Anxiety

Defined

Anxiety is the anticipation of an imminent threat, either real or perceived. It is characterized by muscle tension and an increased state of vigilance, caution and avoidance (DSM-5). When someone experiences anxiety, it is often accompanied by an elevated heart rate, elevated respiration, pupil dilation, and trembling (Brown, 2009).

Anxious feelings are sometimes described as fear, uncertainty, distress, apprehension, irritation, dread, uneasiness (Potter, 2020), shame, guilt, excitement, anger or sadness (Weiner, 2010). These feelings may be associated to a specific stressor, or may be generalized in a way that makes it difficult to identify the cause (DSM-5). 

Anxiety and fear both motivate self preservation responses, however fear is present focused. Anxiety is a response to what could happen. In this future-oriented emotional state, a sense of apprehension or worry is experienced alongside reduced cognitive function (Weiner, 2010). 

At a mild level of anxious arousal, heightened perceptions allow for improved learning and problem solving, giving anxiety an evolutionary advantage (Potter, 2020). 

At a moderate level, anxiety decreases attention span and reduces the ability of a person to perceive their surroundings. Once someone enters a severe or panic level of anxiety, their ability to accurately assess their surroundings and adapt to stimuli becomes incapacitated. The experience of severe anxiety or panic may be acute (sudden onset) or chronic (persistent to the point of becoming a character trait) (Potter, 2020).

Transient symptoms of anxiety related to stressful life events is biologically typical and developmentally appropriate. Put another way, anxiety is a normal part of the human condition (DSM-5). Once the stressor has passed, someone without anxiety should be able to return to their pre-arousal state within 20 to 30 minutes (Cleveland, 2019). Anxiety is known to be somewhat 'contagious'. We can sense the anxiety of others and become more anxious ourselves (Potter, 2020).  

Anxiety is a motivating force and when effectively channeled, it can positively influence creativity, problem-solving, and adaptive change. Excess anxiety however, may interfere with performance, especially when the task at hand requires careful evaluation (Weiner, 2010). 

Acute Anxiety

When an acute anxious episode occurs, the body enters a state of fight/flight/freeze/fawn and the autonomic nervous system launches a cascade of chemical reactions designed to help our body defend itself physically against a stressor. Adrenaline, noradrenaline and cortisol are released and act to increase heart rate, increase respiration rate, dilate our blood vessels, increase muscle tension and trembling, decrease digestion and increase metabolism of glucose for energy (APA, 2018). Dry mouth, shortness of breath, irritability, exaggerated startle response and sleeping difficulties may also occur (Weiner, 2010). 

If we have underlying respiratory illnesses including asthma or COPD, or bowel conditions like IBS, an acute anxiety attack can exacerbate those conditions to cause a flare up (APA 2018). 

When anxiety occurs proportionally in response to a stressor, and resolves quickly after the stressor is gone, the overall response is considered positive. Should the anxious response be considerably greater than the stressor, and the autonomic activation resolves in a reasonable time frame, the overall response is considered tolerable. A toxic stress response occurs when a stressor causes a disproportionate and prolonged state of anxiety that cannot be mediated by supportive and protective factors (Potter, 2020). 

Chronic Anxiety

Chronic anxiety causes the body to remain in the state of fight/flight/freeze/fawn for longer than our biological systems were designed to maintain (APA, 2018). 

When the body remains in an anxious state, we may experience more frequent, and more severe, feelings of fear, uncertainty, uneasiness, distress, apprehension, dread, agitation, irritation, frustration, or worry. Over time, we may experience a decrease in the ability to pay attention, memory lapses, physical sensations of choking or smothering, and feelings of impending doom (NIMH, 2021).  

One of the most significant long term outcomes of chronic anxiety relates to the stress hormones that the body produces in an effort to self-regulate (APA, 2018). When a stressful event occurs, the hypothalamus communicates with the pituitary gland, which in turn communicates with the adrenal glands, which go on to produce the hormones cortisol, adrenaline and noradrenaline (APA, 2018). These stress hormones play a critical role in the mediation of the inflammatory response of the immune system, including the activation of white blood cells (Felger, 2018).

This increased level of inflammation is known to cause changes to every single process in the body, including the vital function of the heart and lungs (APA, 2018). Inflammation of the blood vessels can lead to elevated blood pressure (hypertension) and can reduce the movement of nutrients into, and waste products out of, the vessels surrounding the heart (APA, 2018). Inflammation of the respiratory tract can decrease the flow of air into the lungs and alter the movement of oxygen into the bloodstream (APA, 2018). 

Inflammation alters the surfaces of the digestive tract, specifically the stomach and bowels (APA, 2018). These changes can reduce nutrition absorption and increase the risk of infection and associated ulcers (APA, 2018). When combined with the decreased mobility of the bowels caused by stress hormones, alterations in function can lead to constipation or diarrhea, stomach pain from muscle spasms, and bloating (APA, 2018). Inflammation also alters the function of muscles and skeletal structures, and when combined with the muscle tension caused by chronic anxiety, long term pain in the back, shoulders, arms, neck, jaw and head (including headaches) can develop (APA, 2018).

Inflammation is also known to impact the function and connectivity of the brain, which manifests as a reduction in both long and short term memory as well as a reduction in overall cognitive ability (de Souza-Talarico, 2011).

Because the adrenal glands are constantly being instructed to produce stress hormones, these structures may grow in response to the increased demand (hypertrophy), or strain to the point of cell death (atrophy) (Ulrich-Lai, 2006). When excessive amount of stress hormones are persistent in the body, physical systems adapt by developing increased receptors for those hormones and producing compensatory chemicals in an effort to maintain homeostasis (Ulrich-Lai, 2006). With these additional physical structures in place, the body has not only adapted to increased levels of anxiety, it is pre-programmed to respond to future stressors using those same tools, further perpetuating anxious responses (Felger, 2018).

Just as our body adapts to chronic anxiety, our behaviors adapt as well. When experiencing a state of anxiety, many individuals will develop coping behaviors that they feel reduce their symptomatic burden (APA, 2018). Eating 'comfort' foods, eating foods high in sugar, acid or fat, smoking, alcohol use, and substance use all impact the bacteria living in our digestive tract. This type of consumption is directly associated with an increased likelihood of developing acid reflux and heartburn, and although intended to relieve symptoms, these behaviors tend to increase the number of symptoms, and their severity, over time (APA, 2018). 

Anxiety is known to compound, meaning that if we are experiencing anxiety, we are at a higher risk for developing an anxious response to any additional stressors that may occur (Ulrich-Lai, 2006). The state of chronic anxiety reduces our ability to achieve resiliency, and increases the risk that our coping resources will become overwhelmed (Potter, 2020).

Chronic anxiety has also been correlated with an increased likelihood of developing pathological cognitive decline, which includes the development of Alzheimer’s disease and dementia (de Souza-Talarico, 2011).

How Anxiety Develops 

Many of the symptoms of anxiety listed above begin in childhood and continues into adulthood if not addressed through early interventions (DSM-5). Anxiety most often presents in young children in the form of separation anxiety, which is present in 1-4% of the general pediatric population with an average onset of 6 years of age (Feriante, 2021). Selective mutism is another manifestation of early onset anxiety, occurring in less than 1% of the general pediatric population with an average onset between 3 and 6 years of age (Wong, 2021). 

Children are more vulnerable to the impact of stressors due to immature coping  mechanisms and a limited capacity for self-actualization. Children who live through adverse childhood experiences (ACEs) are at a much higher risk of developing an anxiety disorder at some point in their lives (Potter, 2020). ACEs include witnessed or experienced abuse, divorce or separation, and incarceration of a family member (Potter, 2020).

Parents with anxiety are more likely to have children with anxiety through a combination of genetics and learned behaviors (Burstein, 2010). Children with anxiety in their formative years experience altered development and as they reach adulthood, be more susceptible to the impact of stressful events (Felger, 2018).

Anxiety disorders that develop in adulthood are often associated with traumatic life events including domestic violence, homelessness, military service, victimization, and chronic illness (Potter, 2020). The most common diagnosis for these special populations after a traumatic event is post-traumatic stress disorder (Potter, 2020). 

It is possible that an individual can develop a substance and medication induced anxiety disorder through excessive consumption of alcohol, cannabis, caffeine, amphetamines or other substances (DSM-5).

Anxiety Disorders in the United States

When an excessive anxious response persists for a period of 6 months or more, characterized by anxious feelings and a consistently elevated state of autonomic arousal, the symptoms may meet the criteria for clinical diagnosis (DSM-5). When making a diagnosis, the severity of the patient's condition is considered in context of the stressors themselves, the impact of anxiety on the patient's activities of daily living and sense of self, and the ability of the patient to mediate the condition with effective coping strategies (DSM-5). 

Approximately 19.1% of United States residents (approximately 62 million people) are expected to experience an anxiety disorder this year and 31.1% will experience an anxiety disorder at some point in their lives (NIMH, 2021). Women in the United States will experience an anxiety disorder at a rate double that of men (Potter, 2020). 

Of adults with an anxiety disorder, 22.8% have serious impairment, 33.7% have moderate impairment, and 43.5% have mild impairment (NIMH, 2021). Over 65% of those experiencing an anxiety disorder will not receive treatment for their condition in a given year (Potter, 2020). 

Anxiety disorders include separation anxiety disorder (0.9% to 1.9% 12 months prevalence in US residents), selective mutism (0.03% to 1% 12 month prevalence in US residents), panic disorder (2% to 3% 12 month prevalence in US residents), agoraphobia (1.7% 12 month prevalence in US residents), social anxiety (Approximately 7% in the US, compared to 2.3% in Europe), specific phobias (7% to 9% 12 month prevalence in US residents), and generalized anxiety disorder (2.9% 12 month prevalence in US residents), and substance and medication induced anxiety disorder (.009% of the general population in a given year) (DSM-5).

Reducing Anxiety Day by Day 

We can complete a self assessment of anxiety symptoms by visiting the Beck Anxiety Inventory and answering the panel of questions. Retake this questionnaire often, during anxious times and non-anxious times, in order to create a baseline understanding of our stressors and responses. Mental health professionals may alternatively use the Hamilton Anxiety Rating Scale.

Regular self-assessment is most effective when we write down our state of mind for the sake of comparison. Considering tracking the severity of anxiety symptoms each day, and take some time to identify triggers and personal behavior. Every detail is helpful in establishing trends and influences.

Cognitive behavioral therapy (CBT) is often used in combination with medications to treat anxiety. CBT alone has a similar rate of success compared to medications alone. CBT helps us understand anxious thoughts and process difficult feelings quicker (Weiner, 2010). For access to CBT, click here.

Expressing our anxious energy through physical movement and mind/body connectedness allows us to recover faster. Click here for information on physicality.

There are medications and treatments available that offer almost immediate relief. Consider working with a mental health care professional or primary care doctor if the strategies above are not enough.

Coping With an Anxious Person

When engaging someone in a heightened state of anxiety, it is important to remember that anxiety has a tendency to spread (Potter, 2020). We must be sure to make an effort to maintain our sense of calm and patience and set limits when needed. For more information on limits and boundary setting, click here.

It is beneficial to support the anxious person as they try to remain focused. Remain calm and speak in a slow, low voice to convey that sense of calm. Use clear, direct, and brief phrases to promote effective communication. Encourage problem solving, and suggest ways they can engage in physicality to release their anxiety in a helpful way (Potter, 2020). For ideas regarding mind/body connectedness and physicality, click here.

Ask the anxious person about their anxiety triggers and what has helped them relieve their anxiety in the past. Encourage them to practice what was effective before. Offer them comforting foods and calming drinks. Avoid stimulants like caffeine and nicotine. Reduce distractions by turning off televisions or  electronics. Dim the lights (Potter, 2020). 

If safety is a concern, stay with them and ask them to agree verbally to stay safe and ask for help if they feel unsafe. This is called a safety contract. Set short term goals that are specific, measurable, achievable, relevant and time constrained to provide a sense of direction (Potter, 2020).