families may indicate that there is a genetic or inherited component in some anxiety disorders
. For example, there has been found to be a higher rate of anxiety disorders (panic) in identical twins than in fraternal twins.
CHILDHOOD DEVELOPMENT AND ANXIETY. Researchers in early childhood development regard anxiety in adult life as a residue of childhood memories of dependency. Humans learn during the first year of life that they are not self-sufficient and that their basic survival depends on the care of others. It is thought that this early experience of helplessness underlies the most common anxieties of adult life, including fear of powerlessness and fear of being unloved. Thus, adults can be made anxious by symbolic threats to their sense of competence and/or significant relationships, even though they are no longer helpless children.
SYMBOLIZATION. The psychoanalytic model gives considerable weight to the symbolic aspect of human anxiety; examples include phobic disorders, obsessions, compulsions, and other forms of anxiety that are highly individualized. The length of the human maturation process allows many opportunities for children and adolescents to connect their experiences with certain objects or events that can bring back feelings in later life. For example, a person who was frightened as a child by a tall man wearing glasses may feel panicky years later by something that reminds him of that person or experience without consciously knowing why.
Freud thought that anxiety results from a person's internal conflicts. According to his theory, people feel anxious when they feel torn between desires or urges toward certain actions, on the one hand, and moral restrictions, on the other. In some cases, the person's anxiety may attach itself to an object that represents the inner conflict. For example, someone who feels anxious around money may be pulled between a desire to steal and the belief that stealing is wrong. Money becomes a symbol for the inner conflict between doing what is considered right and doing what one wants.
PHOBIAS. Phobias are a special type of anxiety reaction in which the person's anxiety is concentrated on a specific object or situation that the person then tries to avoid. In most cases, the person's fear is out of all proportion to its "cause." Prior to the Diagnostic and Statistical Manual of Mental Disorders
, 4th edition (DSM-IV)
, these specific phobias were called simple phobias. It is estimated that 10-11% of the population will develop a phobia in the course of their lives. Some phobias, such as agoraphobia
(fear of open spaces), claustrophobia (fear of small or confined spaces), and social phobia, are shared by large numbers of people. Others are less common or unique to the patient.
Social and environmental stressors
Anxiety often has a social dimension because humans are social creatures. People frequently report feelings of high anxiety when they anticipate and, therefore, fear the loss of social approval or love. Social phobia is a specific anxiety disorder that is marked by high levels of anxiety or fear of embarrassment in social situations.
Another social stressor is prejudice. People who belong to groups that are targets of bias are at higher risk for developing anxiety disorders. Some experts think, for example, that the higher rates of phobias and panic disorder
among women reflects their greater social and economic vulnerability.
Some controversial studies indicate that the increase in violent or upsetting pictures and stories in news reports and entertainment may raise the anxiety level of many people. Stress and anxiety management programs often suggest that patients cut down their exposure to upsetting stimuli.
Anxiety may also be caused by environmental or occupational factors. People who must live or work around sudden or loud noises, bright or flashing lights, chemical vapors, or similar nuisances, which they cannot avoid or control, may develop heightened anxiety levels.
Another factor that shapes human experiences of anxiety is knowledge of personal mortality. Humans are the only animals that appear to be aware of their limited life span. Some researchers think that awareness of death influences experiences of anxiety from the time that a person is old enough to understand death.
Symptoms of anxiety
In order to understand the diagnosis and treatment of anxiety, it is helpful to have a basic understanding of its symptoms.
SOMATIC. The somatic or physical symptoms of anxiety include headaches, dizziness
or lightheadedness, nausea and/or vomiting, diarrhea, tingling, pale complexion, sweating, numbness, difficulty in breathing, and sensations of tightness in the chest, neck, shoulders, or hands. These symptoms are produced by the hormonal, muscular, and cardiovascular reactions involved in the fight-or-flight reaction. Children and adolescents with generalized anxiety disorder
show a high percentage of physical complaints.
BEHAVIORAL. Behavioral symptoms of anxiety include pacing, trembling, general restlessness, hyperventilation, pressured speech, hand wringing, or finger tapping.
COGNITIVE. Cognitive symptoms of anxiety include recurrent or obsessive thoughts, feelings of doom, morbid or fear-inducing thoughts or ideas, and confusion, or inability to concentrate.
EMOTIONAL. Feeling states associated with anxiety include tension or nervousness, feeling "hyper" or "keyed up," and feelings of unreality, panic, or terror.
DEFENSE MECHANISMS. In psychoanalytic theory, the symptoms of anxiety in humans may arise from or activate a number of unconscious defense mechanisms. Because of these defenses, it is possible for a person to be anxious without being consciously aware of it or appearing anxious to others. These psychological defenses include:
- Repression. The person pushes anxious thoughts or ideas out of conscious awareness.
- Displacement. Anxiety from one source is attached to a different object or event. Phobias are an example of the mechanism of displacement in psychoanalytic theory.
- Rationalization. The person justifies the anxious feelings by saying that any normal person would feel anxious in their situation.
- Somatization. The anxiety emerges in the form of physical complaints and illnesses, such as recurrent headaches, stomach upsets, or muscle and joint pain.
- Delusion formation. The person converts anxious feelings into conspiracy theories or similar ideas without reality testing. Delusion formation can involve groups as well as individuals.
Other theorists attribute some drug addiction
to the desire to relieve symptoms of anxiety. Most addictions, they argue, originate in the use of mood-altering substances or behaviors to "medicate" anxious feelings.
The diagnosis of anxiety is difficult and complex because of the variety of its causes and the highly personalized and individualized nature of its symptom formation. There are no medical tests that can be used to diagnose anxiety by itself. When a doctor examines an anxious patient, he or she will first rule out physical conditions and diseases that have anxiety as a symptom. Apart from these exclusions, the physical examination
is usually inconclusive. Some anxious patients may have their blood pressure or pulse rate affected by anxiety, or may look pale or perspire heavily, but others may appear physically completely normal. The doctor will then take the patient's medication, dietary, and occupational history to see if they are taking prescription drugs that might cause anxiety, if they are abusing alcohol or mood-altering drugs, if they are consuming large amounts of caffeine, or if their workplace is noisy or dangerous. In most cases, the most important source of diagnostic information is the patient's psychological and social history. The doctor may administer a brief psychological test to help evaluate the intensity of the patient's anxiety and some of its features. Some tests that are often given include the Hamilton Anxiety Scale and the Anxiety Disorders Interview Schedule (ADIS). Many doctors will check a number of chemical factors in the blood, such as the level of thyroid hormone and blood sugar.
Not all patients with anxiety require treatment, but for more severe cases, treatment is recommended. Because anxiety often has more than one cause and is experienced in highly individual ways, its treatment usually requires more than one type of therapy. In addition, there is no way to tell in advance how patients will respond to a specific drug or therapy. Sometimes the doctor will need to try different medications or methods of treatment before finding the best combination for the particular patient. It usually takes about six to eight weeks for the doctor to evaluate the effectiveness of a treatment regimen.
Medications are often prescribed to relieve the physical and psychological symptoms of anxiety. Most agents work by counteracting the biochemical and muscular changes involved in the fight-or-flight reaction. Some work directly on the chemicals in the brain that are thought to underlie the anxiety.
ANXIOLYTICS. Anxiolytics are sometimes called tranquilizers. Most anxiolytic drugs are either benzodiazepines
. Barbiturates, once commonly used, are now rarely used in clinical practice. Barbiturates work by slowing down the transmission of nerve impulses from the brain to other parts of the body. They include such drugs as phenobarbital (Luminal) and pentobarbital (Nembutal). Benzodiazepines work by relaxing the skeletal muscles and calming the limbic system. They include such drugs as chlordiazepoxide (Librium) and diazepam (Valium). Both barbiturates and benzodiazepines are potentially habit-forming and may cause withdrawal symptoms, but benzodiazepines are far less likely than barbiturates to cause physical dependency. Both drugs also increase the effects of alcohol and should never be taken in combination with it.
Two other types of anxiolytic medications include meprobamate (Equanil), which is now rarely used, and buspirone (BuSpar), a new type of anxiolytic that appears to work by increasing the efficiency of the body's own emotion-regulating brain chemicals. Buspirone has several advantages over other anxiolytics. It does not cause dependence problems, does not interact with alcohol, and does not affect the patient's ability to drive or operate machinery. However, buspirone is not effective against certain types of anxiety, such as panic disorder.
ANTIDEPRESSANTS AND BETA-BLOCKERS. For some anxiety disorders, such as obsessive-compulsive disorder and panic type anxiety, a type of drugs used to treat depression, selective serotonin reuptake inhibitors
(SSRIs; such as Prozac and Paxil), are the treatment of choice. A newer drug that has been shown as effective as Paxil is called escitalopram oxalate (Lexapro). Because anxiety often coexists with symptoms of depression, many doctors prescribe antidepressant medications for anxious/depressed patients. While SSRIs are more common, antidepressants are sometimes prescribed, including tricyclic antidepressants such as imipramine (Tofranil) or monoamine oxidase inhibitors
(MAO inhibitors) such as phenelzine (Nardil).
Beta-blockers are medications that work by blocking the body's reaction to the stress hormones that are released during the fight-or-flight reaction. They include drugs like propranolol (Inderal) or atenolol (Tenormin). Beta-blockers are sometimes given to patients with post-traumatic anxiety symptoms. More commonly, the beta-blockers are given to patients with a mild form of social phobic anxiety, such as fear of public speaking.
Most patients with anxiety will be given some form of psychotherapy along with medications. Many patients benefit from insight-oriented therapies, which are designed to help them uncover unconscious conflicts and defense mechanisms in order to understand how their symptoms developed. Patients who are extremely anxious may benefit from supportive psychotherapy, which aims at symptom reduction rather than personality restructuring.
Two newer approaches that work well with anxious patients are cognitive-behavioral therapy
(CBT), and relaxation training. In CBT, the patient is taught to identify the thoughts and situations that stimulate his or her anxiety, and to view them more realistically. In the behavioral part of the program, the patient is exposed to the anxiety-provoking object, situation, or internal stimulus (like a rapid heart beat) in gradual stages until he or she is desensitized to it. Relaxation training, which is sometimes called anxiety management training, includes breathing exercises and similar techniques intended to help the patient prevent hyperventilation and relieve the muscle tension associated with the fight-or-flight reaction. Both CBT and relaxation training can be used in group therapy as well as individual treatment. In addition to CBT, support groups are often helpful to anxious patients, because they provide a social network and lessen the embarrassment that often accompanies anxiety symptoms.
Surgery on the brain is very rarely recommended for patients with anxiety; however, some patients with severe cases of obsessive-compulsive disorder
(OCD) have been helped by an operation on a part of the brain that is involved in OCD. Normally, this operation is attempted after all other treatments have failed.
Alternative treatments for anxiety cover a variety of approaches. Meditation
and mindfulness training are thought beneficial to patients with phobias and panic disorder. Hydrotherapy
is useful to some anxious patients because it promotes general relaxation of the nervous system. Yoga
, aikido, t'ai chi, and dance therapy help patients work with the physical, as well as the emotional, tensions that either promote anxiety or are created by the anxiety.
Homeopathy and traditional Chinese medicine approach anxiety as a symptom of a systemic disorder. Homeopathic practitioners select a remedy based on other associated symptoms and the patient's general constitution. Chinese medicine regards anxiety as a blockage of qi
, or vital force, inside the patient's body that is most likely to affect the lung and large intestine meridian flow. The practitioner of Chinese medicine chooses acupuncture
point locations and/or herbal therapy to move the qi and rebalance the entire system in relation to the lung and large intestine.
The prognosis for resolution of anxiety depends on the specific disorder and a wide variety of factors, including the patient's age, sex, general health, living situation, belief system, social support network, and responses to different anxiolytic medications and forms of therapy.
Humans have significant control over thoughts, and, therefore, may learn ways of preventing anxiety by changing irrational ideas and beliefs. Humans also have some power over anxiety arising from social and environmental conditions. Other forms of anxiety, however, are built into the human organism and its life cycle, and cannot be prevented or eliminated.
"Lexapro Found to be as Effective as Paxil." Mental Health Weekly Digest (April 12, 2004): 16.
Masi, Gabriele, et al. "Generalized Anxiety Disorder in Referred Children and Adolescents." Journal of the American Academy of Child and Adolescent Psychiatry (June 2004): 752-761.
"Patients With Traumatic Bone Injuries Have Unrecognized Anxiety." Health & Medicine Week (June 28, 2004): 824.