Anxiety disorders are common. They are experienced by about 10 percent of Americans at any given time. In fact, one in five adults has experienced one in the past year.[1]

Any Anxiety Disorder

Anxiety is an internal experience that is accompanied by physical manifestations. It is sometimes described as a feeling of fear and dread. Other times, the words used to explain the feelings of anxiety are,

• • • unease
    • worry
    • apprehensive expectation

Physical symptoms in moderate to severe anxiety disorders can be quite uncomfortable, including, 

• • • rapid heartbeat
    • sweating
    • frequent urination
    • dry mouth
    • muscle tremors

And, anxiety does not travel alone. When it is felt strongly, it is often accompanied by other psychological states, such as 

• • • poor concentration
    • irritability
    • over-arousal 
    • a feeling of impending doom

Fear vs anxiety

Anxiety can be viewed as a response to a sense of threat. If the focus is very specifically related to some real danger in the world, it is considered to be fear. If the perceived threat is less specific, more uncertain, and future-oriented, it is thought of as anxiety.

Sometimes a distinction is made between “trait anxiety” and “state anxiety.” Trait anxiety is a long-term process that occurs in a person who is somehow more prone to this experience. State anxiety is how a person may feel at a given moment.

In moderation, fear and anxiety can be helpful, attuning us to be vigilant and aware of possible hazards. The ‘fight or flight’ physiology that anxiety generates can help us respond to a truly dangerous situation. In the absence of danger but in the face of a challenge, in moderation, it can also help spur problem-solving and productivity.

Often though, anxiety (and its accompanying features) become so strong that it is detrimental, impairing functioning. It can make life very difficult. When that occurs, we describe the condition as an anxiety disorder. 

Who is affected by anxiety disorders?

Age of onset: People of all ages are affected by anxiety disorders. Overall, the average age of onset of anxiety disorders as a whole is about 21.[2] Phobias, separation anxiety, and social anxiety tend to start younger, with an average age of 15.  Generalized anxiety disorder (GAD) and panic disorder tend to start a bit later, often between 21 and 34 years of age. These numbers represent averages, though. Many children and adolescents—as many as one in three—may have difficulty with anxiety at some point.

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Gender distribution depends on the specific disorder. About twice as many women than men suffer from GAD or panic disorder. On the other hand, social anxiety is experienced about equally by both genders.

Genetics: Anxiety disorders tend to run in families. For instance, research has found that children of anxious parents are at increased risk for anxiety compared to the off-spring of non-anxious parents.[3]

Studies have found the clustering of anxiety disorders and depression.[4] This suggests that their genetics have some commonalities.

Some experts estimate that genetic factors account for 30-40 percent of the likelihood of developing an anxiety disorder. Non-genetic factors may be responsible for 50-70 percent.

The absence (so far) of specific genes suggests that anxiety disorders may appear due to a combination of factors including genetic vulnerability, environmental factors, such as traumatic events, and longer-term qualities of the emotional or physical environment, such as stressful conditions.

Consequences of anxiety disorders

Although we remain unsure about the ultimate causes of anxiety disorders, we are beginning to recognize that they have significant consequences beyond feelings of discomfort. For example, persons with a generalized anxiety disorder (GAD), have lower scores on measures of quality of life, social life, and life satisfaction.[5] 

In the elderly, anxiety often precedes cognitive decline. Further, GAD is often seen co-existing with other illnesses, including in about half of people with depressive disorders.[6] 

Further, people with both anxiety and depression are at 50-80 percent higher risk for cardiac disease, stroke, high blood pressure, and arthritis. This is comparable to the risks associated with obesity and smoking. [7]

Recognizing the many different forms of anxiety

Anxiety disorders come in many different forms. It’s important to consider these differences because they can influence the types of treatment that should be considered. 

Even though we recognize that the particular way anxiety is manifested is unique to each individual, doctors group the symptoms together in a manner that makes it possible to be studied. The following are the most common types of anxiety disorders.

• Generalized Anxiety Disorder (GAD)

The general qualities of GAD, as expressed in a widely used psychiatric manual (the ‘DSM V’) [8], include:

• • • Excessive anxiety or worry on a majority of days for at least six months.
    • A person finds this difficult to control.

The presence of at least three of the following symptoms in adults or one, in the case of children:

1. 1. 1. Restlessness
      2. Fatigue
      3. Muscle 
      4. Irritability
      5. Difficulty concentrating
      6. Sleep difficulty or other symptoms lead to significant distress or decreased functioning at home or work                
      7. The anxiety is not related to the medicine the person may be taking, a medical condition, or some other disorder (for instance, thinking about past trauma in post-traumatic stress disorder).

GAD can occur alone, but also often appears in combination with depression. A person diagnosed with GAD often goes on to develop major depression within one year.[9] 

When the two occur together, the impact on a person’s life and health is often much greater. As discussed, there are commonalities between the two conditions, including some similarities in genetics and overlapping biological features.[10]

Although both conditions may be treated with similar medications (e.g., SSRIs), the general format of the most widely used psychotherapy–cognitive behavioral therapy—is the same for both, though with different emphases.

There is evidence that there may be a similar type of susceptibility to both of these disorders.[11] They suggest that some people respond more with anxiety, while others become depressed or both. The reasons for the different responses are not yet understood.

Whether or not this turns out to be the case, these two conditions appear together so often that it is difficult in a practical sense to talk about one without the other.

Other related anxiety disorders

In addition to GAD, there are a number of other related anxiety disorders. These include:

• Panic Disorder

People with panic disorder unexpectedly experience discrete episodes of ‘panic attacks’ characterized by, but not limited to, the following manifestations:

• • • fear
    • rapid heartbeat
    • shortness of breath
    • chest discomfort
    • a sense of choking
    • sweating
    • trembling
    • a sense of impending doom
    • nausea
    • chills 

Panic episodes begin suddenly, peak in intensity within 10 minutes or so, and may last up to 30-45 minutes.

As with GAD, part of the criteria for panic disorder is that the events do not seem to be related to the effects of a substance or medical disorder.

Often, a person experiencing a panic episode may believe they are having a heart attack or another type of life-threatening event. Many go to emergency rooms for help.

Although panic episodes are often thought of as taking place during the day, many people experiencing them have also had them at night.[12]

To meet the formal criteria of panic disorder, the panic attack is followed by at least one month of persistently worrying about future episodes. They may also manifest changes in their behavior that reflect this worry. Indeed, these events can be so frightening that some persons develop qualities of post-traumatic stress disorder. [13]

Some studies have found a significant impact of panic disorder on a sense of well-being as well as self-acceptance and a feeling of having a purpose in life.[14]

Panic episodes, either unexpected or expected, can occur alone or in other anxiety disorders including GAD, agoraphobia, and social anxiety disorder.

• Specific phobias

Excessive fear or anxiety about very specific situations (e.g., flying or being in high places) or objects (blood, animals). This may lead to avoidance of the feared thing and often affects daily functioning.

Often, a person realizes that the fear is irrational but feels unable to control it. If it seems possible that he/she will encounter the feared object, there is anticipatory anxiety, and experiencing it can lead to panic attacks.

Sometimes the phobia begins to incorporate additional objects. Initially, phobias often seem to appear without obvious cause and, once present, can persist for a long time, although sometimes they will clear up on their own.

• Agoraphobia  

Taken from the Greek word ‘agora’ for the marketplace, this is fear of being in open places, public transportation, or crowds. A common theme is that there is a sense of not being able to escape to somewhere safe. The experience may lead to a full or partial panic attack.

Panic attacks may lead to staying home more and more often. This may lead to social isolation that can be so severe that the individual becomes extremely dependent on another person for doing errands or for accompanying them on forays away from home.

• Social anxiety disorder

A diagnosis of a social anxiety disorder requires that the individual experience excessive anxiety of at least six months’ duration about social interaction with others. This includes, for instance, talking to strangers, going out to dinner with a group, or speaking or performing in public. There is a tendency on the part of the affected individual to emphasize any threatening qualities of the situation. Afterward, he/she may think about and replay the social event in a negative way. Sometimes alcohol or drugs are taken in an attempt to deal with the anxiety and that, of course, can create problems of its own.

• Separation anxiety disorder

Excessive worry and anxiety about being away from a person important in one’s life are called separation anxiety disorder. Although at first glance this sounds like a condition in children, it may appear in adults too. When seen in adulthood, there is not necessarily a history of difficulty with separation persisting from childhood.

Typical symptoms can include a great deal of worry about being separated from an important figure, that harm will come to this person, or a desire to stay home to be close. There are often nightmares involving separation.

The formal diagnosis requires that these symptoms go on for at least six months and result in distress or impaired functioning socially or at work.

• Selective mutism

Selective mutism is an uncommon condition that occurs in less than 0.05 percent of school children. It often starts before the age of 5. Affected individuals do not speak in certain social settings even though having normal language ability in other situations. A child may be mute at school, for instance, while speaking easily at home. Parents can mistakenly believe that the child is simply refusing to speak. And they may believe that the mutism is a manipulative or controlling behavior.

Selective mutism is usually associated with shyness and withdrawal. It is often accompanied by other anxiety disorders and can persist into adulthood. Children with selective mutism are not more likely to have histories of abuse or neglect. The hesitancy of some immigrant children who are uncomfortable with a new language to speak in strange situations is not usually thought of as selective mutism.

Anxiety may have many sources

It is important to understand that anxiety may have many sources. Among them are medical illnesses, some medications, and psychiatric conditions. Let’s look at each of these in turn.

• Medical illnesses underlying anxiety

Many medical conditions are associated with anxiety symptoms. Here are some of them:

• • • hormone disorders such as having an overactive thyroid
    • nutritional problems such as Vitamin B12 deficiency
    • heart disorders such as angina
    • abnormal rhythms

• Medications and other substances can cause anxiety

Among these are stimulants and medicines for ADHD, thyroid, asthma, and Parkinson’s disease. If it appears that a medication may be involved in anxiety, it’s important to not immediately stop it. Rather, the patient should consult a doctor who will consider whether lowering the dose or changing to an alternative medicine can relieve the symptoms.

Many over-the-counter drugs contain caffeine and can potentially contribute to anxiety symptoms from excessive caffeine consumption. These include some preparations for pain, menstrual discomfort, and migraine. 

• Psychiatric conditions and anxiety

In addition to anxiety disorders, the symptom of anxiety may be a part of a wide range of psychiatric conditions which have specific treatments of their own. Among these are the following:

• • • an obsessive-compulsive disorder
    • post-traumatic stress disorder (PTSD)
    • eating disorders
    • substance abuse.

After causes such as medical illnesses, medications, and other psychiatric disorders have been ruled out, it is time to address the anxiety and determine whether treatment is in order.

Anxiety is a part of everyday life, and indeed in moderation can have useful purposes. It can be a spur to solving problems, to learning, to be more productive. Every life has its ups and downs, and often these ‘downs’ can be anxiety-producing. The point at which normal anxiety becomes a disorder, such as GAD, is when it rises to the level where it,

• becomes more frequent (on most days for at least six months)
• is difficult to control
• leads to significant distress 
• starts to inhibit one’s ability to function.

When anxiety is present but falls short of this mark, if it still feels uncomfortable, one option is to address it in psychotherapy.

It may come out in therapy, for instance, that the anxiety stems from conflicts between a person’s desires and their beliefs about what is appropriate. Or it could arise from an unhelpful way of thinking about relationships. Therapy may help the person learn ways to better tolerate a certain amount of anxiety.

On the other hand, when anxiety crosses the mark into anxiety disorders due to its frequency, an uncontrollable quality and an effect on functioning, it is clearly time to seek treatment.

Treatments for anxiety disorders

Unfortunately, anxiety disorders are not always recognized. Only about half of people with anxiety disorders in primary care practices are receiving treatment.[15]

There is a wide range of effective treatments for anxiety disorders. As no single one is clearly the best for everyone, choosing often involves personal preferences. 

• Medications

Medications are usually reserved for moderate-to-severe anxiety. They come in a large variety of types.  Some such as the benzodiazepines (‘Valium-like’ drugs) have a relatively rapid onset of action. Others, such as the selective serotonin reuptake inhibitors (SSRIs) are more for long-term use.

The benzodiazepines also raise concerns about the potential for dependence and changes in thinking and memory. For these and other reasons tend to be used less widely. 

Some medicines such as hydroxyzine can be helpful but use may be limited because of drowsiness. Other drugs, such as mirtazapine, are approved by the Food and Drug Administration for other purposes (such as depression) [16] but sometimes are prescribed ‘off-label’ for anxiety. 

In working with a doctor to choose medication, it is important to learn about its possible benefits and side effects and to find a balance that feels right.

• Talk therapy

Non-medicine (‘talking’) therapies are widely used, particularly for mild-to-moderate levels of anxiety. There are different types: 

• • • Some experts view anxiety as a learned response that needs to be unlearned.
    • Therapies that are considered ‘psychodynamic’ look into how one’s past experiences influence the present situation. 
    • Interpersonal therapy emphasizes relationships with others. 
    • Cognitive therapies consider possibly unhelpful or incorrect assumptions that a person may be making as well as inaccurate ways of thinking. 

These approaches are all compatible with taking medicines.  Indeed, they often work well hand in hand at the same time, and complement each other’s benefits.

Choosing the type of treatment

As described in the author’s book, Understanding Medicines for Anxiety,  a basic choice is between medications and psychotherapy or combination treatment. Medications may lead to more rapid relief of symptoms than psychotherapy alone. On the other hand, medications might cause unpleasant or intolerable side effects.

Initial factors favoring medication are:

• • • if symptoms are moderate-to-severe
    • whether the speed of response is important.

Medication might also be considered if a person does not have the time or wherewithal for psychotherapy or has been in therapy but does not feel the desired symptom relief.

Factors that would favor psychotherapy include the following:

• • • being pregnant or nursing
    • having more mild-to-moderate symptoms
    • having the available time and resources

Many psychotherapies for anxiety are relatively brief, often 3-4 months. They are also advantageous if a person is particularly concerned about the possibility of medicine side effects.

Another factor favoring therapy would be that if in addition to anxiety, a person seems to have habitual ways of dealing with others that are not helpful, for instance, typically being dramatic and emotional, being extremely sensitive to rejection, or overly suspicious or manipulative. These kinds of habits can be addressed in psychotherapy which can often benefit anxiety.

Finally, the most important incentive for choosing the medicine or the non-medicine approach would be the lack of adequate improvement with the other treatment.   Medicines and therapy are also not incompatible and are often combined.

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Setting Realistic Goals

It is valuable to think about what a reasonable outcome would be from the very beginning of treatment. It’s natural to want relief from the uncomfortable feeling of excessive anxiety.

But it is also important not to imagine the goal of living in a kind of blissful state completely free of anxieties and worries. The world won’t allow it. Life has too many ups and downs. Further, in moderation, anxiety can help with the difficult parts.

Even if it were possible to eliminate all anxiety, upon reflection, it might be a kind of dreary, colorless kind of existence. The good news is that the kinds of treatments we have described here can greatly decrease levels of excessive anxiety.

Therefore a more reasonable goal might be to bringing the anxiety to a point where it is manageable, not inhibiting how one functions, or diminishing the capacity to experience a pleasure.

Although it is possible that anxiety might reappear in the future, it is good to know that it was dealt with in the past and that it can be again this time. The important thing to remember is that you are not helpless in the face of anxiety. There are many options available. Learning about them can help in making the choices that are best for you.

The bottom line

Anxiety is not only common but also multifaceted in its appearance. It occurs in all ages affecting men, women, and children. It’s of particular concern when it occurs in combination with depression where it is associated with a number of health issues. 

The good news is that there are many effective treatments. If you suspect that you might have an anxiety disorder, it’s important to seek consultation from a doctor or therapist.

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References:

1. The National Institue of Mental Health, Statistics, Any Anxiety Disorders. The wide variety of anxiety disorders differ by the objects or situations that induce them, but share features of excessive anxiety and related behavioral disturbances.  Nov 2017. https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder.shtml

2. Jasmijn M. de Lijster, MSc, Bram Dierckx, PhD,  Elisabeth M.W.J. Utens, PhD, et el. The objective was to estimate the age of onset (AOO) for all anxiety disorders and for specific subtypes. US National Library of Medicine, The Age of Onset Anxiety Disorders, A Meta-analysis, 2017 Apr; 62(4): 237–246.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5407545/

3. Peter J.Lawrence DClinPsych, Kou Murayama PhD, Cathy Creswell PhD. We conducted meta-analyses to assess risk for anxiety disorders among offspring of parents with anxiety disorders. Science Direct, Systematic Review and Meta-Analysis: Anxiety and Depressive Disorders in Offspring of Parents With Anxiety Disorders, Volume 58, Issue 1, January 2019, Pages 46-60  https://www.sciencedirect.com/science/article/pii/S08,  90856718319130

4. Robert Preidt, HealthDay Reporter. New research involving the DNA of 200,000 U.S. veterans suggests that there really is such a thing as a “worry gene.” WebMD,  Veterans’ Study Shows Genetic Origins of Anxiety, published Jan. 20,2020 (HealthDay News) https://www.webmd.com/anxiety-panic/news/20200110/veterans-study-shows-genetic-origins-of-anxiety

5. Terri L. Barrera and Peter J. Norton, The present study examined quality of life impairments in individuals with Generalized Anxiety Disorder (GAD), Social Phobia, and Panic Disorder.  US National Library of Medicine, Quality of Life Impairment in Generalized Anxiety Disorder, Social Phobia, and Panic Disorder, Published: J Anxiety Disord. 2009 Dec; 23(8): 1086–1090. Published online 2009 Jul 14.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2782397/

6. Anxiety and Depression Association of America, Understanding the Facts & Statistics, Sources: National Institue of Mental Health and World Health Organization: Mental Health https://adaa.org/about-adaa/press-room/facts-statistics

7. University of California – San Francisco, a new study suggests health care providers may be overlooking a critical question: Are you depressed or anxious? Science News; Releases; December 17, 2018 https://www.sciencedaily.com/releases/2018/12/181217144140.htm

8.  Diagnostic and Statistic Manual of Mental Disorders (DSM-5); DSM-5  is the product of more than 10 years of effort by hundreds of international experts in all aspects of mental health.  Updated October 1, 2018  https://www.psychiatry.org/psychiatrists/practice/dsm

9. Robert M. A. Hirschfeld, M.D., Depressive and anxiety disorders commonly occur together in patients presenting in the primary care setting.  The Comorbidity of Major Depression and Anxiety Disorders: Recognition and Management in Primary Care, Prim Care Companion J Clin Psychiatry. 2001; 3(6): 244–254. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC181193/

10. Laren Walters,  This article will explore the similarities between depression and anxiety. PsychCentral, Coping with Depression, 24 November 2016 https://blogs.psychcentral.com/coping-depression/2016/11/similarities-between-depression-and-anxiety/

11.  Andrew S. Fox, Jonathan A. Oler, Alexander J. Shackman, et el. According to the WHO, anxiety and depressive disorders are a leading source of disability, affecting hundreds of millions of people. Intergenerational neural mediators of early-life anxious temperament.  National Academy of Sciences of the US; Published July 6, 2015 https://www.pnas.org/content/early/2015/07/01/1508593112.abstract

12.  Masaki Nakamura, M.D., Ph.D., Tatsuki Sugiura, M.D., Ph.D., Shingo Nishida, M.D., et el, We investigated the differences in demographic variables and symptom characteristics. Is Nocturnal Panic a Distinct Disease Category? Comparison of Clinical Characteristics among Patients with Primary Nocturnal Panic, Daytime Panic, and Coexistence of Nocturnal and Daytime Panic; US National Library of Medicine, National Institutes of Health;  2013 May 15; 9(5): 461–467.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3629320/

13. Tomer Shasha, Michael J Dolgin, Dana Tzur Bitan, Eli Somer^; The current study assessed the incidence and associated features of posttraumatic stress after the experience of panic. ; US National Library of Medicine, National  Center of Biotehcnology Information; J Nerv Ment Dis, 206 (7), 501-506; July 2018  . 

14. Fava GA, Rafanelli C, Ottolini F, Ruini C, Cazzaro M, Grandi S.; Little is known about psychological well-being in remitted patients with panic disorder and agoraphobia and its interactions with residual symptoms.  Psychological well-being and residual symptoms in remitted patients with panic disorder and agoraphobia. US National Library of Medicine; National Institutes of Health;  J Affect Disord. 2001 Jul;65(2):185-90. https://www.ncbi.nlm.nih.gov/pubmed/11356243

15. AARON LEVIN; In a study of 15 New England medical practices, only half the primary care patients with anxiety disorders were receiving treatment; Anxiety Disorders Often Untreated in Primary Care; Psychiatric News; Published Online:2 Feb 2007 https://psychnews.psychiatryonline.org/doi/full/10.1176/pn.42.3.0028

16. Understanding Antidepressants by Wallace B. Mendelson, MD https://www.amazon.com/Understanding-Antidepressants-Wallace-B-Mendelson/dp/1980438293