What is Anxiety?

Types of Anxiety Disorders

Abigail Powers Lott, PhD, and Anaïs Stenson, PhD

Categorically, anxiety-related disorders can be divided into three primary groups, as described by Abigail Powers Lott, PhD, and Anaïs Stenson, PhD:

1. Anxiety disorders: These disorders are characterized by an overarching sense of excessive fear in which the individual exhibits emotional responses to perceived or actual threats. In addition, anxiety disorders involve worry about future threats, leading to negative behavioral and emotional consequences.
2. Obsessive-compulsive and related disorders: This group includes conditions characterized by intrusive, persistent thoughts known as obsessions. These thoughts trigger specific compulsive behaviors to relieve the anxiety associated with the obsessions. Examples include unrelenting preoccupations with cleanliness or body image that compel individuals to engage in repetitive behaviors such as excessive hand washing or extreme exercise.
3. Trauma and stressor-related disorders: Disorders in this category are closely related to traumatic experiences or significant stressors. Trauma includes events such as the unexpected loss of a loved one, involvement in a car accident, or exposure to violence such as war or sexual assault. Stressors include life events such as divorce, starting college, or moving.

• If a person has a persistent and excessive fear of a Specific Phobia, such as flying, heights, animals, toilets, or seeing blood, they may be diagnosed with a specific phobia – an anxiety disorder. The fear is triggered by the presence or anticipation of the feared object or situation, causing an immediate fear response or panic attack. Characteristically, the intensity of the fear experienced is disproportionate to the actual threat. Adults with specific phobias often recognize the irrationality of their fear. Learn more about Phobias.
• Social Anxiety Disorder (SAD) may be indicated when an individual exhibits an excessive fear of embarrassment or humiliation in social settings, resulting in significant avoidance behaviors. It is advisable to seek further information about Social Anxiety Disorder, especially if the fear of social situations persists for more than six months.
• Post-traumatic stress disorder (PTSD) is the most widely recognized trauma and stressor-related disorder. These disorders result from traumatic experiences such as the sudden loss of a loved one, involvement in a car accident, exposure to combat or other violent incidents, as well as significant stressors such as divorce, starting college, or moving. This category also includes acute stress disorder and adjustment disorder. Extensive resources are available for in-depth exploration of PTSD symptoms and treatment.
• Generalized anxiety disorder (GAD) is characterized by excessive and uncontrollable worry about events, activities, and possible negative outcomes. The anxiety and worry must cause significant distress or interfere with an individual’s daily life, including occupational, academic, or social functioning, to meet the diagnostic criteria. Importantly, the symptoms must not be better explained by another mental disorder or by substances, medications, or medical conditions. For more information on Generalized Anxiety Disorder, please consult the appropriate resources.
• Panic disorder manifests as sudden panic symptoms, often without identifiable triggers, along with persistent anxiety about the possible return of panic symptoms. Symptoms include recurrent panic attacks that may be anticipated or unexpected and may last from a few minutes to an hour.
• Obsessive-compulsive disorder (OCD) is one of several related disorders that share common features. It involves persistent and repetitive thoughts, known as obsessions, that typically cause distress. To relieve this distress, the individual performs specific actions known as compulsions. Examples of common obsessions include fears that failure to perform certain rituals will result in harm to oneself or others, extreme fears of contamination or germs, concerns about forgetting important tasks leading to negative outcomes, or obsessions with precision and symmetry. Common compulsions may involve checking for mistakes, counting or organizing items, or engaging in mental rituals such as praying. Other disorders in this category include 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 induced by substance use or resulting from other medical conditions.

Causes and Risk Factors

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

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

Anxiety is a common emotional experience that everyone experiences to some degree throughout their lives. Fear and anxiety serve important functions, allowing us to identify and respond to threats, ensure our safety, and facilitate adaptation to our environment. However, when anxiety becomes overwhelming and significantly interferes with daily functioning in important areas such as work, school, or relationships, it may indicate the presence of an anxiety disorder.

While numerous potential risk factors such as genetic markers, neurobiological factors, environmental factors, and life experiences contribute to the development of anxiety disorders, the precise causes of these disorders remain incompletely understood.

Comorbidity, the co-occurrence of multiple anxiety disorders, is more common than isolated occurrences. As a result, many risk factors are common to different anxiety disorders or result from similar underlying causes. Extensive research has identified multiple risk factors for anxiety disorders, highlighting the importance of both genetic and environmental factors and life experiences. It is important to note that no single risk factor definitively predicts the development of a disorder, as individuals may have risk factors without experiencing the disorder. Nevertheless, awareness of potential risk factors can be valuable in helping individuals seek support and preventative measures.

Genetic factors have been implicated in all anxiety disorders. Clinical genetic studies have yielded heritability estimates ranging from 30% to 67% for anxiety disorders. Extensive research has focused on identifying specific genetic variants that increase the risk of developing an anxiety disorder. In particular, several single nucleotide polymorphisms (SNPs), small variations in the genetic code, have been discovered, primarily within genes critical for neurotransmitter systems or stress hormone regulation, and have been shown to be associated with an increased risk of anxiety.

It is important to recognize that genetic factors may also confer resilience to anxiety disorders. Therefore, ongoing large-scale genomic studies aim to identify novel genetic factors associated with anxiety disorders. The ultimate goal is to improve our understanding of the biological pathways involved in the development and maintenance of anxiety and to develop more effective treatments.

While most individuals are unaware of their specific genetic markers that predispose them to anxiety disorders, a family history of anxiety disorders generally indicates a genetic susceptibility to anxiety. It is important to consider both genetic and environmental influences when assessing the presence of anxiety disorders in families.

Environmental factors within the family can significantly influence the risk of developing anxiety disorders. Parenting behaviors play a critical role, with high levels of control and low levels of autonomy being associated with increased risk. In addition, parental modeling of anxious behaviors and parental rejection of the child may also contribute to greater anxiety risk. The experience of stressful life events or chronic stress has been associated with the development of anxiety disorders.

Childhood adversity, such as abuse, parental loss or separation, or traumatic events, may increase the risk of anxiety disorders later in life. The presence of chronic medical conditions or serious illnesses, either in oneself or in family members, is also associated with a higher risk of anxiety. Socioeconomic disadvantage and minority status have been suggested to be associated with greater risk due to reduced access to resources.

Behavioral choices can influence anxiety risk, with excessive use of tobacco or caffeine increasing anxiety and regular exercise decreasing it. Certain temperamental and personality traits can also put people at risk for anxiety disorders. Shyness and behavioral inhibition in childhood increase the risk of developing anxiety disorders later in life. Diabetes, Personality traits such as high neuroticism or low conscientiousness are associated with higher risk for all anxiety disorders. Certain narrow personality traits, including anxiety sensitivity, negative attributional style, and self-criticism, have also been associated with anxiety risk. Personality disorders are another factor that increases the risk of anxiety disorders.

Demographic factors also play a role in anxiety risk. Women are more likely than men to have anxiety disorders, and the severity of symptoms is often greater in women. This gender difference in prevalence and severity is not specific to anxiety disorders, but is observed for depression and other stress-related health outcomes. Hormonal fluctuations, particularly estrogen and progesterone, are thought to contribute to this sex difference, although the exact mechanisms are not fully understood.

Anxiety Physical Symptoms

Vasiliki Michopoulos, PhD

There is a significant link between anxiety disorders and a number of physical ailments, particularly cardiovascular conditions such as obesity, heart disease, and diabetes. Researchers have found associations between anxiety and several physical symptoms, including increased body weight, excess abdominal fat, high blood pressure, elevated cholesterol and triglyceride levels, and elevated blood glucose levels.

While the exact mechanisms underlying the strong comorbidity between anxiety and poor physical health remain unclear, studies suggest that the biological changes characteristic of anxiety may contribute to the development of these physical conditions over time. Factors such as changes in stress hormones, autonomic responses, and systemic inflammation appear to play a critical role in both anxiety disorders and adverse health outcomes. These common physiological states imply a common underlying biology, suggesting that anxiety may manifest as a systemic condition.

Anxiety disorders are closely linked to chronic stress in daily life. Prolonged exposure to unpredictable, unyielding, and irresolvable stressors continually stimulates the stress hormone and cardiovascular systems, resulting in a constant state of heightened activity.

Biologically, the human body has evolved to deal with immediate and tangible threats in the environment, not to endure continuous stressors. When faced with sudden dangers under normal conditions of low chronic stress, the autonomic nervous system is activated, resulting in increased levels of adrenaline, accelerated breathing, and a rapid heart rate.

As a result, stress hormones such as cortisol are released, increasing glucose levels in the bloodstream to prepare the muscles for the fight-or-flight response. Another consequence of stress hormones is the suppression of the immune system, as processes such as healing and repair can be postponed until the threat has passed. However, individuals with anxiety disorders experience persistent activation of these responses due to everyday stressors, resulting in a loss of the stress hormone system’s ability to regulate immune function.

This phenomenon contributes to increased systemic inflammation, which increases the risk of cardiovascular disease and even autoimmune disease. Ongoing neuroscientific and clinical research aims to elucidate how anxiety disorders increase the likelihood of developing physical health comorbidities, with the ultimate goal of identifying new treatments to alleviate suffering and prevent the onset of these systemic disorders.

Treatment Options

Yvonne Ogbonmwan, PhD

When it comes to managing anxiety and related disorders, there are many highly effective treatment options available. These treatments can be broadly categorized as: 1) psychotherapy; 2) medications; and 3) complementary and alternative therapies. Depending on the individual, a combination of these therapies may be beneficial in treating anxiety. In this article, we will explore evidence-based therapies and emerging treatment modalities, as well as discuss different types of care providers.

Evidence-Based Therapies

Counseling

Counseling, a form of talk therapy, is designed to help patients develop strategies and coping skills to address specific issues, such as stress management and interpersonal problems. Counseling is usually a short-term therapy option.

About Psychotherapy

Psychotherapy encompasses a wide range of approaches used to treat anxiety. Unlike counseling, psychotherapy is a more long-term endeavor that addresses a variety of issues, including behavioral patterns. The choice of therapy depends on the patient’s specific anxiety diagnosis and personal preferences.

The ultimate goal of psychotherapy is to help patients regulate their emotions, manage stress, and gain insight into patterns of behavior that affect their relationships. Some of the most effective evidence-based therapies for anxiety include cognitive behavioral therapy (CBT), prolonged exposure therapy (PE), and dialectical behavioral therapy (DBT).

Cognitive Behavioral Therapy (CBT)

CBT is a short-term treatment designed to identify and address inaccurate and negative thought patterns associated with anxiety, such as panic attacks and help patients. This therapy can be done on an individual basis or in a group setting where people with similar challenges come together. CBT focuses primarily on the patient’s current life problems and provides them with new ways to process their thoughts, emotions, and behaviors, thereby promoting more effective coping mechanisms.

In cases where patients suffer from post-traumatic stress disorder (PTSD), CBT can take a trauma-focused approach, with the goal of processing and reframing the traumatic experiences underlying the symptoms. On average, CBT treatment consists of approximately 10-15 weekly one-hour sessions, which may vary depending on the nature and severity of the symptoms.

Prolonged Exposure Therapy (PE)

PE is a specific type of CBT often used to treat PTSD and phobias. The goal of this therapy is to help patients overcome the overwhelming distress caused by reminders of past traumas or confronting their fears. Under the guidance of a licensed therapist, patients are gradually exposed to the memories or cues associated with their trauma.

Throughout the exposure, the therapist assists the patient in using 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 threatening and do not need to be avoided. This treatment typically involves 8-16 weekly sessions.

Eye Movement Desensitization and Reprocessing Therapy (EMDR)

EMDR is a psychotherapy that reduces distress and emotional disturbance caused by memories of traumatic events. It is primarily used in the treatment of PTSD and is similar to exposure therapy. EMDR facilitates the processing of trauma in order to promote healing.

During therapy, patients focus on a back-and-forth movement or sound as they recall their traumatic memories. Sessions continue until the memory is no longer distressing. EMDR sessions typically last 50-90 minutes and are administered weekly for 1-3 months, although many patients report symptom reduction after only a few sessions.

Dialectical Behavior Therapy (DBT)

DBT is a skills-based approach that helps patients learn to regulate their emotions. While commonly used for borderline personality disorder, it has also been shown to be effective in treating anxiety disorders such as PTSD. This therapy teaches patients skills in emotional regulation, stress management, mindfulness, and interpersonal effectiveness. DBT can be administered in either individual or group therapy sessions and is typically a long-term treatment, lasting a year or more.

Acceptance and Commitment Therapy (ACT)

A form of CBT, ACT encourages patients to engage in positive behaviors in spite of negative thoughts and emotions. The goal is to improve daily functioning while living with the disorder. ACT is particularly useful for treatment-resistant generalized anxiety disorder and depression. The length of treatment varies depending on the severity of the symptoms.

Family Therapy

Family therapy involves the patient’s family in group therapy sessions to improve communication and conflict resolution skills. This therapy is valuable when family dynamics contribute to the patient’s anxiety. During this short-term therapy, the patient’s family learns strategies to avoid exacerbating anxiety symptoms and gain a better understanding of the patient’s experience. The length of treatment depends on the severity of the symptoms.

Medications

Medications are sometimes used in conjunction with psychotherapy. Although medications are generally safe, they can have side effects. The specific medications prescribed depend on the patient’s symptoms and overall health, as determined by their healthcare provider.

Antidepressants

Antidepressants are commonly prescribed for depression, but can also be effective in relieving symptoms of anxiety. Selective serotonin reuptake inhibitors (SSRIs) and selective norepinephrine reuptake inhibitors (SNRIs) are the main classes of antidepressants used to treat anxiety. SSRIs such as escitalopram (Lexapro) and paroxetine (Paxil, Pexeva) are commonly prescribed, while SNRIs such as duloxetine (Cymbalta) and venlafaxine (Effexor XR) are also used.

Buspirone

Buspirone is an anxiety-specific medication recommended for generalized anxiety disorder. It shows high efficacy in reducing cognitive and interpersonal problems associated with anxiety. Unlike benzodiazepines, buspirone does not cause sedation or interact negatively with alcohol. In addition, the risk of dependence on buspirone is low. Possible side effects include dizziness, nervousness, and headache. BuSpar and Vanspar are common trade names for buspirone.

Benzodiazepines

Benzodiazepines are sedative medicines used for anxiety, alcohol withdrawal, epilepsy, and muscle spasms. They provide short-term relief for generalized anxiety disorder and may help with sleep problems. While benzodiazepines may be prescribed for short-term relief of acute anxiety symptoms, long-term use is discouraged because of their sedative effects and potential for dependence. Combining benzodiazepines with psychotherapy, such as Prolonged Exposure Therapy (PE), may reduce the effectiveness of exposure therapy. Common brand names include Librium, Xanax, Valium, and Ativan.

Beta Blockers

Beta blockers, also known as beta-adrenergic blocking agents, work by blocking the effects of the neurotransmitter adrenaline. By reducing heart muscle contraction and dilating blood vessels, beta blockers lower blood pressure. While historically used to treat somatic symptoms of anxiety, such as heart rate and tremors, they are not particularly effective in treating generalized anxiety, panic attacks, or phobias. Popular brand names include Lopressor and Inderal.

Complementary and Alternative Therapies

Complementary and alternative therapies can serve as valuable adjuncts to conventional treatments for the relief of anxiety symptoms. These non-invasive approaches have gained increasing interest due to their potential benefits and ability to improve patient well-being. It is important to note that these therapies are typically not intended to replace conventional treatments, but rather to complement them and improve overall quality of life.

Stress Management

Stress management techniques include a variety of activities designed to consciously induce the body’s relaxation response. This response involves slower breathing, resulting in lower blood pressure and an overall sense of well-being. Examples of stress management techniques include progressive relaxation, guided imagery, biofeedback, self-hypnosis, and deep breathing exercises.

Meditation

Meditation is a mind-body practice that encourages individuals to cultivate mindfulness of their thoughts, emotions, and physical sensations in a non-judgmental manner. It has shown promise in reducing psychological stress symptoms in patients with anxiety.

Yoga

Yoga is a mindful practice that combines physical postures, meditation, breathing exercises, and a unique philosophy. It has been shown to be effective in reducing certain symptoms of anxiety and depression.

Emerging Therapies

In addition to established treatment approaches, there are several experimental therapies that show promise in treating anxiety symptoms. Here is a brief overview of some of these emerging treatments, including neurostimulation, acupuncture, and the use of psychoactive drugs such as marijuana and ecstasy.

Neurostimulation

Anxiety is often associated with abnormal patterns of brain activity, making direct targeting of these patterns a potential treatment avenue. Neurostimulation, a non-invasive and painless therapy, involves stimulating the brain to modulate nerve cell activity. Recent clinical trials have demonstrated reduced symptoms of anxiety and depression in patients who have not responded to traditional treatments such as medication. There are two major types of neurostimulation:

Repetitive Transcranial Magnetic Stimulation (rTMS)

In this technique, a brief current is passed through a coil of wire placed on the front of the head near mood-regulating areas of the brain. The current creates a magnetic field that generates an electrical current in the brain, stimulating nerve cells in the targeted region. The current primarily affects brain regions up to 5 centimeters deep, allowing for selective treatment of specific areas. Sessions typically last 30-60 minutes and do not require anesthesia.

Treatment is administered 4-5 times per week for approximately six weeks. While generally painless, patients may experience a slight tapping sensation at the site of current administration. Side effects are minimal and include headache, mild tingling, or discomfort in the treated area. rTMS can be used alone or in combination with medication and/or psychotherapy.

Deep Transcranial Magnetic Stimulation (dTMS)

This approach uses special coils to target deeper regions of the brain than rTMS. Patients wear a padded helmet similar to that used during an fMRI scan. While the FDA approved the dTMS coil for the treatment of depression in 2013, it is currently being studied for anxiety disorders such as OCD. The procedure takes 20 minutes and is administered for 4-6 weeks. Patients can return to their normal activities immediately after each treatment.

Acupuncture

Acupuncture, derived from traditional Chinese medicine, involves inserting thin needles into specific areas of the body. While there is limited evidence to support acupuncture as a significant treatment for generalized anxiety, ongoing research studies are investigating its potential for PTSD. One study found that acupuncture may reduce preoperative anxiety.

Psychoactive Drugs

There has been growing interest in the use of psychoactive substances alongside psychotherapy for the treatment of anxiety, particularly cannabis (marijuana) and methylenedioxymethamphetamine (MDMA, known as ecstasy or Molly). These drugs are somewhat controversial because of their psychoactive effects. However, with the increasing legalization of marijuana, it is important to investigate whether these substances can alleviate clinical anxiety symptoms.

Although few randomized clinical trials have been conducted, certain forms of cannabis, particularly cannabidiol, have shown efficacy in the treatment of social anxiety disorder, while tetrahydrocannabinol (THC) has shown benefits for PTSD patients. Caution is advised when using the plant form of cannabis, as it may worsen symptoms and should only be used under professional supervision. MDMA has shown promise in the treatment of PTSD, but should only be used as an adjunct to psychotherapy under clinical supervision.

Types of Anxiety Treatment Providers

When seeking treatment for anxiety and related disorders, patients have access to a variety of licensed mental health professionals who specialize in providing comprehensive care. Here are some of the most important providers in the field.

Primary Care Physician

Many patients first consult their primary care physician (PCP) when they experience symptoms. PCPs perform thorough physical examinations to rule out underlying hormonal imbalances, medication side effects, or other medical conditions. If anxiety is diagnosed, the PCP may refer the patient to a psychologist or psychiatrist for further evaluation and treatment. PCPs practice in hospitals, clinics, and private offices.

Clinical Psychologist

Clinical psychologists have a Ph.D. in clinical psychology and specialize in treating emotional, mental, and behavioral problems. They provide counseling, psychotherapy, and psychological testing, with an emphasis on the treatment of mental disorders. Generally, clinical psychologists do not prescribe medication, except in the states of Illinois, Louisiana, and New Mexico, where limited prescriptive authority is granted.

Collaboration with psychiatrists and PCPs is common, with psychologists providing psychotherapy while other health care providers handle the medical aspects. Clinical psychologists practice in hospitals, schools, counseling centers, and group or private medical practices.

Psychiatrist

Psychiatrists are medical doctors (MDs) who specialize in the diagnosis and treatment of mental disorders. They have the ability to provide psychotherapy and prescribe medication. Psychiatrists often work in hospitals, counseling centers, and group or private medical practices.

Psychiatric Nurse Practitioner

Psychiatric nurses have a master’s or doctoral degree in mental health. They are qualified to diagnose and treat mental illness, primarily through psychotherapy. In some states, psychiatric nurses are authorized to prescribe medications. They serve as patient advocates and may provide case management services. Psychiatric nurse practitioners can be found in private practice, hospitals, and schools.

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

Licensed mental health professionals with master’s degrees and diverse educational backgrounds (e.g., counseling, social work, marriage and family counseling) play an important role in providing comprehensive mental health care. After completing their formal education, these clinicians typically complete at least two years of supervised clinical experience and pass a state-specific licensing exam. Their licenses allow them to diagnose and treat emotional, mental, and behavioral health issues.

They provide mental health treatment through counseling and psychotherapy, and may also serve as patient advocates or care managers. Master’s-level licensed clinicians work in a variety of settings, including hospitals, community mental health clinics, private practices, schools, nursing homes, and social service agencies. Titles and licensing requirements may vary from state to state.

Clinical Social Worker

Clinical social workers (CSWs) hold a master’s degree in social work and receive additional training to provide mental health services. They are qualified to provide case management and hospital discharge planning, and often serve as patient advocates. Clinical social workers typically work in hospitals, schools, clinics, social service agencies, or private practice.

Finding Treatment

Anxiety disorder treatment providers can be found in hospitals, clinics, private or group practices. Some also work in school settings (licensed mental health counselors, clinical social workers, or psychiatric nurses). Telehealth, a growing field, allows mental health professionals to provide services remotely through Internet video platforms, streaming media, video conferencing, or wireless communications. Telehealth is particularly valuable for individuals who live in remote rural areas far from mental health facilities. Telehealth providers are limited to providing services to patients within the state in which they are licensed.

Preventing and Coping with Anxiety

Sierra Carter, PhD

Anxiety is a universal human experience, and while it can serve as a motivating force, it can also become overwhelming. The following tips and strategies can help individuals prevent anxiety from reaching clinical levels and manage the normal anxiety that occurs in everyday life.