All About Anxiety

What is Anxiety?

Anxiety is a normal response to a threat. For this reason, anxiety serves an important purpose. In the presence of danger, anxiety starts a cascade of events that help to increase our chance of survival. If a lion is charging at you, the anxiety response (or “fight or flight” response) is critical for your survival. Elevated heart rate helps blood flow to your muscles, elevated respiratory rate helps improve oxygenation for fighting (or running away), sweating cools your body temperature, and hyperawareness or hypervigilance keeps you “on guard” for future threats.
Normally, the anxiety response turns off once the threat is removed. But in some individuals, the anxiety response does not turn off and remains constantly elevated or “out of proportion” to the threat. When anxiety disrupts the quality of a person’s life, we call it an anxiety disorder.
The term “Anxiety” is also sometimes used to describe temporary feelings of nervousness or fear in response to specific situations, thoughts, or events. For example, starting a new job, moving into a new home, giving a presentation, or thinking disturbing thoughts. Other times, “Anxiety” is used to describe more persistent feelings of worry, nervousness, or fear that occur without a trigger. It is important to mention that anxiety is a fear-based emotion that often causes avoidant behaviors.
Many people with anxiety disorders struggle with intrusive and unwanted thoughts. That is, anxious thoughts that “pop up” at inconvenient times and stay there. These annoying thoughts can cause a lot of anxiety and distress. But why?
The figure below will help explain.

The marbles represent all the thoughts, feelings, and sensations we have, and the spotlight represents the focus of our attention. Normally, we filter the thoughts, feelings, and sensations so we direct our attention only to those that are truly meaningful and important.
However, those with anxiety may place significance on nearly every thought, emotion, and sensation they experience.
This is because the “alarm system” is constantly signaling that “something is wrong.” It’s difficult to be mentally present when your attention is constantly being hijacked and directed to thoughts, feelings, and sensations that aren’t helpful. It’s also exhausting.

Flavors of Anxiety

Anxiety comes in many “flavors.” We organize anxiety symptoms into four general categories:
  • Feelings
  • Behaviors
  • Thoughts
  • Physical Symptoms

Anxiety Disorders

When anxiety symptoms are persistent and disrupt the quality of a person’s life, we call it an anxiety disorder. Below is basic information about the most common anxiety disorders. Please note that Obsessive Compulsive Disorder (OCD) and Post Traumatic Stress Disorder (PTSD) are considered anxiety disorders but are reviewed elsewhere.

Anxiety due to medical conditions and medications

Medical Problems known to cause or worsen anxiety

  • Cardiac Disease (e.g., ischemic heart failure, coronary artery disease, myocarditis)
  • Respiratory/lung disease (e.g., Asthma, COPD, Pulmonary Fibrosis, Cystic Fibrosis, Pneumonia, Pleuritis)
  • Hyperthyroidism
  • Hypothyroidism
  • Hypoglycemia
  • Pheochromocytoma
  • Anemia
  • Seizures
  • Drugs of Abuse (Stimulants, PCP, MDMA, Cannabis, Nicotine Caffeine, Alcohol withdrawal)
  • Medications (see below)

Medications known to cause or worsen anxiety

  • Pseudoephedrine
  • Methylphenidate
  • Amphetamines
  • Beta-agonists (e.g., bronchodilators)
  • Amantadine
  • Bromocriptine
  • L-Dopa
  • Metoclopramide
  • Corticosteroids (e.g., prednisone, methylprednisolone) 
  • Anabolic steroids
  • Oxybutynin
  • Theophylline
  • Bupropion (rarely)
  • Selective Serotonin Reuptake Inhibitors (initially)
  • Serotonin Norepinephrine Reuptake Inhibitors (initially)
  • Other antidepressants (initially)

Diagnosing anxiety disorders

Anxiety disorders can be categorized based on whether a trigger can be identified for the anxiety symptoms. See the algorithm below.

Generalized Anxiety Disorder

Generalized Anxiety Disorder can be described as excessive anxiety and worry about a number of events or activities in a person’s life. The anxiety is persistent and is very difficult to control or stop. Individuals suffering with Generalized Anxiety Disorder “sweat the small stuff” and dwell on past experiences or worry about the future. Catastrophizing, or immediately thinking of the worst-case scenario, is common. The anxiety and worry are usually associated with a feeling of restlessness, difficulty relaxing, feeling “tense” or “on edge”, tiredness, and irritability. In addition, individuals with generalized anxiety often report problems concentrating or falling asleep.
Treatment of Generalized Anxiety Disorder: The best treatment for Generalized Anxiety Disorder is a combination of psychotherapy and medication. Research studies suggest that both therapy and medication together lead to better outcomes then either alone. The best therapy modalities are cognitive behavioral therapy (CBT) and exposure therapies.

Social Anxiety Disorder (Social Phobia)

Social Anxiety Disorder is characterized by significant fear or anxiety about being in social situations. There is distressing anxiety about being scrutinized, judged, or criticized by others. Examples of social situations that might provoke anxiety include having a conversation, meeting unfamiliar people, being observed eating or drinking, and performing in front of others. Often there is a fear of being humiliated, embarrassed, or rejected by others. These social situations are often avoided by people with social anxiety or experienced with significant discomfort. Many times, drugs and alcohol are used in excess to minimize the anxious feelings.  
Treatment of Social Anxiety Disorder: The best treatment for Social Anxiety Disorder is a combination of psychotherapy and medication. Research studies suggest that both therapy and medication together lead to better outcomes then either alone. The best therapy modalities are cognitive behavioral therapy (CBT) and exposure therapies. Medications for social anxiety include propranolol (Inderal), selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), and benzodiazepines.

Panic Attacks

Panic attacks can occur alone or as part of another anxiety disorder or psychiatric disorder such as depression, posttraumatic stress disorder, and substance use disorders. Panic attacks can also be caused or worsened by some medical conditions such as heart disease, thyroid disease, lung disease, inner ear problems, or stomach/intestinal issues. Panic attacks are defined as an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes. During a panic attack, an individual may experience any combination of the following symptoms:
  • Palpitations, pounding heart, or accelerated heart rate.
  • Sweating.
  • Trembling or shaking.
  • Sensations of shortness of breath or smothering.
  • Feelings of choking.
  • Chest pain or discomfort.
  • Nausea or abdominal distress.
  • Feeling dizzy, unsteady, light-headed, or faint.
  • Chills or heat sensations.
  • Paresthesia (numbness or tingling sensations).
  • Derealization (feelings of unreality) or depersonalization (being detached from oneself).
  • Fear of losing control or “going crazy.”
  • Fear of dying
*It is important to note that panic attacks alone are not a mental disorder.

Panic Disorder

When an individual experiences repeated and unexpected panic attacks we call it Panic Disorder. The individual begins to worry about having future panic attacks (in other words, worries about worrying). The fear of having another panic attack causes isolating and avoiding behaviors. This can lead to problems in their lives.
Treatment of Panic Disorder: Like most anxiety disorder, the best treatment is a combination of therapy and medication. The best therapy modalities are cognitive behavioral therapy (CBT) and exposure therapies. Medications for panic disorder include selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) to prevent panic attacks. To abort panic attacks, benzodiazepines are often used.

Agoraphobia

Agoraphobia is a marked fear or anxiety about any of the following situations:

  • Using public transportation (e.g., automobiles, buses, trains, ships, planes).
  • Being in open spaces (e.g., parking lots, marketplaces, bridges).
  • Being in enclosed places (e.g., shops, theaters, cinemas).
  • Standing in line or being in a crowd.
  • Being outside of the home alone.
Individuals with agoraphobia avoid these situations because they feel that escape might be difficult and/or help might not be available.  Typically, individuals experience fear or anxiety that is out of proportion to the actual danger posed by the situation.

References

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Neurobiology of Anxiety, Worrying, and Fear

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