Anxiety

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Anxiety
A. Morison "Physiognomy of mental diseases", cases Wellcome L0022722 (cropped).jpg
A person diagnosed with panphobia, from Alexander Morison's 1843 book The Physiognomy of Mental Diseases.
Specialty Psychiatry

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] [ need quotation to verify ]

Emotion is a mental state associated with the nervous system brought on by chemical changes variously associated with thoughts, feelings, behavioural responses, and a degree of pleasure or displeasure. There is currently no scientific consensus on a definition. Emotion is often intertwined with mood, temperament, personality, disposition, and motivation.

Somatic anxiety is the physical symptoms of anxiety, such as butterflies in the stomach. It is also known as somatization. It is commonly contrasted with cognitive anxiety, which is the mental manifestations of anxiety, or the specific thought processes that occur during anxiety, such as concern or worry. These different components of anxiety are especially studied in sports psychology, specifically relating to how the anxiety symptoms affect athletic performance.

Rumination (psychology)

Rumination is the focused attention on the symptoms of one's distress, and on its possible causes and consequences, as opposed to its solutions, according to the Response Styles Theory proposed by Nolen-Hoeksema (1998). Because the Response Styles Theory has been empirically supported, this model of rumination is the most widely used conceptualization. Other theories, however, have proposed different definitions for rumination. For example, in the Goal Progress Theory, rumination is conceptualized not as a reaction to a mood state, but as a "response to failure to progress satisfactorily towards a goal". As such, both rumination and worry are associated with anxiety and other negative emotional states; however, its measures have not been unified.

Contents

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. [3] It is often accompanied by muscular tension, [4] restlessness, fatigue and problems in concentration. Anxiety can be appropriate, but when experienced regularly the individual may suffer from an anxiety disorder. [4] Anxiety is not the same as fear, which is a response to a real or perceived immediate threat; anxiety involves the expectation of future threat. [4] [4] People facing anxiety may withdraw from situations which have provoked anxiety in the past. [5]

Anxiety disorder cognitive disorder with an excessive, irrational dread of everyday situations

Anxiety disorders are a group of mental disorders characterized by significant feelings of anxiety and fear. 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 several 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.

Fear Basic emotion induced by a perceived threat

Fear is a feeling induced by perceived danger or threat that occurs in certain types of organisms, which causes a change in metabolic and organ functions and ultimately a change in behavior, such as fleeing, hiding, or freezing from perceived traumatic events. Fear in human beings may occur in response to a certain stimulus occurring in the present, or in anticipation or expectation of a future threat perceived as a risk to body or life. The fear response arises from the perception of danger leading to confrontation with or escape from/avoiding the threat, which in extreme cases of fear can be a freeze response or paralysis.

Threat one persons statement that they intend to harm another, or anothers property

A threat is a communicated intent to inflict harm or loss on another person. Intimidation is widely observed in animal behavior chiefly in order to avoid the unnecessary physical violence that can lead to physical damage or the death of both conflicting parties. A threat is considered an act of coercion.

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. [6] Anxiety disorders are partly genetic, with twin studies suggesting 30-40% genetic influence on individual differences in anxiety. [7] Environmental factors are also important. Twin studies show that individual-specific environments have a large influence on anxiety, whereas shared environmental influences (environments that affect twins in the same way) operate during childhood but decline through adolescence. [8] Specific measured ‘environments’ that have been associated with anxiety include child abuse, family history of mental health disorders, and poverty. [9] Anxiety is also associated with drug use, including alcohol, caffeine, and benzodiazepines (which are often prescribed to treat anxiety).

In psychology, trait theory is an approach to the study of human personality. Trait theorists are primarily interested in the measurement of traits, which can be defined as habitual patterns of behavior, thought, and emotion. According to this perspective, traits are aspects of personality that are relatively stable over time, differ across individuals, are relatively consistent over situations, and influence behavior. Traits are in contrast to states, which are more transitory dispositions.

Mental disorder Distressing thought or behavior pattern

A mental disorder, also called a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitting, or occur as a single episode. Many disorders have been described, with signs and symptoms that vary widely between specific disorders. Such disorders may be diagnosed by a mental health professional.

Child abuse maltreatment or neglect of a child

Child abuse or child maltreatment is physical, sexual, and/or psychological maltreatment or neglect of a child or children, especially by a parent or a caregiver. Child abuse may include any act or failure to act by a parent or a caregiver that results in actual or potential harm to a child, and can occur in a child's home, or in the organizations, schools or communities the child interacts with.

There are various types of anxiety. Existential anxiety can occur when a person faces angst, an existential crisis, or nihilistic feelings. 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.

Angst emotion

Angst means fear or anxiety. The dictionary definition for angst is a feeling of anxiety, apprehension, or insecurity. The word angst was introduced into English from the Danish, Norwegian, and Dutch word angst and the German word Angst. It is attested since the 19th century in English translations of the works of Kierkegaard and Freud. It is used in English to describe an intense feeling of apprehension, anxiety, or inner turmoil.

Existential crisis feeling

An existential crisis is a moment at which an individual questions if their life has meaning, purpose, or value. It may be commonly, but not necessarily, tied to depression or inevitably negative speculations on purpose in life. This issue of the meaning and purpose of human existence is a major focus of the philosophical tradition of existentialism.

Nihilism is the philosophical viewpoint that suggests the denial of, or lack of belief in, the reputedly meaningful aspects of life. Most commonly, nihilism is presented in the form of existential nihilism, which argues that life is without objective meaning, purpose, or intrinsic value. Moral nihilists assert that there is no inherent morality, and that accepted moral values are abstractly contrived. Nihilism may also take epistemological, ontological, or metaphysical forms, meaning respectively that, in some aspect, knowledge is not possible, or reality does not actually exist.

Anxiety disorders often occur with other mental health disorders, particularly major depressive disorder, bipolar disorder, eating disorders, or certain personality disorders. It also commonly occurs with personality traits such as neuroticism. This observed co-occurrence is partly due to genetic and environmental influences shared between these traits and anxiety. [10] [11]

Major depressive disorder all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities.

Major depressive disorder (MDD), also known simply as depression, is a mental disorder characterized by at least two weeks of low mood that is present across most situations. It is often accompanied by low self-esteem, loss of interest in normally enjoyable activities, low energy, and pain without a clear cause. People may also occasionally have false beliefs or see or hear things that others cannot. Some people have periods of depression separated by years in which they are normal, while others nearly always have symptoms present. Major depressive disorder can negatively affect a person's personal life, work life, or education, as well as sleeping, eating habits, and general health. Between 2–8% of adults with major depression die by suicide, and about 50% of people who die by suicide had depression or another mood disorder.

Bipolar disorder mental disorder that causes periods of depression and periods of abnormally elevated mood

Bipolar disorder, previously known as manic depression, is a mental disorder that causes periods of depression and periods of abnormally elevated mood. The elevated mood is significant and is known as mania, or hypomania if less severe and symptoms of psychosis are absent. During mania, an individual behaves or feels abnormally energetic, happy, or irritable. Individuals often make poorly thought out decisions with little regard to the consequences. The need for sleep is usually reduced during manic phases. During periods of depression, there may be crying, a negative outlook on life, and poor eye contact with others. The risk of suicide among those with the illness is high at greater than 6 percent over 20 years, while self-harm occurs in 30–40 percent. Other mental health issues such as anxiety disorders and substance use disorder are commonly associated with bipolar disorder.

Eating disorder specific developmental disorder that is characterized by abnormal eating habits that may involve either insufficient or excessive food intake to the detriment of an individuals physical and emotional health

An eating disorder is a mental disorder defined by abnormal eating habits that negatively affect a person's physical or mental health. They include binge eating disorder, where people eat a large amount in a short period of time; anorexia nervosa, where people eat very little and thus have a low body weight; bulimia nervosa, where people eat a lot and then try to rid themselves of the food; pica, where people eat non-food items; rumination disorder, where people regurgitate food; avoidant/restrictive food intake disorder, where people have a lack of interest in food; and a group of other specified feeding or eating disorders. Anxiety disorders, depression, and substance abuse are common among people with eating disorders. These disorders do not include obesity.

Stress hormones released in an anxious state have an impact on bowel function and can manifest physical symptoms that may contribute to or exacerbate IBS. Anxiety is often experienced by those with obsessive–compulsive disorder and is an acute presence in panic disorder.

Irritable bowel syndrome (IBS) is a group of symptoms—including abdominal pain and changes in the pattern of bowel movements without any evidence of underlying damage. These symptoms occur over a long time, often years. It has been classified into four main types depending on whether diarrhea is common, constipation is common, both are common, or neither occurs very often. IBS negatively affects quality of life and may result in missed school or work. Disorders such as anxiety, major depression, and chronic fatigue syndrome are common among people with IBS.

Obsessive–compulsive disorder anxiety disorder that involves unwanted and repeated thoughts, feelings, ideas, sensations (obsessions), or behaviors that make them feel driven to do something (compulsions)

Obsessive–compulsive disorder (OCD) is a mental disorder in which a person feels the need to perform certain routines repeatedly, or has certain thoughts repeatedly. The person is unable to control either the thoughts or activities for more than a short period of time. Common compulsions include hand washing, counting of things, and checking to see if a door is locked. Some may have difficulty throwing things out. These activities occur to such a degree that the person's daily life is negatively affected. This often takes up more than an hour a day. Most adults realize that the behaviors do not make sense. The condition is associated with tics, anxiety disorder, and an increased risk of suicide.

Panic disorder an anxiety disorder characterized by unexpected and repeated episodes of intense fear accompanied by physical symptoms

Panic disorder is an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen. The maximum degree of symptoms occurs within minutes. There may be ongoing worries about having further attacks and avoidance of places where attacks have occurred in the past.

The first step in the management of a person with anxiety symptoms involves evaluating the possible presence of an underlying medical cause, whose recognition is essential in order to decide the correct treatment. [12] [13] Anxiety symptoms may mask an organic disease, or appear associated with or as a result of a medical disorder. [12] [13] [14] [15]

Symptoms

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. [16] 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. [12] [15]

The risk of anxiety leading to depression could possibly even lead to an individual harming themselves, which is why there are many 24-hour suicide prevention hotlines. [17]

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" [18] as well as "nightmares/bad dreams, obsessions about sensations, déjà vu, a trapped-in-your-mind feeling, and feeling like everything is scary." [19]

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." [20]

The physiological symptoms of anxiety may include: [12] [15]

Types

Painting entitled Anxiety, 1894, by Edvard Munch Edvard Munch - Anxiety - Google Art Project.jpg
Painting entitled Anxiety , 1894, by Edvard Munch

Existential

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 [21] 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". [21]

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. [22]

Depending on the source of the threat, psychoanalytic theory distinguishes the following types of anxiety:

Test and performance

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

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

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]

Personality can also be a trait leading towards anxiety and depression. Through experience many find it difficult to collect themselves due to their own personal nature. [42]

Choice or decision

Anxiety induced by the need to choose between similar options is increasingly being recognized as a problem for individuals and for organizations. [43] 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." [44]

In a decision context, unpredictability or uncertainty may trigger emotional responses in anxious individuals that systematically alter decision-making. [45] 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. [45]

Anxiety disorders

Anxiety disorders are a group of mental disorders characterized by exaggerated feelings of anxiety and fear responses. [6] 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. [6]

Anxiety disorders are caused by a complex combination of genetic and environmental factors. [47]   To be diagnosed, symptoms typically need to be present for at least six months, be more than would be expected for the situation, and decrease a person's ability to function in their daily lives. [10] [49] Other problems that may result in similar symptoms include hyperthyroidism, heart disease, caffeine, alcohol, or cannabis use, and withdrawal from certain drugs, among others. [49] [7]

Without treatment, anxiety disorders tend to remain. [6] [46] Treatment may include lifestyle changes, counselling, and medications. Counselling is typically with a type of cognitive behavioural therapy. [47] Medications, such as antidepressants or beta blockers, may improve symptoms. [46]

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. [47] [48] They occur about twice as often in women than they do in men, and generally begin before the age of 25. [6] [47] 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. [47]

Risk factors

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". Emperor Traianus Decius (Mary Harrsch).jpg
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".

Neuroanatomy

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. [50] People who have anxiety tend to show high activity in response to emotional stimuli in the amygdala. [51] 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. [52] [53]

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. [54] 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". [54]

The gut-brain axis

The microbes of the gut can connect with the brain to affect anxiety. There are various pathways along which this communication can take place. One is through the major neurotransmitters. [55] The gut microbes such as Bifidobacterium and Bacillus produce the neurotransmitters GABA and dopamine, respectively. [56] The neurotransmitters signal to the nervous system of the gastrointestinal tract, and those signals will be carried to the brain through the vagus nerve or the spinal system. [55] [56] [57] This is demonstrated by the fact that altering the microbiome has shown anxiety- and depression-reducing effects in mice, but not in subjects without vagus nerves. [58]

Another key pathway is the HPA axis, as mentioned above. [57] The microbes can control the levels of cytokines in the body, and altering cytokine levels creates direct effects on areas of the brain such as the hypothalmus, the area that triggers HPA axis activity. The HPA axis regulates production of cortisol, a hormone that takes part in the body's stress response. [57] When HPA activity spikes, cortisol levels increase, processing and reducing anxiety in stressful situations. These pathways, as well as the specific effects of individual taxa of microbes, are not yet completely clear, but the communication between the gut microbiome and the brain is undeniable, as is the ability of these pathways to alter anxiety levels.

With this communication comes the potential to treat anxiety. Prebiotics and probiotics have been shown to reduced anxiety. For example, experiments in which mice were given fructo- and galacto-oligosaccharide prebiotics [59] and Lactobacillus probiotics [58] have both demonstrated a capability to reduce anxiety. In humans, results are not as concrete, but promising. [60] [61]

Genetics

Genetics and family history (e.g. parental anxiety) may put an individual at increased risk of an anxiety disorder, but generally external stimuli will trigger its onset or exacerbation. [57] Estimates of genetic influence on anxiety, based on studies of twins, range from 25–40% depending on the specific type and age-group under study. For example, genetic differences account for about 43% of variance in panic disorder and 28% in generalized anxiety disorder. [58] Longitudinal twin studies have shown the moderate stability of anxiety from childhood through to adulthood is mainly influenced by stability in genetic influence. [62] [63] When investigating how anxiety is passed on from parents to children, it is important to account for sharing of genes as well as environments, for example using the intergenerational children-of-twins design. [64]

Many studies in the past used a candidate gene approach to test whether single genes were associated with anxiety. These investigations were based on hypotheses about how certain known genes influence neurotransmitters (such as serotonin and norepinephrine) and hormones (such as cortisol) that are implicated in anxiety. None of these findings are well replicated. [59] [60] [61] , with the possible exception of TMEM132D, COMT and MAO-A. [65] The epigenetic signature of BDNF, a gene that codes for a protein called brain derived neurotrophic factor that is found in the brain, has also been associated with anxiety and specific patterns of neural activity. [62] and a receptor gene for BDNF called NTRK2 was associated with anxiety in a large genome-wide investigation. [66] The reason that most candidate gene findings have not replicated is that anxiety is a complex trait that is influenced by many genomic variants, each of which has a small effect on its own. Increasingly, studies of anxiety are using a hypothesis-free approach to look for parts of the genome that are implicated in anxiety using big enough samples to find associations with variants that have small effects. The largest explorations of the common genetic architecture of anxiety have been facilitated by the UK Biobank, the ANGST consortium and the CRC Fear, Anxiety and Anxiety Disorders. [66] [67] [68]

Medical conditions

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. [69] [70] [71] Conditions that cause abdominal pain or chest pain can cause anxiety and may in some cases be a somatization of anxiety; [72] [73] the same is true for some sexual dysfunctions. [74] [75] Conditions that affect the face or the skin can cause social anxiety especially among adolescents, [76] and developmental disabilities often lead to social anxiety for children as well. [77] Life-threatening conditions like cancer also cause anxiety. [78]

Furthermore, certain organic diseases may present with anxiety or symptoms that mimic anxiety. [12] [13] These disorders include certain endocrine diseases (hypo- and hyperthyroidism, hyperprolactinemia), [13] [79] metabolic disorders (diabetes), [13] [80] [81] deficiency states (low levels of vitamin D, B2, B12, folic acid), [13] gastrointestinal diseases (celiac disease, non-celiac gluten sensitivity, inflammatory bowel disease), [82] [83] [84] heart diseases, blood diseases (anemia), [13] cerebral vascular accidents (transient ischemic attack, stroke), [13] and brain degenerative diseases (Parkinson's disease, dementia, multiple sclerosis, Huntington's disease), among others. [13] [85] [86] [87]

Substance-induced

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. [88] 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. [89]

Psychological

Poor coping skills (e.g., rigidity/inflexible problem solving, denial, avoidance, impulsivity, extreme self-expectation, negative thoughts, 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. [90] Temperament (e.g., neuroticism) [40] and attitudes (e.g. pessimism) have been found to be risk factors for anxiety. [88] [91]

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. [92] 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

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. [93]

When people are confronted with unpleasant and potentially harmful stimuli such as foul odors or tastes, PET-scans show increased bloodflow in the amygdala. [94] [95] 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.

Social

Social risk factors for anxiety include a history of trauma (e.g., physical, sexual or emotional abuse or assault), early life experiences and parenting factors (e.g., rejection, lack of warmth, high hostility, harsh discipline, high parental negative affect, anxious childrearing, modelling of dysfunctional and drug-abusing behaviour, discouragement of emotions, poor socialization, poor attachment, and child abuse and neglect), cultural factors (e.g., stoic families/cultures, persecuted minorities including the disabled), and socioeconomics (e.g., uneducated, unemployed, impoverished although developed countries have higher rates of anxiety disorders than developing countries). [88] [96] A recent comprehensive systematic review of over 50 studies showed that food insecurity in the United States is strongly associated with depression, anxiety, and sleep disorders. [97] Food-insecure individuals had an almost 3 fold risk increase of testing positive for anxiety when compared to food-secure individuals.

Gender socialization

Contextual factors that are thought to contribute to anxiety include gender socialization and learning experiences. In particular, learning mastery (the degree to which people perceive their lives to be under their own control) and instrumentality, which includes such traits as self-confidence, independence, and competitiveness fully mediate the relation between gender and anxiety. That is, though gender differences in anxiety exist, with higher levels of anxiety in women compared to men, gender socialization and learning mastery explain these gender differences. [98] [ medical citation needed ] Research has demonstrated the ways in which facial prominence in photographic images differs between men and women. More specifically, in official online photographs of politicians around the world, women's faces are less prominent than men's. The difference in these images actually tended to be greater in cultures with greater institutional gender equality. [99]

Pathophysiology

Anxiety disorder appears to be a genetically inherited neurochemical dysfunction that may involve autonomic imbalance; decreased GABA-ergic tone; allelic polymorphism of the catechol-O-methyltransferase (COMT) gene; increased adenosine receptor function; increased cortisol.

In the central nervous system (CNS), the major mediators of the symptoms of anxiety disorders appear to be norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA). Other neurotransmitters and peptides, such as corticotropin-releasing factor, may be involved. Peripherally, the autonomic nervous system, especially the sympathetic nervous system, mediates many of the symptoms. Increased flow in the right parahippocampal region and reduced serotonin type 1A receptor binding in the anterior and posterior cingulate and raphe of patients are the diagnostic factors for prevalence of anxiety disorder.

The amygdala is central to the processing of fear and anxiety, and its function may be disrupted in anxiety disorders. Anxiety processing in the basolateral amygdala has been implicated with dendritic arborization of the amygdaloid neurons. SK2 potassium channels mediate inhibitory influence on action potentials and reduce arborization.

Joseph E. LeDoux and Lisa Feldman Barrett have both sought to separate automatic threat responses from additional associated cognitive activity within anxiety.

Fear

A job applicant with a worried facial expression Los Angeles, California. Lockheed Employment. A worried applicant waiting to be interviewed - NARA - 532210.tif
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. [100] 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. [101] 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," [102] 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. [103] In positive psychology, anxiety is described as the mental state that results from a difficult challenge for which the subject has insufficient coping skills. [104]

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 short lived, present focused, geared towards a specific threat, and facilitating escape from threat; anxiety, on the other hand, is long-acting, future focused, broadly focused towards a diffuse threat, and promoting excessive caution while approaching a potential threat and interferes with constructive coping. [105]

See also

Related Research Articles

Phobia an anxiety disorder defined by a persistent and excessive fear of an object or situation

A phobia is a type of anxiety disorder, defined by a persistent and excessive fear of an object or situation. The phobia typically results in a rapid onset of fear and is present for more than six months. The affected person goes to great lengths to avoid the situation or object, to a degree greater than the actual danger posed. If the feared object or situation cannot be avoided, the affected person experiences significant distress. With blood or injury phobia, fainting may occur. Agoraphobia is often associated with panic attacks. Usually a person has phobias to a number of objects or situations.

Panic attack period of intense fear of sudden onset

Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something bad is going to happen. The maximum degree of symptoms occurs within minutes. Typically they last for about 30 minutes but the duration can vary from seconds to hours. There may be a fear of losing control or chest pain. Panic attacks themselves are not typically dangerous physically.

Hypochondriasis or hypochondria is a condition in which a person is excessively and unduly worried about having a serious illness. An old concept, its meaning has repeatedly changed due to redefinitions in its source metaphors. It has been claimed that this debilitating condition results from an inaccurate perception of the condition of body or mind despite the absence of an actual medical diagnosis. An individual with hypochondriasis is known as a hypochondriac. Hypochondriacs become unduly alarmed about any physical or psychological symptoms they detect, no matter how minor the symptom may be, and are convinced that they or others have, or are about to be diagnosed with, a serious illness.

Postpartum depression (PPD), also called postnatal depression, is a type of mood disorder associated with childbirth, which can affect both sexes. Symptoms may include extreme sadness, low energy, anxiety, crying episodes, irritability, and changes in sleeping or eating patterns. Onset is typically between one week and one month following childbirth. PPD can also negatively affect the newborn child.

Anhedonia is a diverse array of deficits in hedonic function, including reduced motivation or ability to experience pleasure. While earlier definitions of anhedonia emphasized the inability to experience pleasure, anhedonia is used by researchers to refer to reduced motivation, reduced anticipatory pleasure (wanting), reduced consummatory pleasure (liking), and deficits in reinforcement learning. In the DSM-5, anhedonia is a component of depressive disorders, substance related disorders, psychotic disorders, and personality disorders, where it is defined by either a reduced ability to experience pleasure, or a diminished interest in engaging in pleasurable activities. While the ICD-10 does not explicitly mention anhedonia, the depressive symptom analogous to anhedonia as described in the DSM-V is a loss of interest or pleasure.

Obsessive–compulsive personality disorder (OCPD) is a personality disorder characterized by a general pattern of excessive concern with orderliness, perfectionism, attention to details, mental and interpersonal control, and a need for control over one's environment, which interferes with personal flexibility, openness to experience, and efficiency, as well as interfering with relationships. Workaholism and miserliness are also seen often in those with this personality disorder. Persons affected with this disorder may find it hard to relax, always feeling that time is running out for their activities, and that more effort is needed to achieve their goals. They may plan their activities down to the minute – a manifestation of the compulsive tendency to keep control over their environment and to dislike unpredictable events as elements beyond their control.

Depersonalization can consist of a detachment within the self, regarding one's mind or body, or being a detached observer of oneself. Subjects feel they have changed and that the world has become vague, dreamlike, less real, lacking in significance or being outside reality while looking in. It can be a disturbing experience. Chronic depersonalization refers to depersonalization-derealization disorder, which is classified by the DSM-5 as a dissociative disorder.

Generalized anxiety disorder (GAD) is an anxiety disorder characterized by excessive, uncontrollable and often irrational worry about events or activities. This excessive worry often interferes with daily functioning, and sufferers are overly concerned about everyday matters such as health issues, money, death, family problems, friendship problems, interpersonal relationship problems, or work difficulties. Symptoms may include excessive worry, restlessness, trouble sleeping, feeling tired, irritability, sweating, and trembling.

Depression (mood) state of low mood and aversion to activity

Depression is a state of low mood and aversion to activity. It can affect a person's thoughts, behavior, motivation, feelings, and sense of well-being. It may feature sadness, difficulty in thinking and concentration and a significant increase/decrease in appetite and time spent sleeping, and people experiencing depression may have feelings of dejection, hopelessness and, sometimes, suicidal thoughts. It can either be short term or long term. Depressed mood is a symptom of some mood disorders such as major depressive disorder or dysthymia; it is a normal temporary reaction to life events, such as the loss of a loved one; and it is also a symptom of some physical diseases and a side effect of some drugs and medical treatments.

The Beck Anxiety Inventory (BAI), created by Aaron T. Beck and other colleagues, is a 21-question multiple-choice self-report inventory that is used for measuring the severity of anxiety in children and adults. The questions used in this measure ask about common symptoms of anxiety that the subject has had during the past week. It is designed for individuals who are of 17 years of age or older and takes 5 to 10 minutes to complete. Several studies have found the Beck Anxiety Inventory to be an accurate measure of anxiety symptoms in children and adults.

Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by a significant amount of fear in one or more social situations, causing considerable distress and impaired ability to function in at least some parts of daily life. These fears can be triggered by perceived or actual scrutiny from others. Individuals with social anxiety disorder fear negative evaluation from other people.

Cognitive bias modification (CBM) refers to the process of modifying cognitive biases in healthy people and also refers to a growing area of psychological (non-pharmaceutical) therapies for anxiety, depression and addiction called cognitive bias modification therapy (CBMT). CBMT is sub-group of therapies within a growing area of psychological therapies based on modifying cognitive processes with or without accompanying medication and talk therapy, sometimes referred to as applied cognitive processing therapies (ACPT). Other ACPTs include attention training, interpretation modification, approach/avoid training, imagery modification training, eye movement desensitization and reprocessing therapy for PTSD.

Separation anxiety disorder (SAD) is an anxiety disorder in which an individual experiences excessive anxiety regarding separation from home and/or from people to whom the individual has a strong emotional attachment. It is most common in infants and small children, typically between the ages of six to seven months to three years, although it may pathologically manifest itself in older children, adolescents and adults. Separation anxiety is a natural part of the developmental process. Unlike SAD, normal separation anxiety indicates healthy advancements in a child's cognitive maturation and should not be considered a developing behavioral problem.

Major depression is often associated with increased immune function, and the two are thought to share similar physiological pathways and risk factors. Primarily seen through increased inflammation, this relationship is bidirectional with depression often resulting in increased immune response and illness resulting in prolonged sadness and lack of activity. This association is seen both long-term and short-term, with the presence of one often being accompanied by the other and both inflammation and depression often being co-morbid with other conditions.

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D
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