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Learning Objectives
Upon completion of this module, participants will be able to:
- Define the concept anxiety
- Differentiate between stress, anxiety, and fear
- Identify and describe the different types of anxiety disorders
- Identify and explain the etiology of anxiety disorders
Introduction
Anxiety is a complex, yet normal, emotional response. It is when a person experiences chronic and excessive distress and/or worry regarding everyday life/situations, above a normal protective anxiety threshold, that it can be problematic. That is, the symptoms of anxiety are no longer temporary, protective, or transient. These symptoms can become debilitating thus impacting the ability to function day to day. For example, a person may not be able to function at work if they are consumed with worrying thoughts about their job performance. This worry can cause a person to engage in avoidance behavior (i.e., excessively calling in sick to work) or maladaptive coping (i.e., substance use). A person struggling with an anxiety disorder may experience a range of symptoms including physiological (i.e., rapid heart rate, increased sweating, shortness of breath, difficulty sleeping), behavioral (i.e., avoidance, use of illicit substances, fidgety), and cognitive (i.e., sense of impending doom, worry, thoughts of not being able to cope) (Hendel, 2021). This module will introduce readers to the conceptualization of anxiety, general prevalence and incidence rates related to anxiety and treatment, classification of anxiety disorders, and the etiology and risk factors associated with anxiety.
Conceptualizing Anxiety
Anxiety is a term that is often tossed around without people really knowing what it entails or means. I am sure you have heard a friend, partner, colleague, or perhaps yourself say, “I struggle with anxiety” OR “I am such an anxious person” OR “I am such a worry wart.” When people make such statements, what do they really mean? Are they aware that some anxiety is normal and adaptive? Have they been professionally diagnosed? Self-diagnosed? Are they aware there are different types of anxiety disorders such as agoraphobia? Are they confusing fear with anxiety? As a mental health provider, you may be required to assess and determine if an anxiety disorder exists and if so, which one(s). Don’t fret, we will explore the various types of anxiety disorders later in this module.
There are numerous definitions of anxiety and among these definitions there is slight variation. Before reading the next statement, how would you define anxiety? For our purposes, we will use the definition provided by the American Psychological Association (APA). According to the APA (2022), “anxiety is an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure. People with anxiety disorders usually have recurring intrusive thoughts or concerns. They may avoid certain situations out of worry. They may also have physical symptoms such as sweating, trembling, dizziness or a rapid heartbeat.”
As we explore anxiety, you may be wondering what the difference is between anxiety, stress, and fear. While there is a bit of an overlap with these emotional responses, they have some differing characteristics. First, stress is usually set off by an external trigger (i.e., a deadline for a school or work project) (APA, 2022). Once the external trigger is resolved, the symptoms of stress tend to diminish. However, chronic stress can lead to symptoms of anxiety and in some cases, it can lead to disordered anxiety. This type of chronic stress and anxiety can trigger what we call a stress response. Once the stress response is activated, specific parts of the brain are instructed to release certain hormones for the purpose of protection (i.e., cortisol, adrenaline). Second, anxiety is usually set off by an internal trigger which can include physical sensations, stress/fear response or thoughts (known as cognitions). Symptoms may include shortness of breath, worry, panic, and/or apprehension. These negative emotions and symptoms often stick around even in the absence of the trigger (Heshmet, 2018). Third, fear occurs when there is a real or perceived imminent threat. Fear is known to be present oriented. In contrast, a person who experiences anxiety as an emotional response is responding to the anticipation of a future perceived and/or uncertain threat (Heshmet, 2018). For example, a person with anxiety may experience excessive worry or dread about an upcoming college exam or an upcoming medical procedure. Anxiety is future oriented (i.e., anticipation, worry). According to the American Psychiatric Association (2013, p. 189), “these two states overlap, but they also differ. Fear is more often associated with surges of arousal necessary for fight/flight/freeze responses, thoughts of immediate danger, and escape behaviors, and anxiety is more often associated with muscle tension and vigilance in preparation for future danger and cautious or avoidant behaviors.” Here is another example to illustrate the difference between fear and anxiety. You are preparing for a camping trip and in anticipation, you begin to worry about encountering spiders and other bugs (anticipatory anxiety). Once you have arrived at your location, you begin to set-up your campsite. During that process, you encounter a spider on your backpack which triggers a stress/fear response. Your body automatically goes into protection mode (increased heart rate and alertness, pupils dilate etc.). For some, the body can calm once the trigger has been eliminated and for others, they struggle to calm the parts of the brain that facilitate a stress/fear response. In the end, both anxiety and fear responses go through the similar brain pathways that cause behavioral and physiological symptoms. Furthermore, they can both impact a person’s ability to function day to day.
Context of Anxiety
Now that you have a better conceptual understanding of anxiety, let’s put things into a larger context by looking at prevalence rates and other important data points. Many of the statistics below use anxiety as an umbrella term. According to Anxiety and Depression Association of America (2018),
- Anxiety disorders are the most common mental illness in the U.S., affecting 40 million adults in the United States age 18 and older, or 18.1% of the population every year.
- Approximately 7% of children aged 3-17 experience issues with anxiety each year. Most people develop symptoms before age 21.
- Anxiety disorders are highly treatable, yet only 36.9% of those suffering receive treatment.
- People with an anxiety disorder are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than those who do not suffer from anxiety disorders.
Answer the following questions based on the links below:
- What percentage of adults will experience anxiety in their lifetime?
- Do males or females have a higher prevalence of anxiety disorders?
- Which anxiety disorder has the highest prevalence overall?
- In the United States, what is the prevalence of social anxiety for African Americans? White Americans? Asian Americans, Hispanic Americans?
Click the following links to explore additional statistics by race, age, and gender.
https://www.singlecare.com/blog/news/anxiety-statistics/
https://www.therecoveryvillage.com/mental-health/anxiety/related/anxiety-disorder-statistics/
Anxiety Disorder Classification
It is often assumed that anxiety is one specific disorder when in fact, there are several types. As indicated earlier, anxiety disorders are an umbrella term which includes generalized anxiety disorder, social anxiety disorder, panic disorder, specific phobia, and agoraphobia (historically, OCD and PTSD were captured as anxiety disorders but have since been placed within their own chapters in the DSM 5 classification system). These disorders can be differentiated from one another by the type of object and/or situations that produce a fear/stress response, avoidance behaviors and length of time symptoms have been present. Beyond the listed anxiety disorders below, it is also important to consider anxiety that is induced by the misuse of substance (licit and/or illicit substances). Furthermore, consider anxiety symptoms as the result of substance withdrawal (Mayo clinic, 2018).
Table 1: Common Anxiety Disorders and Associated Characteristics
(Mayo Clinic (2021); NAMI (2022)
| TYPE | CHARACTERIZED BY |
| Generalized anxiety (GAD) | excessive and persistent worry about everyday life events and situations. This ongoing worry can impact a person’s day to day life and is often difficult to manage. Common symptoms include, muscle tension, irritability, difficulty sleeping, restlessness, and fatigue. |
| Panic Disorder | unexpected/out of the blue and often repeated episodes of fear which leads to the fear of future attacks. This fear can trigger physical symptoms such as feeling faint/lightheaded, chest pain, heart palpitations, and dizziness. |
| Agoraphobia | an intense and extreme fear (usually irrational in nature) of places and/or situations where escape may be difficult and/or where help may not be readily available. This intense fear can lead to panic-like symptoms. To cope with agoraphobia, people adopt avoidance behaviors which tends to exacerbate the condition alleviate it. Known as fear of fear disorder. |
| Specific Phobia | an intense, irrational, persistent, often unreasonable fear of an object, situation and in some cases an activity. The fear tends to be out of proportion to the actual risk level. This intense fear can lead to panic like symptoms. It is not uncommon for people to experience multiple phobias at one time. |
| Social Anxiety | an intense and persistent fear of being watched and judged negatively by others. There is also a worry about being embarrassed or humiliated. This fear and anxiety can be disruptive to a person’s life. Avoidance behaviors are utilized to navigate the fear and anxiety associated with social anxiety. Symptoms can include blushing, muscle tension, GI issues, trembling, intense fear of interacting with strangers, and a fear that others will notice you appear anxious. |
| Obsessive Compulsive Disorder (OCD) | obsessions are repetitive, unwanted thoughts, images, or urges/impulses that can be emotionally distressing and often feel out of a person’s control (i.e., contamination, unwanted sexual thoughts). In contrast, compulsions are ways of managing the distress associated with the obsessions (i.e., washing, cleaning, checking). OCD becomes problematic when it becomes time consuming and impacts daily functioning (i.e., ability to work, parent). |
Note: Although selective mutism and separation anxiety are considered anxiety disorders, they are not included in this series of modules. Historically, obsessive compulsive disorder and PTSD were categorized as anxiety disorders, but that is no longer the case as anxiety is not considered a defining feature. However, OCD is often treated with cognitive behavior therapy which is why it is added to the table.
While on the topic of anxiety disorders, I want to highlight another concept you may have encountered. That is the concept of functional anxiety. It is typically used in contrast to generalized anxiety disorder. While those with generalized anxiety tend to appear externally anxious and can struggle with day to day functioning, those with functional anxiety may present as calm, organized, confident, and outgoing. However, they are internally anxious and are able to function day to day by hiding or masking their anxiety (Cleveland Clinic, 2022).
PANS and PANDAS
When assessing children for a possible anxiety disorder, it is important to screen for one of two possible conditions: Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS). Both conditions have an acute onset and symptoms appear out of the blue. Symptoms often reflect the diagnostic criteria for obsessive-compulsive disorder. Other symptoms include changes in personality, tics, and restrictive eating (Child Mind Institute, n.d.). Acute onset of OCD like symptoms are an indicator to screen for PANS and PANDAS. While the cause is unclear, there has been a correlation between children who have recently had an infection, such as strep and PANS/PANDAS (PANDAS Network, 2022).
Click the link below for additional information on PANS and PANDAS.
Challenge question: Now that you have a general sense of the common anxiety disorders, which do you believe is the most prevalent? Before jumping into a search engine to find the answer, try to answer on your own. Try ranking them from most to least prevalent.
Click the link below to find the answer to this challenge question.
https://www.therecoveryvillage.com/mental-health/anxiety/related/anxiety-disorder-statistics/
Click the video link below for additional information on the definition of anxiety and the various types of anxiety.
https://www.youtube.com/watch?v=oSeJQVOLXPU
Etiology and Risk Factors of Anxiety
Assessing and diagnosing mental health conditions can be a complex process. During this process, one question clinicians often get is “what causes anxiety?” Although pinpointing the exact cause(s) is not always possible, providing psychoeducation can provide some insight and comfort. More importantly, although there is usually more than one cause and/or risk factor, research supported treatments are available to support those with an anxiety disorder. While knowing the exact cause may provide some relief for those struggling with anxiety, the underlying cause is not necessarily required for treatment. That said, it is always important to engage in the process of differential diagnosis in order to rule out possible substance use, medical conditions, or cultural elements that may be contributing factors. There are two overarching areas that are known causes (or etiology) of anxiety disorders; biological and sociocultural/environmental (NAMI, 2022).
Biological
Genetics: Research has shown that anxiety, as well as other mental health conditions that run within families increases one’s risk of developing the disorder (NAMI, 2022). Research indicates that a combination of genetics and exposure to a stressful environment account for greater risk than genetics alone.
Medical: When conducting an assessment, mental health providers should always engage in the process of differential diagnosis. There are several medical conditions that may contribute to someone experiencing symptoms of anxiety. For example, the following conditions are known to be associated with symptoms of anxiety; diabetes, hypoglycemia, medication use/misuse, thyroid issues (i.e., hyperthyroidism), and respiratory issues (i.e., asthma or COPD) (NAMI, 2022).
Neurobiology: Learning brain anatomy and physiology will not only help the mental health provider understand anxiety from a neurobiological viewpoint, but it will also help the consumer (i.e., psychoeducation). It can help make sense of the phenomenon that the client is experiencing such as learning about the two brain pathways that lead to anxiety. Understanding the neurobiology also assists in the treatment and recovery process.
The nervous system, which has two primary branches (central and peripheral nervous systems) plays a role in mental health disorders. For example, the parts of the brain that play a critical role in anxiety include the amygdala, thalamus, hypothalamus, and cortex (pre-frontal cortex) (Bridley & Daffin, 2018). Furthermore, there are specific chemicals within the brain and body that have an influence on anxiety and one’s response to anxiety, fear, and stress (known as neurotransmitters and hormones). You may be familiar with some of these chemicals which include serotonin, adrenaline, and cortisol.
At the most basic level, the building blocks of anxiety involve the central and peripheral nervous systems. To fully appreciate the complexity and nature of the fear/stress response and anxiety, it is important to take a deeper look into these systems. We know that anxiety impacts the brain in numerous ways including flooding the brain with chemicals including the stress hormone cortisol and adrenaline, increases hyperactivity in various parts of brain (amygdala), impacts your ability to thinking rationally/logically, and anxiety can train your brain to hold onto negative memories (conditioning).
Interestingly, decades of research have shown that the brain is very malleable. That is, the brain can change and/or modify various structures and functions, even beyond the developmental age of 25. This process of change and modification is known as neuroplasticity.
** NOTE: Please note that while this is a brief overview of neurobiology, we will go into more depth regarding the anatomy and physiology of the brain in modules 2.
Sociocultural/Environmental
In reference to sociocultural factors, we are referring to things such as, but not limited to, socioeconomic status, immigration status, gender identity, sexual orientation, race, ethnicity, religious affiliation etc. It can be helpful to view these factors from an ecological perspective. That is, the reciprocal interaction between the person and their environment. Often a poor fit can lead to stress, fear, and anxiety and in many cases this experience can be chronic in nature. It is also important to consider the impact of the social determinants of health which can have an impact on a person’s overall health and well-being. Such determinants include access to quality healthcare, education, economic stability, and one’s community (i.e., neighborhood) (Bridley & Daffin, 2018).
Other Potential Causes
While biological and sociocultural factors are the most common causes of anxiety disorders, there are other factors to take into consideration. Other known anxiety contributors include, substance use (licit or illicit), personality and temperament, childhood abuse/neglect, chronic stress, and cognitive styles.
Conclusion
This chapter provided readers with an introduction and overview of the anxiety disorders. An important element addressed in this chapter was addressing the difference between stress, anxiety, and fear. Several areas associated with anxiety disorders, including the etiology and common characteristics were covered as they play a critical role in assessment, diagnosis, and intervention. Understanding anxiety disorders from both a medical, biological, and sociological/sociocultural perspective are critical for a more balanced and holistic perspective.
Learning Activities and Questions
- ______________ is known as the fear of fear disorder.
- Given what you have learned about anxiety disorders, which one is the most prevalent in the United States?
- Anxiety disorders is an umbrella term that captures several disorders. Identify two disorders and briefly describe how they are characterized.
- In your own words, briefly describe the differences and similarities between anxiety, fear, and stress.
- How would you describe PANS and PANDAS to a parent whose child is being considered for one of these conditions as part of the differential diagnosis process?
- For this scenario, video record your response. Scenario: One of your client’s whom you diagnosed as having generalized anxiety disorder is curious how they developed such a disorder. Verbatim, how would you respond to your client’s curiosity/question about the etiology of anxiety disorders?
References
American Psychological Association (2022). Anxiety. https://www.apa.org/topics/anxiety
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders 5 (5th Ed.). Washington, DC, American Psychiatric Press.
American Psychological Association. (2022). What’s the difference between stress and anxiety?
Anxiety and Depression Association of America (2018). Did you know? https://adaa.org/understanding-anxiety/facts-statistics
Bridley, A., & Daffin, L. W., (2018). Essentials of Abnormal Psychology (1st ed).
https://opentext.wsu.edu/abnormalpsychology/chapter/4-6-anxiety-disorders-etiology/
Child Mind Institute (n.d.). Complete Guide to PANS and PANDAS. https://childmind.org/guide/parents-guide-to-pans-and-pandas/#block_8a5183dd-a8e7-482d-8f56-e2274e5e521f
Cleveland Clinic (May 16, 2022). Signs you have functional anxiety.
https://health.clevelandclinic.org/what-is-high-functioning anxiety/#:~:text=What%20is%20high%2Dfunctioning%20anxiety,You%20may%20overreact%20at%20times.
Hendel, H.J., (2021). Anxiety and Fear: What’s the difference? NAMI. https://www.nami.org/Blogs/NAMI-Blog/May-2021/Anxiety-And-Fear-What-s-The-Difference
Heshmat, S. (2018). Anxiety vs. fear: What is the difference? Psychology Today.
https://www.psychologytoday.com/us/blog/science-choice/201812/anxiety-vs-fear
Mayo Clinic (2021). Anxiety disorders.
https://www.mayoclinic.org/diseases-conditions/anxiety/symptoms-causes/syc-20350961
National Alliance of Mental Illness [NAMI], (2022). Anxiety disorders. https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Anxiety-Disorders
PANDAS Network (2022). Understanding PANDAS and PANS. https://pandasnetwork.org/understanding-pandas/
