What is Anxiety?

Anxiety is the mind and body's reaction to stressful, dangerous, or unfamiliar situations. It's the sense of uneasiness, distress, or dread you feel before a significant event. A certain level of Anxiety helps us stay alert and aware, but for those suffering from an anxiety disorder, it feels far from normal - it can be completely debilitating.

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Types of Anxiety Disorders

Abigail Powers Lott, PhD, and Anaïs Stenson, PhD

There are many anxiety-related disorders, and they are divided into three main categories:

1. Anxiety disorders: Anxiety disorders are characterized by a general feature of excessive fear (i.e. emotional response to perceived or real threat) and/or anxiety (i.e. worrying about a future threat) and can have negative behavioral and emotional consequences.

2. Obsessive-compulsive and related disorders: Obsessive-compulsive and related disorders are characterized by obsessive, intrusive thoughts (e.g., constantly worrying about staying clean, or about one's body size) that trigger related, compulsive behaviors (e.g. repeated hand-washing, or excessive exercise). These behaviors are performed to alleviate the anxiety associated with the obsessive thoughts.

3. Trauma- and stressor- related disorders: Trauma- and stressor- related anxiety disorders are related to the experience of a trauma (e.g., unexpected death of a loved one, a car accident, or a violent incident like war or sexual assault) or stressor (e.g., divorce, beginning college, moving).

Anxiety treatments  Child Anxiety

• Your anxiety disorder may be a Specific Phobia if you have a persistent and excessive fear of a specific object or situation, such as flying, heights, animals, toilets, or seeing blood. Fear is cued by the presence or anticipation of the object/situation and exposure to the phobic stimulus results in an immediate fear response or panic attack. The fear is disproportionate to the actual danger posed by the object or situation. Commonly, adults with specific phobias will recognize that their fear is excessive or unreasonable. Learn more about Phobias here.
• An excessive fear of becoming embarrassed or humiliated in social situations, which often leads to significant avoidance behaviors may be an indicator of Social Anxiety Disorder (SAD). Find out more about social anxiety disorder - especially if your fear of social situations last for more than six months.
• Post-Traumatic Stress Disorder (PTSD) is the most well-known trauma- and stressor related disorder. These are disorders that are related to the experience of a trauma (e.g., unexpected death of a loved one, a car accident, combat, or a violent incident) or stressor (e.g., divorce, beginning college, moving). This category also includes Acute Stress Disorder and Adjustment Disorder. A full discussion of the symptoms and treatment of PTSD can be found here.
• Generalized Anxiety Disorder (GAD) is characterized by excessive, uncontrollable worry over events and activities and potential negative outcomes. The anxiety and worry must cause significant distress or interfere with the individual's daily life, occupational, academic, or social functioning to meet diagnosis. The symptoms cannot be better accounted for by another mental disorder or be caused by substances, medications, or medical illness. Find more information here about Generalized Anxiety Disorder.
• Panic Disorder reflects the experience of sudden panic symptoms (generally out of the blue, without specific triggers) in combination with persistent, lingering worry that panic symptoms will return and fear of those panic symptoms. Symptoms include recurrent expected or unexpected panic attacks that can last from a few minutes to up to an hour.
• Obsessive-Compulsive Disorder (OCD) is one of a number of related disorders that share certain characteristics. Repeated and persistent thoughts ("obsessions") that typically cause distress and that an individual attempts to alleviate by repeatedly performing specific actions ("compulsions"). Examples of common obsessions include: fear that failing to do things in a particular way will result in harm to self or others, extreme anxiety about being dirty or contaminated by germs, concern about forgetting to do something important that may result in bad outcomes, or obsessions around exactness or symmetry. Examples of common compulsions include: checking (e.g., that the door is locked or for an error), counting or ordering (e.g., money or household items), and performing a mental action (e.g., praying). Other disorders included excoriation (skin-picking), hoarding, body dysmorphic disorder, and trichotillomania (hair-pulling).
• Other categories of anxiety disorders include: Separation Anxiety Disorder, Selective Mutism, and Agoraphobia as well as disorders that are substance-induced or are a result of other medical conditions.

Causes and Risk Factors

Jessica Maples-Keller, PhD, and Vasiliki Michopoulos, PhD

• Comorbidities
• Genetics
• Environment Factors
• Medical Condition 
• Behavioral Choices
• Demographics

It's important to note that everyone feels anxiety to some degree regularly throughout their life. Fear and anxiety are helpful emotions that can function to help us notice danger or threats that keep us safe and help us adapt to our environment. Anxiety disorders occur when significant distress impairs your ability to function in important facets of life, such as work, school, or relationships. There are many potential risk factors for anxiety disorders, and most people likely experience multiple different combinations of risk factors, such as neurobiological factors, genetic markers, environmental factors, and life experiences. However, we do not yet fully understand what causes some people to have anxiety disorders.

Comorbidity is more common than not with anxiety disorders, meaning that most individuals who experience significant anxiety experience multiple different types of anxiety. Given this comorbidity, it is not surprising that many risk factors are shared across anxiety disorders, or have the same underlying causes. There is a lot of research identifying risk factors for anxiety disorders, and this research suggests that both nature and nurture are very relevant. It is important to note that no single risk factor is definitive. Many people may have a risk factor for a disorder and not ever develop that disorder. However, it is helpful for research to identify risk factors and for people to be aware of them. Being aware of who might be at risk can potentially help people get support or assistance to prevent the development of a disorder.

Genetic risk factors have been documented for all anxiety disorders. Clinical genetic studies indicate that heritability estimates for anxiety disorders range from 30-67%. Many studies, past and present, have focused on identifying specific genetic factors that increase one's risk for an anxiety disorder. To date, an array of single nucleotide polymorphisms (SNPs) or small variations in genetic code, that confer heightened risk for anxiety have been discovered. For the most part, the variants that have been associated with risk for anxiety are located within genes that are critical for the expression and regulation of neurotransmitter systems or stress hormones.

It is important to note that genetic factors can also bestow resilience to anxiety disorders, and the field continues to pursue large-scale genomics studies to identify novel genetic factors that are associated with anxiety disorders in hopes of better understanding biological pathways that 1) contribute to the development and maintenance of anxiety; and 2) may lead to better treatment for these disorders. Most people are not aware of what specific genetic markers they may have that confer risk for anxiety disorders, so a straightforward way to approximate genetic risk is if an individual has a history of anxiety disorders in their family. While both nature and nurture can be at play with family history, if several people have anxiety disorders, genetic vulnerability to anxiety likely exists in that family.

Concerning environmental factors within the family, parenting behavior can also impact risk for anxiety disorders. Parents who demonstrate high levels of control (versus granting child autonomy) while interacting with their children has been associated with the development of anxiety disorders. Parental modeling of anxious behaviors and parental rejection of the child has also been shown to relate to greater risk for anxiety potentially. Experiencing stressful life events or chronic stress is also related to the development of anxiety disorders. Stressful life events in childhood, including experiencing adversity, sexual, physical, or emotional abuse, or parental loss or separation may increase the risk of experiencing an anxiety disorder later in life. Having experienced a traumatic event or very stressful event can be a risk factor for the development of anxiety across different age groups. Consistent with the notion of chronic life stress resulting in increased anxiety risk, having lower access to socioeconomic resources or being a member of a minority group has also been suggested to relate to greater risk.

Experiencing a chronic medical condition or severe or frequent illness, can also increase the risk for anxiety disorders, as well as dealing with a significant illness of a family member or loved one. Given that several medical conditions have been linked to significant anxiety, in some cases, a physician may perform medical tests to rule out an underlying medical condition. For instance, thyroid disease is often characterized by experiencing significant symptoms of anxiety. Menopause, heart disease, and diabetes have also been linked to anxiety symptoms. Additionally, drug abuse or withdrawal for many substances is characterized by acute anxiety, and chronic substance abuse can increase the risk of developing an anxiety disorder. Anxiety can also be a side effect of certain medications. Experiencing significant sleep disturbances, such as difficulty falling asleep or staying asleep, may also be a risk factor for developing an anxiety disorder.

Behavioral choices can also significantly impact risk, as excessive tobacco or caffeine use can increase anxiety, whereas regular exercise can decrease anxiety. Specific temperament and personality traits also may confer risk of having an anxiety disorder. With regards to temperament, shyness, and behavioral inhibition in childhood can increase the risk of developing an anxiety disorder later in life. About personality traits, the Five-Factor Model of Personality consists of five broad trait domains, including Neuroticism, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness. An individual higher on trait Neuroticism or low on Conscientiousness is at a higher risk for all anxiety disorders, and an individual low on trait Extraversion is at a higher risk of developing social phobia and agoraphobia. Some more narrow personality traits have also been found to relate to risk for anxiety, including anxiety sensitivity, a negative or hostile attributional style, and self-criticism. Personality disorders have also been shown to relate to increased risk for anxiety disorders.

Demographic factors also impact the risk of anxiety disorders. While there is not a strong consensus, research suggests that risk for anxiety disorders decreases over the lifespan with the lower risk being demonstrated later in life. Women are significantly more likely to experience anxiety disorders. Another robust biological and sociodemographic risk factor for anxiety disorders is gender, as women are twice as likely as men to suffer from anxiety. Overall symptom severity has also been shown to be more severe in women compared to men, and women with anxiety disorders typically report a lower quality of life than men. This sex difference in the prevalence and severity of anxiety disorders that put women at a disadvantage over men is not specific to anxiety disorders but is also found in depression and other stress-related adverse health outcomes (i.e., obesity and cardiometabolic disease). Basic science and clinical studies suggest that ovarian hormones, such as estrogen and progesterone, and their fluctuations may play an important role in this sex difference in anxiety disorder prevalence and severity. While changes in estrogen and progesterone, over the month as well as over the lifetime, are linked to change in anxiety symptom severity and have been shown to impact systems implicated in the etiology of anxiety disorders (i.e., the stress axis), it still remains unclear how these hormones and their fluctuations increase women's vulnerability to anxiety.

Anxiety Physical Symptoms

Vasiliki Michopoulos, PhD

Anxiety disorders increase one's chances for suffering from other physical medical illnesses, such as cardiovascular disorders, including obesity, heart disease, and diabetes. More specifically, increased body weight and abdominal fat, high blood pressure, and greater levels of cholesterol, triglycerides, and glucose have all been linked to anxiety. While it is still unclear what causes the high co-morbidity between anxiety and bad physical health outcomes, research suggests that changes in underlying biology that is characteristic of anxiety may also facilitate the emergence for these other physical health outcomes over time. For example, changes in stress hormones, autonomic responses, as well as heightened systemic inflammation are all associated with anxiety disorders and negative health outcomes. These shared physiological states suggest they shared underlying biology and that anxiety may be a whole-body condition.

Anxiety disorders are associated with chronic life stress. Unpredictable, unrelenting, unresolvable stressors chronically stimulate the stress hormone system and cardiovascular system and lead to states of constant increased activity. Biologically, the body has evolved to deal with imminent and concrete danger in the environment, rather than continuous stressors. Under normal conditions where chronic stress is low, exposure to a sudden threat activates the autonomic nervous system, i.e., increased levels of adrenaline and faster breathing, and racing heart rate. These reactions, in turn, trigger activation of stress hormones, such as cortisol. One of the effects of these stress hormones is to increase glucose levels in the bloodstream to respond to the imminent threat so that muscles can be activated for the flight or fight response. Another effect of stress hormones is to suppress the immune system since processes such as healing and repair can wait until after the threat subsides. However, in someone with an anxiety disorder, where there is constant activation of these responses to everyday stressors, the stress hormone system loses its ability to control immune function, thus contributing to heightened systemic inflammation that increases the risk for cardiovascular and even autoimmune disorders. Neuroscience and clinical research continue to investigate how anxiety disorders increase the individual risk for developing physical health co-morbidities in hopes of identifying new treatments that may alleviate suffering from and prevent the development of these whole-body disorders.

Treatment Options

Yvonne Ogbonmwan, PhD

There are many highly effective treatment options available for anxiety and anxiety-related disorders. These treatments can be broadly categorized as: 1) Psychotherapy; 2) Medications; and 3) Complementary and Alternative Therapies. Patients diagnosed with anxiety can benefit from one or a combination of these various therapies. Discussions of emerging therapies and types of care providers are also included.

Evidence-Based Therapies

Counseling

Counseling is a form of talk therapy in which a mental healthcare provider helps patients develop strategies and coping skills to address specific issues like stress management or interpersonal problems. Counseling is generally designed to be a short-term therapy.

Psychotherapy

There are many types of psychotherapies used to treat anxiety. Unlike counseling, psychotherapy is more long-term and targets a broader range of issues such as patterns of behavior. The patient's particular anxiety diagnosis and personal preference guide what therapies would be best suited to treat them. The ultimate goal with any type of psychotherapy is to help the patient regulate their emotions, manage stress, understand patterns in behavior that affect their interpersonal relationships. Evidenced-based therapies like Cognitive Behavioral Therapy (CBT), Prolonged Exposure Therapy (PE), and Dialectical Behavioral Therapy (DBT) are some of the most effective at treating anxiety.

Cognitive Behavioral Therapy (CBT)

CBT is a short-term treatment designed to help patients identify inaccurate and negative thinking in situations that cause anxiety like panic attacks. CBT can be used in one-on-one therapy or in a group therapy session with people facing similar problems. CBT primarily focuses on the ongoing problems in a patient's life and helps them develop new ways of processing their feelings, thoughts and behaviors to develop more effective ways of coping with their life. In patients who suffer from PTSD, CBT can take on a trauma-focused approach, where the goal is to process and reframe the traumatic experience that lead to the symptoms. On average, the length of treatment is around 10-15 weekly one-hour sessions depending on the type and severity of symptoms.

Prolonged Exposure Therapy (PE)

Prolonged exposure therapy is a specific type of CBT used to treat PTSD and phobias. The goal of this therapy is to help patients overcome the overwhelming distress they experience when reminded of past traumas or in confronting their fears. With the guidance of a licensed therapist, the patient is carefully reintroduced to the trauma memories or reminders. During the exposure, the therapist guides the patient to use coping techniques such as mindfulness or relaxation therapy/imagery. The goal of this therapy is to help patients realize that trauma-related memories (or phobias) are no longer dangerous and do not need to be avoided. This type of treatment usually lasts 8-16 weekly sessions.

Eye Movement Desensitization Reprocessing Therapy (EMDR)

EMDR is a psychotherapy that alleviates the distress and emotional disturbances that are elicited from the memories of traumatic events. It is primarily administered to treat PTSD and is very similar to exposure therapy. This therapy helps patients to process the trauma so that they can heal. During the therapy, patients pay attention to a back and forth movement or sound while recounting their traumatic memories. Patients continue these sessions until the memory becomes less distressing. EMDR sessions typically last 50-90 minutes and are administered weekly for 1-3 months, although many patients report experiencing a reduction of symptoms after a few sessions of EMDR.

Dialectical Behavioral Therapy (DBT)

DBT uses a skills-based approach to help patients regulate their emotions. It is a preferred treatment for Borderline Personality Disorder, but call also be effective for anxiety disorders such as PTSD. This treatment teaches patients how to develop skills for how to regulate their emotions, stress-management, mindfulness, and interpersonal effectiveness. It was developed to be employed in either one-on-one therapy sessions or group sessions. This type of therapy is typically long-term, and patients are usually in treatment for a year or more.

Acceptance and Commitment Therapy (ACT)

ACT is a type of CBT that encourages patients to gain in positive behaviors even in the presence of negative thoughts and behaviors. The goal is to improve daily functioning despite having the disorder. It is particularly useful for treatment-resistant Generalized Anxiety Disorder and Depression. The length of treatment varies depending on the severity of symptoms.

Family Therapy

Family Therapy is a type of group therapy that includes the patient's family to help them improve communication and develop better skills for solving conflicts. This therapy is useful if the family is contributing to the patient's anxiety. During this short-term therapy, the patient's family learns how not to make the anxiety symptoms worse and to understand the patient better. The length of treatment varies depending on the severity of symptoms.

Medications

Medications are sometimes used in conjunction with psychotherapy. The most commonly prescribed medications are generally safe, although some do have side effects to consider. The specific type of medication administered to patients will be determined by their providers based on the patient's specific symptoms and other factors like general health.

Antidepressants

Antidepressants are medications used to treat symptoms of depression but can also used to treat anxiety symptoms as well. In particular, selective serotonin re-uptake inhibitors (SSRI) and selective norepinephrine re-uptake inhibitors (SNRI) are the primary class of antidepressant used to treat anxiety. SSRIs commonly used to treat anxiety are escitalopram (Lexapro) and paroxetine (Paxil, Pexeva). SNRI medications used to treat anxiety include duloxetine (Cymbalta), venlafaxine (Effexor XR).

Buspirone

Buspirone is a drug indicated for the treatment of anxiety. This drug has high efficacy for Generalized Anxiety Disorder and is particularly effective at reducing the cognitive and interpersonal problems associated with anxiety. Unlike benzodiazepines, buspirone does not have a sedative effect or interact with alcohol. Most importantly, there is a low risk of developing a dependence on buspirone. Its side effects are minimal but can include dizziness, nervousness, and headaches. BuSpar and Vanspar are brand names associated with buspirone.

Benzodiazepines

Benzodiazepines are sedatives indicated for anxiety, epilepsy, alcohol withdrawal, and muscle spasms. Benzodiazepines demonstrate short-term effectiveness in the treatment of Generalized Anxiety Disorder and can help with sleep disturbances. A doctor may prescribe these drugs for a limited period to relieve acute symptoms of anxiety. However, long-term use of these medications is discouraged because they have a strong sedative effect and can be habit-forming. Also, taking benzodiazepines while also engaging in psychotherapy such as PE can reduce the effectiveness of exposure therapy. Some well-known brand names are Librium, Xanax, Valium, and Ativan.

Beta Blockers

Beta Blockers, also known as beta-adrenergic blocking agents, work by blocking the neurotransmitter epinephrine (adrenaline). Blocking adrenaline slows down and reduces the force of heart muscle contraction, resulting in decreased blood pressure. Beta-blockers also increase the diameter of blood vessels resulting in increased blood flow. Historically, beta-blockers have been prescribed to treat the somatic symptoms of anxiety (heart rate and tremors), but they are not very effective at treating generalized anxiety, panic attacks, or phobias. Lopressor and Inderal are some of the brand names with which you might be familiar.

Complementary and Alternative Therapies

Complementary and Alternative Therapies can be used in conjunction with conventional therapies to reduce the symptoms of anxiety. There is a growing interest in these types of alternative therapies since they are non-invasive and can be useful to patients. They are typically not intended to replace conventional therapies but rather can be an adjunct therapy that can improve the overall quality of life of patients.

Stress Management

A collection of activities focused in which an individual consciously produces the relaxation response in their body. This response consists of slower breathing, resulting in lower blood pressure and overall feeling of well-being. These activities include: progressive relaxation, guided imagery, biofeedback, and self-hypnosis and deep-breathing exercises.

Meditation

A mind and body practice in which individuals are instructed to be mindful of thoughts, feelings and sensations in non-judgmental way. It has been shown to be useful in reducing the symptoms of psychological stress in patients with anxiety.

Yoga

A mindfulness practice that combines meditation, physical postures, breathing exercises and a distinct philosophy. It has been shown to be useful in reducing some symptoms of anxiety and depression.

Emerging Therapies

There are also a number of experimental treatments that have shown promise in treating the symptoms of anxiety. Here we include a brief description of a few of those, including brain stimulation (neurostimulation), acupuncture, and psychoactive drugs (marijuana and ecstasy).

Neurostimulation

Anxiety is associated with abnormal patterns of activity in the brain. One way to treat anxiety is to target abnormal nerve cell activity directly. Neuromodulation or brain stimulation therapy is a non-invasive and painless therapy that stimulates the human brain. In some recent clinical trials, patients that did not respond to more traditional forms of treatment (i.e., medication) showed a reduction in symptoms of depression and anxiety. There are two main types of neuromodulation:

• Repetitive transcranial magnetic stimulation (rTMS)

A large brief current is passed through a wire coil that is placed on the front of the head, which is near the areas that regulate mood. The transient current creates a magnetic field that produces an electric current in the brain and stimulates nerve cells in the targeted region. The current typically only affects brain regions that are 5 centimeters deep into the brain, which allows doctors to target which brain regions to treat selectively. Typical sessions last 30-60 minutes and do not require anesthesia. Sessions are administered 4-5 times a week for about six weeks. Although the procedure is painless, patients may experience a gentle tapping in the area of the head where the current is being administered. Neuromodulation has very few side effects, but they may include headaches, slight tingling, or discomfort in the area in which the coil is placed. rTMS may be administered alone or in combination with medication and/or psychotherapy.

• Deep Transcranial Magnetic Stimulation (dTMS)

Specialized coils that target deeper brain regions than rTMS. A patient wears a cushioned helmet (similar to the type of helmet worn during an fMRI). The coil used in dTMS was approved by the FDA in 2013 for treating depression but is currently being studied for the treatment of anxiety disorders such as OCD. The procedure is administered for 20 minutes for 4-6 weeks. Patients can resume their daily lives right after each treatment.

Acupuncture

Acupuncture is a treatment derived from traditional Chinese medicine. It consists of inserting thin needles into the body in targeted areas. To date, there is very little evidence that acupuncture can significantly treat generalized anxiety, although there are currently ongoing research trials for PTSD. One study did find that acupuncture can reduce pre-operative anxiety.

Psychoactive drugs

There has been recent interest in using psychoactive substances in conjunction with psychotherapy; the two that have received increased attention have been cannabis (marijuana) and methylenedioxymethamphetamine (MDMA, known as ecstasy or molly). These drugs are somewhat controversial, given that they also have psychoactive, i.e., "feeling high" effects. However, with increasing legalization of marijuana, it is important to address whether these substances could be used to alleviate clinical symptoms of anxiety. While there have been only a few randomized clinical trials for these drugs, certain forms of cannabis have demonstrated positive effects on anxiety. Specifically, cannabidiol, a component of cannabis has been effective for Social Anxiety Disorder, and tetrahydrocannabinol (THC) has helped PTSD patients. However, the plant form of cannabis has not shown great efficacy and has the potential to worsen symptoms, so should be used with caution and only under the supervision of a provider. MDMA has shown some positive effects for PTSD, but should only be used as an adjunct to psychotherapy, again under clinical care.

Types of Care Providers

There are a number of different types of licensed mental health providers that can treat the range of anxiety and other related disorders.

Primary Care Physician

Many patients first report symptoms to their primary care physician. Primary care physicians (PCPs) will administer a thorough physical exam to rule out hormonal imbalances, side effects of medications, and certain illnesses. If the symptoms are not due to other conditions, the physician may diagnose the patient with anxiety and therefore refer the patient to a psychologist or psychiatrist. Physicians practice in hospitals, clinics, and private practices.

Clinical Psychologist

A licensed mental health specialist with a doctorate (Ph.D.) in clinical psychology who treats emotional, mental, and behavioral problems. Clinical psychologists are trained to provide counseling and psychotherapy, perform psychological testing, and provide treatment for mental disorders. They generally do not prescribe medications; however, Illinois, Louisiana, and New Mexico are the only states that allow psychologists to prescribe. It is common for clinical psychologists to work in conjunction with a psychiatrist and /or a PCP who provides the medical treatment for the patients while the psychologists provide the psychotherapy. Clinical psychologists can be found at hospitals, schools, counseling centers, and group or private health care practices.

Psychiatrist

A medical doctor (MD) who specializes in diagnosing and treating mental health disorders. A psychiatrist can provide psychotherapy and prescribe medications to patients. They typically work in hospitals, counseling centers and group or private health care practices.

Psychiatric Nurse

A nurse with a master's or doctoral degree in mental health disorders. A psychiatric nurse can diagnose and treat mental health disorders. They mainly provide psychotherapy but in some states that can also prescribe medications. Psychiatric nurses also serve as patient advocates and provide case-management services. They often work in private practices, hospitals, and schools.

Licensed Mental Health Counselor (LMHC) - Licensed Clinical Professional Counselor (LCPC) - Licensed Clinical Social Worker (LCSW) - Licensed Marriage and Family Therapist (LMFT)

A licensed mental health professional that has earned a master’s degree from a variety of educational backgrounds (e.g., general counseling background, social work, marriage, and family counseling). Once their formal education is completed, these clinicians usually undergo at least two years of supervised clinical experience in the field and pass an exam to become fully licensed in the state in which they practice. These mental health professionals are licensed to diagnose emotional, mental health, and behavioral health problems. They can provide mental health treatment in the form of counseling and psychotherapy, or work in other capacities as patient advocates or care managers. Licensed Master’s level clinicians work in many settings, including hospitals, community mental health clinics, private practice, school settings, nursing homes, and other social service agencies. Titles and licensing requirements may vary from state to state.

Clinical Social Worker

CSWs usually have a master's degree in social work and additional training to provide mental health services. They are qualified to provide case management and hospital discharge planning. They often work as patient advocates. Clinical social workers typically work in hospital settings, schools, clinics, social services or private practices

Where to Find Treatment

Most treatment providers for anxiety-related disorders can be found in hospitals, clinics, private or group practices. Some also operate in schools (licensed mental health counselors, clinical social workers, or psychiatric nurses ). There is also the growing field of telehealth in which mental health workers provide their services through an internet video service, streaming media, video conferencing, or wireless communication. Telehealth is particularly useful for patients that live in remote rural locations that are far from institutions that provide mental health services. Mental health providers that work in telehealth can only provide services to patients currently located in the state in which the provider is licensed.

Prevention and Coping With Anxiety

Sierra Carter, PhD

All human beings experience anxiety. In many cases, anxiety can have some beneficial and adaptive qualities such as pushing one to study for an upcoming difficult exam or propelling a person to flee from danger. Although experiencing some anxiety with life stressors and worries is normal, sometimes it can be difficult to manage and can feel overwhelming. Below we provide a list of tips and strategies to help individuals prevent anxiety from reaching a diagnosable level. Even though not everyone will struggle with a diagnosable anxiety disorder, learning strategies to aid in relief from anxiety and to manage the "normal" anxiety experienced in everyday life can help you live the life you desire.

Learning Relaxation Strategies

• Relaxation strategies, such as deep diaphragmatic breathing, have been shown to lower blood pressure, slow heart rate, and reduce the tension that is commonly associated with stress. Engaging in relaxation strategies can equip you to reduce anxiety when it occurs, by allowing your body to switch from its anxious state to a more relaxed and calm state in response to stressors.
• Guided imagery is another relaxation strategy that can help reduce or prevent overwhelming anxiety. Guided imagery involves directed mental visualization to evoke relaxation. This could involve imagining your favorite beach or a peaceful garden that can distract you from your anxious state and allow your mind and body to focus on the positive thoughts and sensations of the imagery exercise.
• Learning to utilize relaxation strategies as a coping strategy for anxiety can boost your confidence that you will be able to cope with anxiety during distressful situations. Relaxation strategies are a great tool for anxiety prevention because they are free, simple, and can provide instant results.

Mindfulness, Meditation, and Yoga

• A simple definition of mindfulness includes the practice of being aware, without judgment, in the present moment. When feeling anxious, often, you might feel that you don't have control over your mind or your body's reaction to stress. You also might feel that anxiety causes you to focus and dwell on past mistakes or future fears.
• Mindfulness, meditation and yoga can increase one's awareness of the world around you and increase your control over how you experience situations and how you respond. Loss of feelings of control is often a symptom of anxiety when a person is feeling overwhelmed and stressed. Practicing these strategies can help you live life in the present moment and enjoy the present things in your life that bring you joy.

Exercise, Healthy Diet, and Rest

• Another important prevention strategy for anxiety is to incorporate exercise into your daily activities. Exercise has been shown to decrease stress hormones that influence anxiety and also improve overall mood. Exercise can also help you disengage from worry and stress and focus on the current task of exercising. Exercises such as light jogging or brisk walking that can be incorporated into your daily activities can help reduce the impact of anxiety when it occurs.
• A healthy diet is also important to reduce and prevent anxiety. It seems counterintuitive that you can "eat your way to calm" but sustaining a healthy diet can really help you to feel more at ease on a regular basis, despite stressors. Some foods that are particularly helpful for reducing anxiety include foods with omega 3 fatty acids (i.e., salmon, walnuts, and flaxseed) and probiotics. Avoid greasy, sugary, high-fat, and processed foods. Additionally, avoiding caffeine when feeling anxious as well as unhealthy substances (i.e., alcohol) could be beneficial. Drinking alcohol might seem like a good way to calm down, but it can lead to sustained anxious symptoms. Incorporating a healthy diet into your lifestyle is fundamental to preventing and reducing anxiety.
• Not getting enough restful sleep can trigger anxiety. Stress and anxiety can also interfere with sleep and cause you to stay awake at night. It can be a frustrating cycle when the stressors of the day and future worries cause you to stay up at night. Take some time to wind down before bed, such as utilizing some of the above relaxation and meditation strategies. Also, instead of letting your mind continuously race at night, try putting your thoughts, worries, and plans for the next day on paper before bed - this will ease your anxiety about forgetting something you need to accomplish in the future and allow you to relax and rest.

Awareness and Identifying Triggers

• A key component to the prevention of anxiety is awareness. Learning to recognize your anxious thinking patterns when they arise can help you manage and reduce them quickly. Awareness of anxiety begins with trying to identify the cause and/or trigger of anxiety and gaining an understanding of how it affects your mood and behaviors. Is it that your boss recently gave you negative feedback at work and you are worried each day that you are not doing well enough for their standards? Is it that you waited until the last minute to study for a test and are feeling anxious that you will not perform well? Awareness of the source of your anxiety is the first step to finding out the best way to relieve it.
• Sometimes there are things in your life that you already know trigger anxiety. It could be a big test, having to give a speech or perform in front of an audience, and/or the stress and anxiety related to parenting. Once you identify your triggers, you can start to practice coping strategies that can help calm your anxiety before and as it occurs.
  • For example, if you know you often procrastinate when it comes to studying for a test and get significant test anxiety, try out study strategies that prompt you to start studying earlier and set realistic study schedules.
  • If you can identify that after a long day of parenting you often feel exhausted and overcome with anxiety by all of the things you need to do, you can work to schedule in "me time" where you can make sure that you have time to relax, exercise or engage in an enjoyable activity that you know helps to reduce your anxiety. Taking care of yourself is important to be able to take care of others.
  • It could be helpful to have a journal that you use to track your stressors, mood, thoughts, and behaviors that are impacted by anxiety. This will further help you identify the cause of your anxiety and notice when you may be engaging in unhelpful thoughts that only increase your anxiety.

Supportive Friendships & Family/ Contact a Therapist

• Some research shows that people who have close and supportive friendships have a greater ability to fight mental and physical diseases than isolated people. The mind can be our worst enemy when feeling anxious and having a supportive network that you can discuss and decompress your deepest worries to could help prevent anxiety from consuming your life. Find trusted friends during times of anxiety that you can open up to and know that they will provide a listening ear and supportive feedback about your experiences.
• It should be noted that finding the right strategy that works for you to control your anxiety is important. Maybe you feel that you do not have the time to schedule "me time" with your busy schedule or kids, and you need to find another way to reduce your anxiety. A friend or therapist could be a great resource to turn to if you believe you need help with finding the right strategies to reduce your anxiety.
• Therapy services such as Cognitive Behavioral Therapy (CBT) have also been shown to help with the prevention of anxiety symptoms from reaching a diagnosable disorder. Even if you do not have a diagnosed anxiety disorder, attending therapy could be a wonderful resource to aid in gaining strategies to reduce your stress and anxiety.

Recognizing the Disorder in Others

Jennifer Stevens, PhD

How do I recognize if someone close to me is having trouble with anxiety?

Anxiety disorders are the most common mental health disorder in the U.S., affecting more than 18% of the population. They are even more common among children, affecting an estimated 25% of children between the ages of 13 and 18. The most common anxiety disorders are Specific Phobias, affecting 8.7% of the population, and Social Anxiety, affecting 6.8% of the population.

Signs of anxiety in children

You likely know someone with an anxiety disorder.

Although there are several different types of anxiety disorders, each with unique features, there are some common symptoms that might be a clue that someone is suffering from an anxiety disorder:

• The person indicates excessive anxiety or worry about future events. Some examples could be social situations, work demands, or separation from "safe" people or places such as a parent or the home.
• The person has feelings of panic and accompanying physiological reactions (sweaty palms, heart racing, heavy breathing) in certain situations.
• The person experiences sleep disturbances related to the anxiety or worry.
• The person has difficulty concentrating as a result of the anxiety or worry.
• You may also notice general signs of distress, like neglect of personal hygiene, weight gain or loss, a decline in performance at work or school, major changes in mood, or withdrawal from activities or relationships.
• There are two important guidelines to think about, aside from symptoms. These are duration of symptoms and level of impairment. Anxiety is a normal reaction to stressful situations, and even high levels of anxiety can be healthy and beneficial at times. Disorders are only present when anxiety symptoms last for several weeks to months and significantly interfere with everyday function or cause long-lasting distress.

Please note that it is not a good idea to attempt to diagnose or label a friend or family member. Only a mental health professional can diagnose an anxiety disorder, as many disorders have overlapping features, and can go together with other types of mental health difficulties. However, if you notice signs of anxiety, or just feel that something is not quite right with someone that you care about, it's a good idea to reach out to ask the person how they are feeling. You could start with something neutral and supportive like, "It seems like you haven't been quite yourself lately. Is there something going on that you want to talk about?"

What can I do to help a family member or a close friend with anxiety?

One of the most important things you can do is to listen to your family member or friend talk about the things in his/her life that are sources of stress. A first instinct might be to offer advice or ideas for a "quick fix." However, simply accepting your friend's stress levels can help them deal with their anxiety, knowing that they can rely on you as a source of support even when their symptoms might be tough to watch. Studies show that social support from family and friends can be one of the strongest protective factors against debilitating levels of anxiety.

It may also be helpful to:

• Avoid shaming your friend for their anxiety. Comments like "just get over it" or "chill out" can be hurtful.
• Ask your friend how you can help.
• Be patient. If a friend is experiencing an episode of anxiety, it may not be helpful to intervene or try to fix it. It can be most helpful to be available and let your friend know that you support and love them.
• Support the idea of getting treatment. There can be a lot of stigma around seeking help for mental health difficulties. Showing your support for this may allow them to get over initial fears around taking that first step in getting professional help.

What can I do to help my spouse or partner?

Anxiety symptoms can put a major burden on relationships. In addition to seeing your partner experiencing high levels of fear or stress, you're also likely to have more than the ordinary share of everyday responsibilities. Here are four things you can try:

1. Set goals: You and your partner can agree on key objectives, and you can recognize accomplishments. For example, if you and your partner agree that you're both feeling isolated, you could plan to attend one social occasion together every month.
2. Support treatment: Research treatment options with your partner and encourage treatment. There are several useful types of treatment for anxiety, and a number of them actively involve the partner and family members. Find a therapist in your area.
3. Ask how you can help: Don't feel like you should be able to read your partner's needs without asking. Ask what you can do to help, and listen carefully to what they say.
4. Put yourself in their shoes: Acknowledge that you don't understand what your partner feels when they experience a significant bout of anxiety such as a panic attack.

It's also important to take care of yourself. This is not selfish. You can't help your partner or support your family when you are completely overburdened. You could start by:

• Pursuing your own interests and hobbies. These activities will keep you energized, and remind you that you're a real and interesting person, outside of your role as partner or parent.
• Keep up important relationships. Your friends and family are an important source of support for you too! Your social network can provide emotional support and discuss problems that your spouse may not be able to deal with.
• Seek professional help if needed. Caregivers often experience symptoms of anxiety and depression themselves and may benefit from mental health treatment. You can take a look at how you are doing with this caregiver self-assessment tool.

What can I do to help my child with anxiety?

Anxiety disorders often first appear in childhood. This is a good time to intervene or seek treatment, because children's brains are still developing, and can more easily adapt to new "modes" of thinking, relative to adult brains. Helping your child cope with an anxiety disorder can be a complex task, potentially involving family members, friends, teachers and counselors, and mental health professionals. These five basic tips may also help:

1. Positively reinforce healthy behavior, rather than punishing or criticizing problem behaviors (like avoidance, complaints, sleep disturbances)
2. Recognize or praise the child for her own progress or improvement, thinking about how far she has come, rather than comparing to a set of standards.
3. Focus on developing healthy habits that will benefit everyone in your family, such as a good sleep routine, healthy meals and snack, and regular exercise.
4. Foster the development of a strong peer network. It's probably no surprise to hear that peer relationships become a major source of support during adolescence. Encourage your child to engage in interests (like arts, music, and sports) that will help them develop and maintain friendships. If your child already has a hectic and structured schedule, try to carve out some time for more relaxed socializing. However, note that sometimes peers can be the source of anxiety, whether through peer pressure or bullying. Check-in with your child about the nature of their relationships with others in their social circle (school or class).
5. If your child is experiencing separation anxiety, be supportive and caring when they are in distress but try to avoid changing behavior to overly accommodating the anxiety. If you notice the separation anxiety lasting for longer than four weeks, seek professional help from a psychologist or counselor to learn effective behavioral techniques to treat the anxiety.

Just as in the case of taking care of a spouse or partner with anxiety, taking care of a child with anxiety can make you lose sight of your own mental and physical health. See our self-help tips above.

What can I do to help a co-worker?

Signs of mental health difficulty can be different in the workplace than in other settings. The Harvard Mental Health Letter outlined signs that you may notice in your co-workers, which could indicate a significant problem. For anxiety disorders, these can include restlessness, fatigue, difficulty concentrating, excess worrying, and a general impairment in quality of work.

If you think a friend or colleague at work is experiencing an anxiety disorder or another mental health difficulty, you should carefully consider how you react. Your actions in the workplace can have work-related and legal consequences. However, intervening early before an emergency arises can help prevent greater consequences for your colleague's career, health, and safety.

The American Psychiatric Association supports a workplace training program that can help you identify mental health issues in the workplace, and helpful actions to take.

For a practical and sensitive review of mental health issues in the workplace, check out this helpful approach.

Anxiety Disorders: An Overview

Sanne van Rooij, PhD, and Anaïs Stenson, PhD

In an anxiety-related disorder, your fear or worry does not go away and can get worse over time. It can influence your life to the extent that it can interfere with daily activities like school, work and/or relationships. Fear, stress, and anxiety are "normal feelings and experiences" but they are completely different than suffering from any of the seven diagnosable disorders plus substance-induced anxiety, obsessive-compulsive disorders, and trauma- or stressor-related disorders.

Anxiety disorders keep people from sleeping, concentrating, talking to others, or even leaving their home. Anxiety that may need treatment is often irrational, overwhelming, and disproportionate to the situation. It makes sufferers feel as though they have no control over their feelings, and it can involve severe physical symptoms like headaches, nausea, or trembling. It becomes classified as a disorder when normal anxiety becomes irrational and begins to recur and interfere with daily life.

Butterflies in your stomach before an important event? Worried about how you will meet a deadline? Nervous about a medical or dental procedure? If so, you are like most people, for whom some worry about major events (like having a child, taking an exam, or buying a house), and/or practical issues (like money or health conditions), is a normal part of life. Similarly, it is not uncommon to have fears about certain things (like spiders, injections, or heights) that cause you to feel some fear, worry, and/or apprehension. For example, many people get startled and feel nervous when they see a snake or a large insect. People can differ in what causes them to feel anxious, but almost everyone experiences some anxiety in the course of their life.

But, as an example, what if someone will not leave their home for extended periods of time because they are afraid of being in a crowd or being reminded of a past traumatic event. That is not a "normal feeling or experience."

There are several different anxiety-related disorders. Some symptoms overlap across many of these disorders, and others are more specific to a single disorder. In general, however, all anxiety-related disorders feature worry, nervousness, or fear that is ongoing, excessive, and has negative effects on a person's ability to function. It can be tricky to decide when anxiety is typical or linked to a disorder, which is why diagnoses should be made by licensed professionals, such as psychologists or psychiatrists.

A helpful approach to distinguishing normal anxiety from an anxiety disorder is to identify the cause of the anxiety, and then assess whether the anxiety symptoms are a proportional response to it. Worries, fears, and intrusive thoughts that are extreme, unrealistic, or exaggerated and interfere with normal life and functioning could constitute an anxiety disorder. For instance, being concerned about getting sick and taking steps to avoid germs, like using hand sanitizer and avoiding touching door handles, does not necessarily constitute an anxiety disorder; however, if the concern about sickness makes it difficult to leave the house, then it is possible that the person suffers from an anxiety or anxiety-related disorder.

Anxiety disorders are characterized by a general feature of excessive fear (i.e. emotional response to perceived or real threat) and/or anxiety (i.e. worrying about a future threat) and can have negative behavioral and emotional consequences. Obsessive-compulsive and related disorders are characterized by obsessive, intrusive thoughts (e.g., constantly worrying about staying clean, or about one's body size) that trigger related, compulsive behaviors (e.g. repeated hand-washing, or excessive exercise). These behaviors are performed to alleviate the anxiety associated with the obsessive thoughts. Trauma- and stressor- related anxiety disorders are related to the experience of a trauma (e.g., unexpected death of a loved one, a car accident, or a violent incident) or stressor (e.g., divorce, beginning college, moving).

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the handbook used for diagnosis of mental health disorders, and is widely used by health care professionals around the world. For each disorder, the DSM has a description of symptoms and other criteria to diagnose the disorder. The DSM is important, because it allows different clinicians and/or researchers to use the same language when discussing mental health disorders. The first DSM was published in 1952 and has been updated several times after new research and knowledge became available. In 2013, the most recent version of the DSM, the DSM-5, was released. There are a few important differences with its predecessor DSM-IV regarding anxiety disorders. First, Obsessive Compulsive Disorder (OCD) is not part of the anxiety disorders any more, but now has its own category: Obsessive-Compulsive, Stereotypic and related disorders. Second, Post-Traumatic Stress Disorder (PTSD) now also has its own category: Trauma and Stressor-related Disorders.

If you think you might be struggling with an anxiety disorder, you're not alone:

• Anxiety disorders are the most common mental illness in the U.S.
• Over 40 million American adults are afflicted by anxiety disorders
• Women are twice as likely as men to develop PTSD
• 40% of American adults have experienced an Anxiety Disorder at some point in their life
• Only 1/3 of adults suffering from anxiety disorders receive treatment
• Only 1/5 of teenagers suffering anxiety disorders receive treatment
• Anxiety disorders are estimated to cost society over $42 billion per year

Nevertheless, if you are struggling with symptoms of an anxiety disorder it is not uncommon to feel alone and misunderstood. Because the fear that people with an anxiety disorder have is not experienced by others, they may not understand why, for example, being in a crowd of people, not being able to wash your hands after meeting a new person, or driving through the street where you got in a car accident can be really anxiety-provoking for someone with an anxiety disorder. People may comment that "there is no reason to worry about it" or that you "should just let it go".

Not everyone understands is that someone with an anxiety disorder cannot "just let things go". This makes the struggle with an anxiety disorder even harder, and may prevent one from looking for help. However, it is very important to talk about these anxieties with someone and preferably find a health care professional as soon as you experience these symptoms. Anxiety should be considered as severe as a physical disease; however, most people in society do not appreciate the severity of this disorder. Some people may consider anxiety a fault or a weakness; however, it may help if people realize that many research studies have demonstrated biological explanations for (some of) the symptoms observed in anxiety disorders. Brain scans have demonstrated brain abnormalities in certain anxiety disorders, and also altered brain functioning has been demonstrated for individuals with anxiety disorders. Furthermore, there is some evidence that anxiety disorders might be linked to chemical imbalances in the brain.

So, if anxiety has so many negative effects, why is it relatively common? Many scientists who study anxiety disorders believe that many of the symptoms of anxiety (e.g., being easily startled, worrying about having enough resources) helped humans survive under harsh and dangerous conditions. For instance, being afraid of a snake and having a "fight or flight" response is most likely a good idea! It can keep you from being injured or even killed. When humans lived in hunter-gatherer societies and couldn't pick up their next meal at a grocery store or drive-through, it was useful to worry about where the next meal, or food for the winter, would come from. Similarly avoiding an area because you know there might be a bear would keep you alive —worry can serve to motivate behaviors that help you survive. But in modern society, these anxiety-related responses often occur in response to events or concerns that are not linked to survival. For example, seeing a bear in the zoo does not put you at any physical risk, and how well-liked you are at work does not impact your health or safety. In short, most experts believe that anxiety works by taking responses that are appropriate when there are real risks to your physical wellbeing (e.g., a predator or a gun), and then activating those responses when there is no imminent physical risk (e.g., when you are safe at home or work).