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What is Anxiety?

An Introduction to Anxiety

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.

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.

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

1. Anxiety disorders

2. Obsessive-compulsive and related disorders

3. Trauma- and stressor- related 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. 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).

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Anxiety Quiz: Do I Have Anxiety?

Is your everyday anxiety and stress now affecting your lifestyle, health and relationships? Take this simple 7-question quiz to find out if you might benefit from talking with a professional.

Types of Anxiety

Abigail Powers Lott, PhD, and Anaïs Stenson, PhD

Anxiety Disorders

Anxiety disorders reflect disorders that share a general feature of excessive fear (i.e. emotional response to perceived or real threat) and/or anxiety (i.e. anticipation of future threat) and demonstrate behavioral and functional disturbances as a result. Panic attacks are a feature that can occur in the context of many anxiety disorders and reflect a type of fear response.

Separation Anxiety Disorder

Excessive anxiety concerning separation from home or major attachment figures that is beyond what would be expected for one's developmental level. This can occur in children, adolescents, or adults, but is more commonly found in children.

Symptoms:

  • Recurrent excessive distress when separation from home or major attachment figures occurs (or is anticipated)
  • Persistent, excessive worry about losing major attachment figures (or something harmful happening to them)
  • Persistent and excessive worry that something traumatic will lead to separation from a major attachment figure (e.g., being kidnapped)
  • Persistent reluctance or refusal to go to school or other places because of fear of separation\
  • Persistent or excessive fear or reluctance to be alone or without major attachment figures at home or in other settings
  • Persistent reluctance or refusal to go to sleep without being near a near a major attachment figure (or to sleep away from home)
  • Repeated nightmares involving separation
  • Repeated complaints of physical symptoms (e.g. headaches, stomachaches, vomiting) when separated from major attachment figures (or separation is anticipated)

These symptoms must cause clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning to meet diagnosis. The symptoms cannot be better accounted for by another mental disorder or be caused by substances, medications, or medical illness.

Duration: at least 4 weeks in children; 6 months or longer in adults

Learn more about Separation Anxiety Disorder.

Selective Mutism

A rare disorder characterized by a persistent failure to speak in certain social situations (e.g., with playmates or in the classroom), despite engagement in speaking in other situations.

The mutism must also include impairment in social, academic, or occupational achievement or functioning to qualify as a diagnosis. Selective mutism is not present if it is related to lack of knowledge or comfort with the spoken language required of the situation or is due to embarrassment from a communication or developmental disorder. The symptoms cannot be better accounted for by another mental disorder or be caused by substances, medications, or medical illness.

Duration: at least 1 month, and not limited to the first month of starting school

Specific Phobia

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.

The feared object/situation is avoided or endured with intense anxiety or distress. The avoidance, anticipation of, or distress of the phobic object/situation must cause significant distress or interferes 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.

Duration: at least 6 months

Learn more about Phobias.

Social Anxiety Disorder (Social Phobia)

Excessive fear of becoming embarrassed or humiliated in social situations, which often leads to significant avoidance behaviors.

Symptoms:

  • Significant and persistent fear of one (or more) social or performance situations in which the individual is exposed to unfamiliar people, or to possible scrutiny by others due to fear of humiliation or embarrassment. Note: In children, the anxiety must be present in peer situations and not only in interactions with adults.
  • Exposure to the feared social or performance situation provokes significant anxiety (including panic attack).
  • The person recognizes that the fear is excessive or unreasonable. Note: In children, there may be limited insight.
  • The feared social or performance situations are avoided or else are endured with intense anxiety or distress.

The avoidance, anticipation of, or distress of the phobic object/situation must cause significant distress or interferes 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.

Specifiers:

Generalized – fear is present across any social situations

Specific – eating in public, public speaking, talking to authority figures (e.g. boss)

Duration: Typically lasts at least 6 months or longer

Learn more about Social Anxiety Disorder.

Panic Disorder

This 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:

  • Recurrent expected or unexpected panic attacks AND one or more of the following symptoms for at least one month:
    • Pounding heart
    • Sweatiness
    • Feeling of weakness
    • Faintness
    • Dizziness
    • Tingling or numbness in hands
    • Feeling flushed
    • Sense of unreality
    • Feeling of loss of control or losing one's mind
    • Fear of dying or something physically wrong (e.g., heart attack, stroke)
  • Persistent concern about the consequences of the attacks (e.g. "going crazy", heart attack) or fears of having additional attacks
  • A significant change in behavior related to attacks (e.g. avoiding exercise)

Duration of panic attacks: a few minutes to 10 minutes (rarely last longer than 1 hour)

It is important that these symptoms are not better accounted for by another disorder (e.g. panic attacks only in social settings). The symptoms also cannot be caused by substances, medications, or medical illness.

Learn more about Panic Disorder.

Agoraphobia

Excessive fear related to being in (or anticipating) situations where escape might be difficult or help may not be available if panic attack (or panic-like symptoms) occur.

Symptoms:

  • Intense fear in response to (or when anticipating) at least two of the five following situations:

1. using public transportation (e.g. cars, buses, planes)

2. being in open spaces (e.g. parking lots, bridges)

3. being in enclosed spaces (e.g. shops, movie theatre)

4. standing in line or being in a crowded place

5. being outside the home alone

  • Immediate anxiety response when confronted with such situations
  • Avoidance of such situations (changes daily routine or restricts travel) or endures such situations with significant distress.
  • Recognition of fear as disproportionate to circumstances

The diagnosis of panic disorder is no longer required for a diagnosis of agoraphobia. The symptoms cannot be better accounted for by another mental disorder or be caused by substances, medications, or medical illness.

Duration: Symptoms present 6 months or longer

Generalized Anxiety Disorder

Characterized by excessive, uncontrollable worry over events and activities and potential negative outcomes.

Symptoms:

  • Excessive anxiety and worry about a variety of events or activities, even when nothing is wrong or when the worry is disproportionate to actual risk.
  • The worry is difficult to control
  • The worry is associated with at least three (adults) or one (children) of the following physical or cognitive symptoms:
    • Restlessness
    • Fatigue
    • Impaired concentration or feeling that mind is going blank
    • Irritability
    • Increased muscle aches or soreness
    • Difficulty sleeping (trouble falling asleep or staying asleep)
  • Sometimes associated with other physical symptoms such as nausea or diarrhea

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.

Duration: Symptoms present 6 months or longer

Learn more about Generalized Anxiety Disorder.

Substance-Medication-Induced Anxiety Disorder

Anxiety or fear caused by the effects of a medication or psychoactive substance.

Symptoms:

  • Anxiety or fear reaction following medication or drug use (can include generalized anxiety, panic attacks, or phobic reactions)
  • Can include physical panic-like symptoms, such as racing heart or shakiness
  • May occur while individual is intoxicated or after using the drug (withdrawal)

Duration: During drug use or up to four weeks after cessation of use; some experience anxiety and panic symptoms for up to 6 months following use. Onset of symptoms must be clearly tied to substance use and not better explained by another mental disorder.

Other (Due to another medical condition)

The anxiety disorder may manifest like any of the above disorders (e.g. GAD), however the cause is due to the direct physiological effect of a medical condition.

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. These types of disorders can restrict participation in everyday life and/or generate significant distress, for instance, by making it difficult to leave the house without many repetitions of a compulsive behavior (e.g. checking that the doors are locked). Periodically experiencing worry or having a few "idiosyncratic" habits does not constitute an obsessive-compulsive or related disorder. Instead, these disorders are characterized by unusually high levels of worry and related compulsive behaviors, in comparison with a typical range of individuals.

Obsessive-Compulsive Disorder (OCD)

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).

Symptoms:

  • Repetitive, intrusive thoughts or images that cause anxiety
  • Devoting more than an hour a day to the obsessions and/or compulsions
  • Experiencing distress because of the obsessions and/or compulsions
  • Interference of the obsessions and/or compulsions with work or social interactions

Other : The symptoms are not triggered by a) the physiological effects of a substance (i.e. drugs or alcohol) or b) another medical condition (e.g., excoriation or hoarding).

Learn more about Obsessive-Compulsive Disorder.

Excoriation

Repetitive skin picking of one's own skin that results in lesions. Many individuals will experience shame about the behavior and/or attempt to conceal the resulting lesions with clothing or makeup.

Symptoms:

  • Skin picking that produces lesions
  • Repeated attempts to reduce or eliminate the skin picking behavior
  • The skin picking leads to reduced or impaired social or professional function

Other: The symptoms are not triggered by a) the physiological effects of a substance (i.e. drugs or alcohol) or b) another mental health issue (e.g., intent to self-harm).

Hoarding Disorder

A condition in which parting with objects (e.g., household items or personal possessions) causes significant distress. In addition, many individuals continuously acquire new things and experience distress if they are not able to do so. The inability to discard possessions can make living spaces nearly unusable. Relatedly, the cluttered living space can interfere with the performance of daily tasks, such as personal hygiene, cooking, and sleeping (e.g., the shower is full of stuff, the bed is covered with clutter).

Symptoms:

  • Individual collects and keeps many items, even if they are not useful or valuable
  • The items impede typical use of the individual's living space
  • The items impede daily life and/or cause distress

Other: The symptoms are not triggered by another medical (e.g., brain damage) or mental health condition (e.g., depression).

Body Dysmorphic Disorder (BDD)

Characterized by a preoccupation with the belief that one's body or appearance are unattractive, ugly, abnormal or deformed. This preoccupation can be directed towards one or many physical attributes (e.g., acne, hair loss, facial features). Muscle dysmorphia is a subtype of this disorder that is characterized by belief that one's body is too small or insufficiently muscular.

Symptoms:

  • Obsession with a perceived flaw in one's appearance that are either minor or unnoticeable to others
  • Concerns about appearance often trigger repetitive behaviors (e.g., looking in the mirror an unreasonable number of times or for extended period of time) or mental acts (e.g., comparing one's appearance to that of others)
  • The preoccupation with appearance impairs social, academic, or professional function

Other: The symptoms are not better explained by concerns with body fat or weight in individuals diagnosed with an eating disorder.

Trichotillomania

Characterized by repeatedly pulling out one's own hair, most commonly from the scalp, eyebrows, or eyelashes.

Symptoms:

  • Repeatedly pulling out hair from one's own body, which results in hair loss
  • Repeated past attempts to stop the hair-pulling behavior
  • The hair pulling is a source of distress or impairment in social and/or professional functioning

Other: The symptoms are not triggered by another medical condition or mental health issue. Many individuals with trichotillomania also display other body-focused repetitive behaviors, such as skin-picking or nail-biting.

Trauma- and Stressor-related Disorders

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).

Post-Traumatic Stress Disorder (PTSD)

Characterized by the development of certain trauma-related symptoms following exposure to a traumatic event (see "Diagnostic criteria" below). While most people experience negative, upsetting, and/or anxious reactions following a traumatic event, a diagnosis of PTSD is made when symptoms and negative reactions persist for more than a month and disrupt daily life and functioning. Symptoms are separated into four main groups: re-experiencing, avoidance, negative cognitions and mood, and hyperarousal. The specific symptoms experienced can vary substantially by individuals; for instance, some individuals with PTSD are irritable and have angry outbursts, while others are not. In addition to the symptoms listed below, some individuals with PTSD feel detached from their own mind and body, or from their surroundings (i.e., PTSD dissociative subtype).

Diagnostic criteria: A PTSD diagnosis entails that the individual's symptoms are related to a traumatic event that meets two criteria:

1.The individual was exposed to serious injury, sexual violence, or actual or threatened death.

2.This exposure happened either by directly experiencing the event(s), witnessing the event(s) in person, learning that the event(s) happened to a close friend or loved one (note: for cases of death or near death, it must have been violent or accidental), or being repeatedly exposed to the aversive details from traumatic events (e.g., as an emergency room doctor or nurse who frequently sees dead and mutilated bodies).

Symptoms:

  • Re-experiencing
    • Recurrent, distressing, and involuntary memories about the traumatic event
    • Distressing dreams about the traumatic event
    • Dissociative episodes in which the individual feels that the trauma is about to recur (e.g., flashbacks)
    • Psychological distress following exposure to cues, either from the external environment (e.g., fireworks) or internal states, associated with the trauma
    • Strong physiological responses to internal or external cues that are associated with the trauma
  • Avoidance
    • Avoiding, or trying to avoid, either or both:
    • Distressing memories, thoughts, or feelings about the traumatic event
    • External reminders of the trauma (e.g., a specific location or song)
  • Negative Cognitions and Mood
    • Inability to remember important aspects of the trauma
    • Persistent and exaggerated negative beliefs or expectations about oneself, others or the world
    • Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others
    • Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame)
    • Markedly diminished interest or participation in significant activities
    • Feelings of detachment or estrangement from others
    • Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings)
  • Hyperarousal
    • Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects
    • Reckless or self-destructive behavior
    • Hypervigilance
    • Exaggerated startle response
    • Problems with concentration
    • Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep)

Duration: Symptoms persists for more than one month.

Dissociative Subtype: Presence of depersonalization (i.e., feeling of detachment from own body or mind) or derealization (i.e., experience of surroundings feeling strange or unusual).

Other: These symptoms are not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Learn more about Post-Traumatic Stress Disorder.

Acute Stress Disorder

Characterized by a suite of symptoms that persist for at least three days and up to one month after a traumatic experience (same diagnostic criteria for "trauma" as listed above). The specific symptoms of the disorder vary across individuals, but a common feature is intense anxiety in response to re-experiencing symptoms (e.g., recurrent intrusive recollections of traumatic event) of the trauma.

Symptoms:

  • Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s)
  • Recurrent distressing dreams in which the content and/or affect of the dream are related to the event(s)
  • Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)
  • Intense or prolonged psychological distress or marked physiological reactions in response to internal or external cues that symbolize or resemble an aspect of the traumatic event(s)
  • Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings)
  • An altered sense of the reality of one's surroundings or oneself (e.g., seeing oneself from another's perspective, being in a daze, time slowing)
  • Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs)
  • Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
  • Efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)
  • Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep)
  • Irritable behavior and angry outbursts (with little or no provocation), typically expressed as verbal or physical aggression toward people or objects
  • Hypervigilance
  • Problems with concentration
  • Exaggerated startle response

Other: These symptoms are not attributable to the physiological effects of a substance (e.g., medication, alcohol), another medical condition, or a brief psychotic episode.

Adjustment Disorder

Characterized by the development of emotional and/or behavioral symptoms in direct response to a significant stressor (e.g., divorce, starting college, moving); the symptoms must emerge within three months of the onset of that identifiable stressor. Specifiers for symptoms include depressed mood, anxiety, and/or disturbance of conduct.

Symptoms:

  • Development of emotional and/or behavioral symptoms as a result of identifiable stressor
  • Emotional or behavioral symptoms are clinically significant and marked by either marked distress that is out of proportion to the severity or intensity of the stressor (important to take external context and cultural factors into account) OR significant impairment in social, academic, occupational, or other important areas of functioning.

Other: Symptoms cannot be better accounted for by another mental disorders and do not represent normal bereavement.

Duration: Acute represents symptoms present for less than six months; chronic represents symptoms present for six months or longer.

Causes and Risk Factors

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

It's important to note that everyone feels anxiety to some degree regularly throughout their life - fear and anxiety are adaptive and helpful emotions that can function to help us notice danger or threat, keep us safe, and help us adapt to the environment. Anxiety disorders represent states when fear or anxiety becomes severe or extreme, to the extent that it causes an individual significant distress, or impairs their ability to function in important facets of life such as work, school, or relationships. It is also important that risk factors don't at all imply that anxiety is anyone's fault; anxiety disorders are a very common difficulty that people experience. In this section, we will review risk factors for anxiety disorders. 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 co-morbidity, 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, as being aware of who might be at risk can potentially help people get support or assistance in order 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 it is likely that a genetic vulnerability to anxiety exists in that family.

With regard to environmental factors within the family, parenting behavior can also impact risk for anxiety disorders. Parents who demonstrate high levels of control (versus granting the child autonomy) while interacting with their children has been associated with development of anxiety disorders. Parental modeling of anxious behaviors and parental rejection of the child has also been shown to potentially relate to greater risk for anxiety. 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 risk for experiencing an anxiety disorder later in life. Having recently 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 risk for anxiety disorders, as well as dealing with 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 risk for 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 risk of developing an anxiety disorder later in life. With regard to 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 risk for anxiety disorders. While there is not a strong consensus, research suggests that risk for anxiety disorders decreases over the lifespan with 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 puts 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 and Physical Health

Vasiliki Michopoulos, PhD

Anxiety disorders increase one's chances for suffering from other medical illness, 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 a shared underlying biology and that anxiety maybe 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 in order 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 supress 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 risk for cardiovascular and even autoimmune disorders. Neuroscience and clinical research continues to investigate how anxiety disorders increase 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 guides 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. 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 disstress 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 prefered 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 again in positive behaviors even in the presence of negative thoughts and behaviors. The goal is to improve daily functioning despire 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 better understand the patient. 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 reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs) 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 very 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 of time 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. In addition, taking benzodiazepines while also engaging in psychotherapy such as PE can reduce the effectiveness of the exposuere 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 the 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 directly target abnormal nerve cell activity. 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 selectively target which brain regions to treat. Typical sessions lasts 30-60 minutes and do not require anesthesia. Sessions are administered 4-5 times a week for about 6 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 targetes 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 procedue 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 very 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 methylenedioxymethamfetamine (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 Disoder, and tetrahydrocannabinol (THC) has helped PTSD patients. However, the plant form of cannabis has not shown great efficacy and has potential to worsen symptoms, so should be used with caution and only under 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 degree (PhD) 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 provides 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)

A licensed mental health specialist with a master's degree in psychology or related field who treats emotional, mental and behavioral problems. LMHC are qualified to provide counseling or psychotherapy.

Clinical Social Worker

CSWs 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 tha 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 tension that is commonly associated with stress. Engaging in relaxation strategies regularly 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 times 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 practice, meditation, and mindfulness 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 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 people who are isolated. 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.

It is likely that you 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 very 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 every day 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?

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 typical share of every day responsibilities. Here are four things you can try:

  1. Set goals: You and your partner can agree on key goals, 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 a number of effective types of treatments 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 closely to what they say.
  4. Put yourself in their shoes: Acknowledge that you don't understand what your partner is feeling when they experience a major bout of anxiety such as a panic attack.

It's also very 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?

Anxiety disorders often first appear in childhood. This is a very 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 very busy 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 accommodate the anxiety. If you notice the separation anxiety lasting for longer than four weeks, seek professional help from a psychologist or counselor in order 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 outlines 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 other 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 situation 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.

You can also download a detailed workplace mental health kit from NAMI NYC.

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https://www.ncbi.nlm.nih.gov/pubmed/27246996

Treatment Options
https://www.samhsa.gov/treatment/mental-disorders/...

http://www.mayoclinic.org/tests-procedures/cogniti...

https://www.beckinstitute.org/get-informed/what-is...

https://behavioraltech.org/resources/faqs/what-is-...

https://psychcentral.com/lib/what-is-exposure-ther...

http://www.mayoclinic.org/diseases-conditions/depr...

http://www.webmd.com/anxiety-panic/guide/medicatio...

Martin JL, Sainz-Pardo M, Furukawa TA, Martín-Sánchez E, Seoane T, Galán C (September 2007). "Benzodiazepines in generalized anxiety disorder: heterogeneity of outcomes based on a systematic review and meta-analysis of clinical trials". Journal of Psychopharmacology. 21 (7): 774–82.

Hayes PE., Schulz SC. Beta-blockers in anxiety disorders. J Affect Disord. 1987;13:119–130.

Rickels K., Weisman K., Norstad N., et al. Buspirone and diazepam in anxiety: a controlled study. J Ciin Psychiatry. 1982;43:81–86.

Kastenholz KV. Buspirone, a novel nonbenzodiazepine anxiolytic. Clin Pharmacol. 1984;3:600–607.

Ganasen KA, Stein DJ. Pharmacotherapy of social anxiety disorder. Curr Top Behav Neurosci. 2010;2:487-503.

https://www.ptsd.va.gov/public/treatment/therapy-m...

https://www.healthline.com/health/anxiety-doctors#...

https://www.apa.org/action/science/clinical/educat...

https://www.apna.org/i4a/pages/index.cfm?pageid=32...

http://www.webmd.com/mental-health/guide-to-psychi...

https://nccih.nih.gov/health/tips/stress

Goyal M, Singh S, Sibinga ES, et al. Meditation Programs for Psychological Stress and Well-being: A Systematic Review and Meta-analysis. JAMA Intern Med. 2014. doi:10.1001/ jamainternmed.2013.13018.

https://adaa.org/finding-help/treatment/complement...

https://www.ncbi.nlm.nih.gov/pubmed/28636769

https://www.ncbi.nlm.nih.gov/pubmed/27067625

Recognizing the Disorder in Others

https://www.nimh.nih.gov/health/statistics/prevale...

https://doi.org/10.1016/j.yfrne.2009.06.001,

https://doi.org/10.1098/rstb.2006.1941

https://doi.org/10.1093/geronb/58.2.P112

http://www.apa.org/monitor/julaug04/tips.aspx

https://my.clevelandclinic.org/health/articles/tee...

https://www.niddk.nih.gov/health-information/weigh...