Anxiety

A woman diagnosed with panphobia, from Alexander Morison's

1843 book The Physiognomy of Mental Diseases.

Classification and external resources

Specialty Psychiatry, psychology

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Anxiety is an emotion characterized by an unpleasant state of inner turmoil, often accompanied by

nervous behaviour such as pacing back and forth, somatic complaints, and rumination.[1] It is the
subjectively unpleasant feelings of dread over anticipated events, such as the feeling of imminent
death.[2] Anxiety is not the same as fear, which is a response to a real or perceived
immediate threat,[3] whereas anxiety is the expectation of future threat.[3] Anxiety is a feeling of
 uneasiness and worry, usually generalized and unfocused as an overreaction to a situation that is
only subjectively seen as menacing.[4] It is often accompanied by muscular
tension,[3]restlessness, fatigue and problems in concentration. Anxiety can be appropriate, but when
experienced regularly the individual may suffer from an anxiety disorder.[3]
People facing anxiety may withdraw from situations which have provoked anxiety in the past.[5] There
are various types of anxiety. Existential anxiety can occur when a person faces angst, an existential
crisis, or nihilisticfeelings. People can also face mathematical anxiety, somatic anxiety, stage fright,
or test anxiety. Social anxiety and stranger anxiety are caused when people are apprehensive
around strangers or other people in general. Furthermore, anxiety has been linked with physical
symptoms such as IBS and can heighten other mental health illnesses such as OCD and panic
disorder. The first step in the management of a person with anxiety symptoms is to evaluate the
possible presence of an underlying medical cause, whose recognition is essential in order to decide
its correct treatment.[6][7] Anxiety symptoms may be masking an organic disease, or appear
associated or as a result of a medical disorder.[6][7][8][9]
Anxiety can be either a short term "state" or a long term "trait". Whereas trait anxiety represents
worrying about future events, anxiety disorders are a group of mental disorders characterized by
feelings of anxiety and fear.[10]Anxiety disorders are partly genetic but may also be due to drug use,
including alcohol, caffeine, and benzodiazepines (which are often prescribed to treat anxiety), as
well as withdrawal from drugs of abuse. They often occur with other mental disorders,
particularly bipolar disorder, eating disorders, major depressive disorder, or certain personality
disorders. Common treatment options include lifestyle changes, medication,
and therapy. Metacognitive therapy seeks to rid anxiety through reducing worry, which is seen as a
consequence of metacognitive beliefs.[11]

Contents
[hide]

 1Descriptions
 2Types
o 2.1Existential
o 2.2Test and performance
o 2.3Stranger, social, and intergroup anxiety
o 2.4Trait
o 2.5Choice or decision
o 2.6Anxiety disorders
 3Risk factors
o 3.1Neuroanatomy
o 3.2Genetics
o 3.3Medical conditions
o 3.4Substance-induced
o 3.5Psychological
o 3.6Social
 4Pathophysiology
 5See also
 6References
 7External links

Descriptions[edit]
A job applicant with a worried facial expression
Anxiety is distinguished from fear, which is an appropriate cognitive and emotional response to a
perceived threat.[12] Anxiety is related to the specific behaviors of fight-or-flight responses, defensive
behavior or escape. It occurs in situations only perceived as uncontrollable or unavoidable, but not
realistically so.[13] David Barlow defines anxiety as "a future-oriented mood state in which one is not
ready or prepared to attempt to cope with upcoming negative events,"[14] and that it is a distinction
between future and present dangers which divides anxiety and fear. Another description of anxiety is
agony, dread, terror, or even apprehension.[15] In positive psychology, anxiety is described as the
mental state that results from a difficult challenge for which the subject has
insufficient coping skills.[16]
Fear and anxiety can be differentiated in four domains: (1) duration of emotional experience, (2)
temporal focus, (3) specificity of the threat, and (4) motivated direction. Fear is defined as short
lived, present focused, geared towards a specific threat, and facilitating escape from threat; anxiety,
on the other hand, is defined as long-acting, future focused, broadly focused towards a diffuse
threat, and promoting excessive caution while approaching a potential threat and interferes with
constructive coping.[17]
Anxiety can be experienced with long, drawn out daily symptoms that reduce quality of life, known as
chronic (or generalized) anxiety, or it can be experienced in short spurts with sporadic,
stressful panic attacks, known as acute anxiety.[18] Symptoms of anxiety can range in number,
intensity, and frequency, depending on the person. While almost everyone has experienced anxiety
at some point in their lives, most do not develop long-term problems with anxiety.
Anxiety may cause psychiatric and physiological symptoms.[6][9]
The behavioral effects of anxiety may include withdrawal from situations which have provoked
anxiety or negative feelings in the past.[5] Other effects may include changes in sleeping patterns,
changes in habits, increase or decrease in food intake, and increased motor tension (such as foot
tapping).[5]
The emotional effects of anxiety may include "feelings of apprehension or dread, trouble
concentrating, feeling tense or jumpy, anticipating the worst, irritability, restlessness, watching (and
waiting) for signs (and occurrences) of danger, and, feeling like your mind's gone blank"[19] as well as
"nightmares/bad dreams, obsessions about sensations, déjà vu, a trapped-in-your-mind feeling, and
feeling like everything is scary."[20]
The cognitive effects of anxiety may include thoughts about suspected dangers, such as fear of
dying. "You may ... fear that the chest pains are a deadly heart attack or that the shooting pains in
your head are the result of a tumor or an aneurysm. You feel an intense fear when you think of
dying, or you may think of it more often than normal, or can't get it out of your mind."[21]
The physiological symptoms of anxiety may include:[6][9]

 Neurological, as headache, paresthesias, vertigo, or presyncope.

 Digestive, as abdominal pain, nausea, diarrhea, indigestion, dry mouth, or bolus.
 Respiratory, as shortness of breath or sighing breathing.
 Cardiac, as palpitations, tachycardia, or chest pain.
 Muscular, as fatigue, tremors, or tetany.
 Cutaneous, as perspiration, or itchy skin.
 Uro-genital, as frequent urination, urinary urgency, dyspareunia, or impotence.

Types[edit]
Painting entitled Anxiety, 1894, by Edvard Munch

Existential[edit]
Further information: Angst, Existential crisis, and Nihilism
The philosopher Søren Kierkegaard, in The Concept of Anxiety (1844), described anxiety or dread
associated with the "dizziness of freedom" and suggested the possibility for positive resolution of
anxiety through the self-conscious exercise of responsibility and choosing. In Art and Artist (1932),
the psychologist Otto Rank wrote that the psychological trauma of birth was the pre-eminent human
symbol of existential anxiety and encompasses the creative person's simultaneous fear of – and
desire for – separation, individuation, and differentiation.
The theologian Paul Tillich characterized existential anxiety[22] as "the state in which a being is aware
of its possible nonbeing" and he listed three categories for the nonbeing and resulting anxiety: ontic
(fate and death), moral (guilt and condemnation), and spiritual (emptiness and meaninglessness).
According to Tillich, the last of these three types of existential anxiety, i.e. spiritual anxiety, is
predominant in modern times while the others were predominant in earlier periods. Tillich argues
that this anxiety can be accepted as part of the human condition or it can be resisted but with
negative consequences. In its pathological form, spiritual anxiety may tend to "drive the person
toward the creation of certitude in systems of meaning which are supported
by tradition and authority" even though such "undoubted certitude is not built on the rock of reality".[22]
According to Viktor Frankl, the author of Man's Search for Meaning, when a person is faced with
extreme mortal dangers, the most basic of all human wishes is to find a meaning of life to combat
the "trauma of nonbeing" as death is near.[23]

Test and performance[edit]

Main articles: Test anxiety, Mathematical anxiety, Stage fright, and Somatic anxiety
According to Yerkes-Dodson law, an optimal level of arousal is necessary to best complete a task
such as an exam, performance, or competitive event. However, when the anxiety or level of arousal
exceeds that optimum, the result is a decline in performance.[24]
Test anxiety is the uneasiness, apprehension, or nervousness felt by students who have a fear of
failing an exam. Students who have test anxiety may experience any of the following: the association
of grades with personal worth; fear of embarrassment by a teacher; fear of alienation from parents or
friends; time pressures; or feeling a loss of control. Sweating, dizziness, headaches, racing
heartbeats, nausea, fidgeting, uncontrollable crying or laughing and drumming on a desk are all
common. Because test anxiety hinges on fear of negative evaluation,[25] debate exists as to whether
test anxiety is itself a unique anxiety disorder or whether it is a specific type of social phobia.[26] The
DSM-IV classifies test anxiety as a type of social phobia.[27]
While the term "test anxiety" refers specifically to students,[28] many workers share the same
experience with regard to their career or profession. The fear of failing at a task and being negatively
evaluated for failure can have a similarly negative effect on the adult.[29]Management of test anxiety
focuses on achieving relaxation and developing mechanisms to manage anxiety.[28]

Stranger, social, and intergroup anxiety[edit]

Main articles: Stranger anxiety and Social anxiety
Humans generally require social acceptance and thus sometimes dread the disapproval of others.
Apprehension of being judged by others may cause anxiety in social environments.[30]
Anxiety during social interactions, particularly between strangers, is common among young people.
It may persist into adulthood and become social anxiety or social phobia. "Stranger anxiety" in small
children is not considered a phobia. In adults, an excessive fear of other people is not a
developmentally common stage; it is called social anxiety. According to Cutting,[31] social phobics do
not fear the crowd but the fact that they may be judged negatively.
Social anxiety varies in degree and severity. For some people, it is characterized by experiencing
discomfort or awkwardness during physical social contact (e.g. embracing, shaking hands, etc.),
while in other cases it can lead to a fear of interacting with unfamiliar people altogether. Those
suffering from this condition may restrict their lifestyles to accommodate the anxiety, minimizing
social interaction whenever possible. Social anxiety also forms a core aspect of certain personality
disorders, including avoidant personality disorder.[32]
To the extent that a person is fearful of social encounters with unfamiliar others, some people may
experience anxiety particularly during interactions with outgroup members, or people who share
different group memberships (i.e., by race, ethnicity, class, gender, etc.). Depending on the nature of
the antecedent relations, cognitions, and situational factors, intergroup contact may be stressful and
lead to feelings of anxiety. This apprehension or fear of contact with outgroup members is often
called interracial or intergroup anxiety.[33]
As is the case the more generalized forms of social anxiety, intergroup anxiety has behavioral,
cognitive, and affective effects. For instance, increases in schematic processing and simplified
information processing can occur when anxiety is high. Indeed, such is consistent with related work
on attentional bias in implicit memory.[34][35][36] Additionally recent research has found that implicit racial
evaluations (i.e. automatic prejudiced attitudes) can be amplified during intergroup
interaction.[37] Negative experiences have been illustrated in producing not only negative
expectations, but also avoidant, or antagonistic, behavior such as hostility.[38] Furthermore, when
compared to anxiety levels and cognitive effort (e.g., impression management and self-presentation)
in intragroup contexts, levels and depletion of resources may be exacerbated in the intergroup
situation.

Trait[edit]
Anxiety can be either a short-term 'state' or a long-term personality "trait". Trait anxiety reflects a
stable tendency across the lifespan of responding with acute, state anxiety in the anticipation of
threatening situations (whether they are actually deemed threatening or not).[39] A meta-analysis
showed that a high level of neuroticism is a risk factor for development of anxiety symptoms and
disorders.[40] Such anxiety may be conscious or unconscious.[41]

Choice or decision[edit]
Anxiety induced by the need to choose between similar options is increasingly being recognized as a
problem for individuals and for organizations.[42] In 2004, Capgemini wrote: "Today we're all faced
with greater choice, more competition and less time to consider our options or seek out the right
advice."[43]
In a decision context, unpredictability or uncertainty may trigger emotional responses in anxious
individuals that systematically alter decision-making.[44] There are primarily two forms of this anxiety
type. The first form refers to a choice in which there are multiple potential outcomes with known or
calculable probabilities. The second form refers to the uncertainty and ambiguity related to a
decision context in which there are multiple possible outcomes with unknown probabilities.[44]

Anxiety disorders[edit]
Main article: Anxiety disorder
Anxiety disorders are a group of mental disorders characterized by exaggerated feelings
of anxiety and fear responses.[10] Anxiety is a worry about future events and fear is a reaction to
current events. These feelings may cause physical symptoms, such as a fast heart rate and
shakiness. There are a number of anxiety disorders: including generalized anxiety disorder, specific
phobia, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder,
and selective mutism. The disorder differs by what results in the symptoms. People often have more
than one anxiety disorder.[10]
The cause of anxiety disorders is a combination of genetic and environmental factors.[45] Risk factors
include a history of child abuse, family history of mental disorders, and poverty. Anxiety disorders
often occur with other mental disorders, particularly major depressive disorder, personality disorder,
and substance use disorder.[46] To be diagnosed symptoms typically need to be present at least six
months, be more than would be expected for the situation, and decrease functioning.[10][46] Other
problems that may result in similar symptoms including hyperthyroidism, heart
disease, caffeine, alcohol, or cannabis use, and withdrawal from certain drugs, among others.[46][7]
Without treatment, anxiety disorders tend to remain.[10][45] Treatment may include lifestyle
changes, counselling, and medications. Counselling is typically with a type of cognitive behavioural
therapy.[46] Medications, such as antidepressants or beta blockers, may improve symptoms.[45]
About 12% of people are affected by an anxiety disorder in a given year and between 5-30% are
affected at some point in their life.[46][47] They occur about twice as often in women than they do in
men, and generally begin before the age of 25.[10][46] The most common are specific phobia which
affects nearly 12% and social anxiety disorder which affects 10% at some point in their life. They
affect those between the ages of 15 and 35 the most and become less common after the age of 55.
Rates appear to be higher in the United States and Europe.[46]

Risk factors[edit]

A marble bust of the Roman Emperor Decius from the Capitoline Museum. This portrait "conveys an
impression of anxiety and weariness, as of a man shouldering heavy [state] responsibilities". [48]
Neuroanatomy[edit]
Neural circuitry involving the amygdala (which regulates emotions like anxiety and fear, stimulating
the HPA Axis and sympathetic nervous system) and hippocampus (which is implicated in emotional
memory along with the amygdala) is thought to underlie anxiety.[49] People who have anxiety tend to
show high activity in response to emotional stimuli in the amygdala.[50] Some writers believe that
excessive anxiety can lead to an overpotentiation of the limbic system (which includes the amygdala
and nucleus accumbens), giving increased future anxiety, but this does not appear to have been
proven.[51][52]
Research upon adolescents who as infants had been highly apprehensive, vigilant, and fearful finds
that their nucleus accumbens is more sensitive than that in other people when deciding to make an
action that determined whether they received a reward.[53] This suggests a link between circuits
responsible for fear and also reward in anxious people. As researchers note, "a sense of
'responsibility', or self-agency, in a context of uncertainty (probabilistic outcomes) drives the neural
system underlying appetitive motivation (i.e., nucleus accumbens) more strongly in temperamentally
inhibited than noninhibited adolescents".[53]

Genetics[edit]
Genetics and family history (e.g., parental anxiety) may predispose an individual for an increased
risk of an anxiety disorder, but generally external stimuli will trigger its onset or
exacerbation.[54] Genetic differences account for about 43% of variance in panic disorder and 28% in
generalized anxiety disorder.[55] Although single genes are neither necessary nor sufficient for anxiety
by themselves, several gene polymorphisms have been found to correlate with
anxiety: PLXNA2, SERT, CRH, COMT and BDNF.[56][57][58] Several of these genes influence
neurotransmitters (such as serotonin and norepinephrine) and hormones (such as cortisol) which are
implicated in anxiety. The epigenetic signature of at least one of these genes BDNF has also been
associated with anxiety and specific patterns of neural activity.[59]

Medical conditions[edit]
Many medical conditions can cause anxiety. This includes conditions that affect the ability to
breathe, like COPD and asthma, and the difficulty in breathing that often occurs near
death.[60][61][62] Conditions that cause abdominal pain or chest pain can cause anxiety and may in some
cases be a somatization of anxiety;[63][64] the same is true for some sexual
dysfunctions.[65][66] Conditions that affect the face or the skin can cause social anxiety especially
among adolescents,[67] and developmental disabilities often lead to social anxiety for children as
well.[68] Life-threatening conditions like cancer also cause anxiety.[69]
Furthermore, certain organic diseases may present with anxiety or symptoms that mimic
anxiety.[6][7] These disorders include certain endocrine diseases
(hypo- and hyperthyroidism, hyperprolactinemia),[7][70] metabolic disorders (diabetes),[7][71][72] deficiency
states (low levels of vitamin D, B2, B12, folic acid),[7] gastrointestinal diseases (celiac disease, non-
celiac gluten sensitivity, inflammatory bowel disease),[73][74][75] heart diseases, blood diseases
(anemia),[7] cerebral vascular accidents (transient ischemic attack, stroke),[7] and brain degenerative
diseases (Parkinson's disease, dementia, multiple sclerosis, Huntington's disease), among
others.[7][76][77][78]

Substance-induced[edit]
Several drugs can cause or worsen anxiety, whether in intoxication, withdrawal or from chronic use.
These include alcohol, tobacco, cannabis, sedatives (including
prescription benzodiazepines), opioids (including prescription pain killers and illicit drugs like
heroin), stimulants (such as caffeine, cocaine and amphetamines), hallucinogens,
and inhalants.[54] While many often report self-medicating anxiety with these substances,
improvements in anxiety from drugs are usually short-lived (with worsening of anxiety in the long-
term, sometimes with acute anxiety as soon as the drug effects wear off) and tend to be
exaggerated. Acute exposure to toxic levels of benzene may cause euphoria, anxiety, and irritability
lasting up to 2 weeks after the exposure.[79]

Psychological[edit]
Poor coping skills (e.g., rigidity/inflexible problem solving, denial, avoidance, impulsivity, extreme
self-expectation, affective instability, and inability to focus on problems) are associated with anxiety.
Anxiety is also linked and perpetuated by the person's own pessimistic outcome expectancy and
how they cope with feedback negativity.[80] Temperament (e.g., neuroticism)[40] and attitudes (e.g.
pessimism) have been found to be risk factors for anxiety.[54][81]
Cognitive distortions such as overgeneralizing, catastrophizing, mind reading, emotional reasoning,
binocular trick, and mental filter can result in anxiety. For example, an overgeneralized belief that
something bad "always" happens may lead someone to have excessive fears of even minimally risky
situations and to avoid benign social situations due to anticipatory anxiety of embarrassment. In
addition, those who have high anxiety can also create future stressful life events. [82] Together, these
findings suggest that anxious thoughts can lead to anticipatory anxiety as well stressful events,
which in turn cause more anxiety. Such unhealthy thoughts can be targets for successful treatment
with cognitive therapy.
Psychodynamic theory posits that anxiety is often the result of opposing unconscious wishes or fears
that manifest via maladaptive defense mechanisms (such as suppression, repression, anticipation,
regression, somatization, passive aggression, dissociation) that develop to adapt to problems with
early objects (e.g., caregivers) and empathic failures in childhood. For example, persistent parental
discouragement of anger may result in repression/suppression of angry feelings which manifests as
gastrointestinal distress (somatization) when provoked by another while the anger remains
unconscious and outside the individual's awareness. Such conflicts can be targets for successful
treatment with psychodynamic therapy. While psychodynamic therapy tends to explore the
underlying roots of anxiety, cognitive behavioral therapy has also been shown to be a successful
treatment for anxiety by altering irrational thoughts and unwanted behaviors.
Evolutionary psychology[edit]
An evolutionary psychology explanation is that increased anxiety serves the purpose of
increased vigilance regarding potential threats in the environment as well as increased tendency to
take proactive actions regarding such possible threats. This may cause false positive reactions but
an individual suffering from anxiety may also avoid real threats. This may explain why anxious
people are less likely to die due to accidents.[83]
When people are confronted with unpleasant and potentially harmful stimuli such as foul odors or
tastes, PET-scans show increased bloodflow in the amygdala.[84][85] In these studies, the participants
also reported moderate anxiety. This might indicate that anxiety is a protective mechanism designed
to prevent the organism from engaging in potentially harmful behaviors.