What is anxiety?
Anxiety can be described as the response to a future or possible threat. Anxiety is closely related to fear, which is the response to a real or perceived immediate threat. Fear and anxiety are normal evolved responses in both humans and animals, and physical responses are linked to the "fight-or-flight" system. The autonomic nervous system controls the fight-or-flight response in the body, and this response generally includes dilation of the pupils in the eyes, increased heart rate, and increased respiration/breathing. Anxiety responses can include increased vigilance (paying attention to one's surroundings) and muscle tension. Anxiety can be constructive, such as improving performance on a test, sporting event, or public speaking. Although these are normal responses and often helpful responses to danger, anxiety can cause problems when it is turned on too easily, not turned off when danger is absent, or when the response is too strong. Excessive anxiety that causes distress or impairment, that interferes with normal function, or causes avoidance of important activities and people in life, is considered an anxiety disorder.
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Anxiety Symptoms & Signs
Anxiety is a feeling of apprehension and fear characterized by physical symptoms such as palpitations, sweating, irritability, and feelings of stress. Anxiety disorders are serious medical illnesses that affect approximately 19 million American adults. In fact, anxiety disorders as a group are the most common mental illness in America.
What are the types of anxiety disorders?
Anxiety disorders are differentiated based on the type of object or situation that causes fear, anxiety, or avoidance as well as the thought patterns associated with the fear or anxiety. To be considered an anxiety disorder, the fear or anxiety also has to be persistent (lasting usually six months or more), and not a normal developmental phase (for example, a young child being afraid of being away from their parent). Anxiety disorders commonly start in childhood but persist into adulthood.
The most common anxiety disorders are specific phobias. Specific phobias are an excessive fear of a specific object or situation, such as spiders (arachnophobia), heights (acrophobia), flying, or closed spaces (claustrophobia). Most people are aware that their fears (phobias) are excessive, but they often feel powerless to control them. Sometimes a phobia may start after a traumatic event (for example, being stuck in a small space; seeing someone injured by an animal), but the symptoms are related to the fear and not related to re-experiencing the trauma (for example, the symptoms don't better fit a post-traumatic stress disorder [PTSD] diagnosis).
In social anxiety disorder (social phobia or performance anxiety), people are excessively fearful or anxious about social interactions or situations that may involve being observed or scrutinized. Self-consciousness about being observed by others, or performing in front of others, is normal. However, social anxiety is much more extreme and gets in the way of completing normal (and often necessary) activities successfully. Social phobia may be limited to performance situations (such as speaking, singing, acting, etc., in front of others), or it may be more general and related to many (or all) situations around other people.
Generalized anxiety disorder (GAD) is characterized by persistent and excessive anxiety and worry about many different areas that are hard to control. Other anxiety disorders include separation anxiety disorder, selective mutism, agoraphobia (fear of being outside of the home in various situations), and panic disorder (recurring unexpected panic attacks and fear of having more panic attacks).
Anxiety disorders may also be caused by drugs, medications, or other substances (including stimulants, caffeine, and corticosteroids). Stimulant medications and herbal preparations include common over-the-counter drugs such as cold medicine and decongestants, ephedra- or ephedrine-containing products, diet pills, or energy drinks. Prescription stimulants are sometimes used to treat ADHD/ADD (attention deficit hyperactivity disorder or attention deficit disorder) and include methylphenidate (Ritalin, Concerta), amphetamine salts (Adderall), lisdexamfetamine (Vyvanse), and others. Withdrawal from alcohol and certain drugs (including benzodiazepines [medicines sometimes used to treat acute anxiety, such as alprazolam (Xanax), lorazepam (Ativan), or clonazepam (Klonopin), barbiturates, or newer seizure medications such as gabapentin (Neurontin)]) can also cause anxiety-like symptoms. When a medication or drug is the primary cause of the anxiety, it is diagnosed as a medication or substance-induced anxiety disorder. Medical illnesses or conditions (such as thyroid conditions, breathing problems [such as asthma or COPD (chronic obstructive pulmonary disease), or rare adrenal gland tumors (pheochromocytoma)]) can also cause anxiety disorders and/or anxiety-like symptoms.
With the introduction of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), some diagnoses that used to be considered anxiety disorders have been recategorized into new sections. Obsessive-compulsive disorder (OCD) is now grouped with other compulsive disorders, like hoarding and trichotillomania (hair pulling). Similarly, post-traumatic stress disorder (PTSD) has been reclassified with other trauma-related disorders. OCD and PTSD often have anxiety-related symptoms, and some treatments overlap with those for anxiety disorders.
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What are anxiety symptoms and signs?
Common symptoms and signs of anxiety disorder can include
- restlessness or feeling edgy;
- becoming tired easily, fatigue;
- trouble concentrating, that may also appear as memory or attention problems;
- feeling as if the mind is going "blank";
- muscle tension;
- sleep problems (trouble falling or staying asleep or having sleep that is not restful).
Anxiety that is associated with specific (specific or simple phobia) or social fears (social phobia) may also result in avoidance of certain situations or an elevation of symptoms to trigger a panic attack.
Panic attacks are sudden episodes of intense fear and/or physical discomfort that reach a peak within minutes. Specific signs and symptoms of panic attack include both physical and emotional symptoms such as:
- palpitations (feelings of rapid and/or irregular heartbeats);
- chest pain, chest tightness or other discomfort, feeling like one is having a heart attack;
- shortness of breath or trouble breathing;
- sweating of the palms;
- nausea or other stomach upset;
- trembling or shaking;
- feeling dizzy, unsteady, lightheaded, or faint;
- derealization (feelings of unreality) or depersonalization (feeling detached from oneself);
- fear of losing control or going insane;
- numbness or tingling sensations;
- chills or hot flashes;
- feeling like one is choking;
- a sense of impending doom;
- feeling like one is dying.
Anxiety in children and teenagers
Many anxiety disorders first develop in childhood or adolescence. Although some may resolve, many persist into adulthood. Some anxiety symptoms are related to childhood development. For example, separation anxiety is normal in young children. However, when the fear of being away from their parent persists or interferes with normal development, separation anxiety disorder is diagnosed. Separation anxiety may start after a traumatic event, such as the death of a loved one. However, if the fear is more about the trauma, and not specifically separation from the child's caregivers, an acute stress disorder or posttraumatic stress disorder diagnosis may be more appropriate.
Selective mutism refers to an inability to speak in social situations where there is an expectation to speak (such as school), but they are still able to speak in other settings. When this pattern persists and causes problems with school, work, or other performance, selective mutism is diagnosed.
The similarities and differences in symptoms of anxiety in adults compared to children and adolescents depend on the specific condition that is causing the anxiety. For example, symptoms of social phobia or specific phobia are quite similar in children and teens compared to adults except that children and teens are less likely to recognize that their thoughts or behaviors are irrational. Symptoms of anxiety in children and teens tend to be consistent with how they express feelings in general. For example, younger children are less able to express feelings verbally compared to older children, and thus tend to express anxiety by complaining of physical symptoms like stomach upset or headaches. They are also more likely to cry, have tantrums, or become clingy. In contrast to younger children, teens tend to express symptoms of anxiety similarly to adults. However, adolescents are more likely than adults to exhibit anxiety by becoming irritable or angry. Anxious teens are also more likely to have wide mood swings from normal (euthymic) to anxious, angry, and irritable.
Anxiety in men and women
Anxiety disorders are diagnosed in women about twice as often as in men. It is difficult to determine if women are more susceptible to anxiety disorders, or if men are less likely to acknowledge or report symptoms and are thus diagnosed less often. Similarly, differences in how men and women experience or recognize anxiety symptoms may also influence anxiety disorder diagnoses.
Studies indicate that men seem to experience effects of anxiety differently compared to women. Specifically, men tend to exhibit more psychological symptoms of anxiety, like tension, irritability, and a sense of impending doom. In contrast, women tend to develop more physical symptoms like chest pain, palpitations, insomnia, shortness of breath, and nausea. Further, it seems that women with such physical symptoms of anxiety are more at risk for developing heart problems.
Panic attacks are repeated attacks of fear that can last for several minutes.
When should people seek treatment for anxiety?
Everyone experiences some symptoms of anxiety, but most often, this occurs in very serious situations. When the symptoms are triggered by normal events that aren't dangerous, or they don't settle down in a reasonable amount of time, you may have an anxiety disorder. Similarly, if the anxiety symptoms are getting in the way of your daily life, consider seeking a formal evaluation, and possible treatment, for an anxiety disorder. Not treating an anxiety disorder can impair your overall well-being, cause self-doubt, and may increase your risk of depression, substance abuse, and even suicide.
What is generalized anxiety disorder (GAD)?
Generalized anxiety disorder (GAD) is an anxiety disorder that is characterized by multiple and/or nonspecific worries. GAD often starts early in life, and people with this diagnosis will often describe being anxious, or being a "worrier," for most of their life. The fear associated with GAD interferes with the person's ability to sleep, think, or function in some other way. Symptoms of anxiety are even described in the word itself. Specifically, the word anxiety comes from the Latin word anxietas, which means to choke or upset. The symptoms therefore include emotional or behavioral symptoms as well as ways of thinking that are responses to feeling as if one is in danger.
How common is generalized anxiety disorder?
GAD is quite common. In fact, it is the most common anxiety disorder seen by most primary care doctors. Up to 9% of people will develop GAD over the course of their lifetime. That translates to millions of GAD sufferers. During any given year in the U.S., up to 0.9% of adolescents (about one in 100) and 2.9% of adults (about one in 30) will have GAD. The prevalence of GAD peaks in middle age and declines in later years. Women are about twice as likely to develop GAD as men. Individuals from developed countries are more likely to report symptoms of GAD than those from non-developed countries.
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Are other mental health diagnoses associated with generalized anxiety disorder?
When people receive a GAD diagnosis, they commonly have (or had) other anxiety disorders. Individuals with GAD very commonly will also have major depressive episodes (unipolar depression; "clinical depression") during their life. GAD is not associated with an increased risk of having a substance use disorder, bipolar disorder, or a psychotic disorder. However, some symptoms of GAD are very common in other disorders, including PTSD, panic disorder, bipolar disorder, and psychotic disorders (such as schizophrenia). However, part of a complete mental health evaluation should be confirming that the diagnosis of GAD is not better explained by another diagnosis.
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What are causes and risk factors for generalized anxiety disorder?
While there is no single cause of GAD, some people are more at risk for developing anxiety than others. Women tend to develop this condition and most other anxiety disorders more often than men, and individuals with a family history of anxiety and depression are more at risk for having GAD. Genetic factors (for example, a family history of anxiety and/or depression) are thought to explain about one-third of the risk for GAD. Younger adults are more likely to have GAD or social anxiety disorder compared to older adults. Other risk factors for developing social anxiety disorder include being of Native-American ethnicity and having a low income. Being of Asian, Hispanic, or black ethnicity, as well as residing in a more populated region, seems to reduce the risk of social anxiety disorder.
Inhibited temperament, parental anxiety, and having family and friends who somehow support avoidant coping mechanisms are risk factors for developing an anxiety disorder. Adolescents who smoke tobacco have been found to be at risk for developing anxiety. In children, girls, particularly those who begin puberty early, seem to be more likely to develop anxiety than their age peers of both genders.
Life stress, involving health problems and family disagreements, has been found to be associated with developing an anxiety disorder. Certain other life stresses put people at risk for developing anxiety, as well. For example, in a study of African-American, Afro-Caribbean, and non-Hispanic white individuals, non-race-based discrimination was found to be a risk factor for developing anxiety in each of those groups while race-based discrimination was found to increase the likelihood of only the African-American people in developing anxiety.
How do health care professionals diagnose generalized anxiety disorder (GAD)?
According to the DSM-5, the diagnosis GAD requires the following criteria, which must be present at least six months for more than half of the time:
- Excessive anxiety and worry. Worry is about a number of events or activities (for example, work or school performance, relationships, social functioning; worry not limited just to one topic).
- The worry is difficult to control.
- The anxiety and worry are associated with at least three of the following symptoms:
- Restlessness or feeling keyed up or on edge
- Easily fatigued
- Difficulty concentrating or mind going blank
- Muscle tension
- Sleep disturbance (difficulty falling or staying asleep; or restless, unsatisfying sleep)
- The anxiety, worry, and/or physical symptoms cause significant distress and/or impairment. Impairment may be in social, occupational, or other important aspects of life.
- The anxiety and worry are not better explained by a medical condition, a substance (drug of abuse or medication). They are also not better explained by a different psychiatric diagnosis.
If a health care professional suspects that you have GAD, you will likely undergo an extensive medical interview and physical examination. As part of this examination, you may be asked a series of questions from a standardized questionnaire or self-test to help assess your risk of anxiety. The answers to these questions will help assess whether you meet the diagnostic criteria for GAD (as described above). Because anxiety may be associated with a number of other medical illnesses or can be a side effect of various medications, routine laboratory tests are often performed during the initial evaluation to rule out other causes of your symptoms. Occasionally, an X-ray, scan, or other imaging study may be needed.
What types of specialists treat generalized anxiety disorder?
Many health care professionals may help determine the diagnosis and recommend treatment for individuals with GAD; these include licensed mental health therapists, family physicians, or other primary care professionals, specialists whom you see for a medical condition, emergency physicians, psychiatrists, psychologists, psychiatric nurses, and social workers.
What are the treatment options for anxiety?
Medication treatments for anxiety
There are a variety of treatments available for controlling anxiety, including several effective anti-anxiety medications and specific forms of psychotherapy. In terms of medications, buspirone (BuSpar) is known to be quite effective for treating GAD. However, it seems to be less effective in managing many other disorders that often co-occur (are comorbid) with GAD. Therefore, specific members of the serotonin reuptake inhibitor (SRI) and the serotonin and norepinephrine reuptake inhibitor (SNRI) classes of drugs, which are also approved by the U.S. Food and Drug Administration (FDA) for effective treatment of GAD, are prescribed more often. Examples of SRI medications include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro). Examples of SNRI medications are duloxetine (Cymbalta), venlafaxine (Effexor), and desvenlafaxine (Pristiq). Some of the newer antidepressants work in a similar way to SRI and SNRI medications but do not yet have an FDA approval for treatment of GAD. Some of these newer medications are mirtazapine (Remeron), levomilnacipran (Fetzima), vilazodone (Viibryd), and vortioxetine (Brintellix).
Benzodiazepine medications like clonazepam (Klonopin) and lorazepam (Ativan) are sedatives sometimes used for treating anxiety. They may be more effective for short-term use (for example, weeks to months), or occasional use in stopping severe anxiety symptoms, like those that occur in panic attacks, rather than the ongoing worry that is usually associated with GAD. Although alprazolam (Xanax) is often used to treat panic attacks, its short duration of action can sometimes result in having to take it several times per day, increasing the risk of tolerance and addiction. Another benzodiazepine, diazepam (Valium), tends to be used less often due to concerns about its long duration of action and addiction potential. Use of benzodiazepines is somewhat controversial; many doctors are reluctant to use them because of the risk of abuse and dependence, and/or withdrawal. There is also some clinical research that suggests PTSD and anxiety disorders may be harder to control later if benzodiazepines are used.
Because of the link between the autonomic nervous system and the fight-or-flight response in anxiety, medications that block this response may be helpful. One example is the beta-blocker family of medications usually used for high blood pressure. Beta-blockers stop some of the effects of epinephrine (adrenaline) that also is involved in anxiety and fear responses. Beta-blockers such as propranolol (Inderal) are sometimes used to decrease episodic anxiety (for example, performance anxiety or test anxiety), and may also relieve some of the physical symptoms associated with a panic attack.
In addition to these medications, a variety of other medication classes are sometimes used to help treat anxiety. Although they don't have a specific approval for treating anxiety from the FDA, people may discuss the risks and benefits with their prescribing doctor and decide which medications may be right for them. Gabapentin (Neurontin) is a medication developed as a seizure medication but has been found to help some individuals with severe anxiety symptoms. Gabapentin may be a less addictive option compared to benzodiazepines. Older sedating anti-histamine medications, such as hydroxyzine (Vistaril), are another nonaddictive type of medication that may be useful for panic attacks or severe episodes of anxiety.
When anxiety disorders are difficult to treat, or an individual has side effects with an SRI/SNRI, they may decide with their doctor to try one of the newer antipsychotic (neuroleptic) medications. This class includes risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), paliperidone (Invega), and lurasidone (Latuda). There are a number of clinical trials showing some reduction of anxiety symptoms from these medications. However, they also have significant possible side effects and require ongoing monitoring by the patient and their doctor.
Zolpidem (Ambien) and trazodone (Desyrel) have been found helpful in treating the insomnia that can often be a symptom of anxiety.
Before SRIs and SNRIs became available, older antidepressant medications including the tricyclic antidepressant (TCA) and monoamine oxidase inhibitor (MAOI) classes were often used to treat anxiety disorders. Although both of these medication classes have been found to be effective in treating anxiety disorders, the newer classes of medications (SRIs and SNRIs) have been proven to be safer and better tolerated. Therefore, TCAs and MAOIs are used much less often than they used to be. When used in the appropriate person with close monitoring, these medications can be quite effective as part of treatment for panic disorder.
What are the side effects of anxiety medications?
All medications, prescribed or over the counter, carry a risk of side effects, and it is important for the person with an anxiety disorder to work closely with their prescribing doctor to decide whether treatment with medications is an appropriate intervention and if so, which medication should be administered. The kinds of side effects caused by a medication are highly specific to the medication itself and each medication class as a whole. The person being treated should therefore discuss potential medications with their treating physician and be closely monitored for the possibility of side effects that can vary from minor to severe and can uncommonly even be life threatening.
The degree of risk from medications to the fetus of a pregnant woman is often not fully known. Some anxiety medications do have known risks for a fetus. Many pregnant women also have strong beliefs or fears about taking medication while pregnant. For each of these reasons, the decision of whether or not to take a medication for anxiety should be made by the woman with her prescribing physician (the woman's obstetrician, or in consultation with her obstetrician). Treatment for anxiety can be individualized and may include psychotherapy alone or combined with medications. Similarly, women who are trying to become pregnant, or who may become pregnant, should consult with their doctor about what treatment choices are best for them.
Alternative, natural, and complementary treatments for anxiety
For people who may be wondering how to treat anxiety without prescribed medications, natural remedies available over the counter may be an option. Alternative and complementary treatment methods such as hypnosis, acupuncture, and herbal supplements (such as kava, valerian, or passionflower) have been found to be helpful for some people with some anxiety disorders, but the research data are still considered to be too limited for many physicians to recommend them. Also, care should be taken when taking any dietary supplements, since dietary supplements and "natural" remedies are not regulated in terms of quality, content, or effectiveness.
Psychotherapy treatments for anxiety
The psychotherapy component of treatment for anxiety disorders is at least as important as the medication treatment. In fact, research shows that counseling alone or the combination of medication and psychotherapy treatment are more effective than medication alone in overcoming anxiety for both adults and children. It has also been found to be potentially effective for people with autism in addition to anxiety. The most common type of therapy used to treat anxiety is cognitive behavioral therapy (CBT). This form of therapy seeks to help those with an anxiety disorder identify and decrease the irrational thoughts and behaviors that reinforce anxiety symptoms and can be administered either individually, in group therapy, and even in partner-assisted therapy. Recently, there have also been more online options for CBT available to treat both anxiety and depression. CBT that seeks to help the anxiety sufferer decrease the tendency to pay excessive attention to potential threats has also been found to be helpful.
Behavioral techniques that are often used to decrease anxiety include relaxation techniques and gradually increasing exposure to situations that may have previously precipitated anxiety in the individual. Another name for this type of psychotherapy is exposure therapy. Helping the anxiety sufferer to understand and how to handle the emotional forces that may have contributed to developing symptoms (anxiety-focused psychodynamic psychotherapy) has also been found to be effective in teaching an individual with panic disorder how to prevent an anxiety attack or to decrease or stop a panic attack once it starts. Other commonly available psychotherapy approaches can also improve symptoms of anxiety. Therapies focused on well-being, including mindfulness-based individual or group therapies, are a widely available option.
Often, a combination of psychotherapy and medications produces good results. Improvement is usually noticed in a fairly short period of time, about two to three months, although a full response (or remission of symptoms) usually takes longer. Thus, appropriate treatment for anxiety can prevent symptoms or at least substantially reduce their severity and frequency, bringing significant relief to many people with anxiety.
There are also self-care measures that people with anxiety can do to help make treatment more effective. Since substances like caffeine, alcohol, and illicit drugs can worsen anxiety, those things should be avoided. Other tips to prevent or manage anxiety symptoms include engaging in aerobic exercise and stress-management techniques like deep breathing, massage therapy, and yoga, since these self-help and well-being activities have also been found to help decrease the frequency and severity of symptoms. Although many people breathe into a paper bag when afflicted by the hyperventilation that can be associated with panic, the benefit received may be the result of the individual believing it will remedy the symptoms (placebo effect). Also, breathing into a paper bag when one is having trouble breathing can make matters worse when the hyperventilation is the result of conditions of oxygen deprivation, as occurs with an asthma attack or a heart attack.
People with an anxiety disorder may also need treatment for other emotional problems. Depression has often been associated with anxiety, as have alcohol and drug abuse. Recent research also suggests that suicide attempts are more frequent in people with an anxiety disorder. Fortunately, these problems associated with panic disorder can be overcome effectively, just like panic disorder itself. Sadly, many people with anxiety do not seek or receive treatment.
What are complications of generalized anxiety disorder?
There are many possible complications associated with anxiety. Mothers who struggle with anxiety during pregnancy are more likely to have babies who are of low birth weight. Children with anxiety often also suffer from depression, behavioral problems like attention deficit hyperactivity disorder (ADHD), or oppositional defiant disorder (ODD), as well as substance abuse. They are at risk for having anxiety as adults, as well as attempting suicide and becoming psychiatrically hospitalized. In terms of achievement, children and teens with anxiety experience a higher rate of failing in school and having low-paying jobs as adults.
Is it possible to prevent anxiety?
Just as inhibited temperament, parental anxiety, and family and friends supporting avoidant coping mechanisms are risk factors for developing an anxiety disorder, encouraging the use of healthier ways to deal with stress can be of great help in the prevention of anxiety. Educating parents on how anxiety fits into their understanding of childhood development and the role of overprotecting parents in developing anxiety disorders have been found to help prevent anxiety disorders in children. Maintaining a healthy lifestyle, including a regular exercise program, eating a balanced diet, and getting adequate sleep can be key to minimizing and perhaps preventing anxiety.
What is the prognosis of generalized anxiety disorder?
Generalized anxiety disorder is often longstanding or lifelong, particularly without treatment. It can significantly interfere with the lives of individuals who have it and usually requires treatment for it to resolve. Therefore, people with generalized anxiety disorder are usually thought to need treatment for at least a year to prevent its recurrence, and some individuals may need to stay in treatment over the long term.
Medically Reviewed on 9/10/2018
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