Anxiety

Anxiety is an emotion characterized by feelings of tension, threat, worry, and changes at the physiological level; while it shares similar aspects with fear from a physiological standpoint, it differs because while fear is an emotional reaction to a real and immediate danger, anxiety is an emotional reaction to a perceived future threat.

The term anxiety comes from the Latin angĕre, meaning to tighten, and is an emotional state, however unpleasant, commonly encountered at various times and situations in human life.

The American Psychiatric Association (1994) describes anxiety as the apprehensive anticipation of a future danger or negative event, accompanied by feelings of dysphoria or physical symptoms of tension. Elements exposed to risk can belong to both the internal and external worlds.

The aspect of ‘immediacy’ typical of fear is in contrast to the act of ‘prediction’ that characterizes anxiety, in fact fear allows us to mobilize all our resources to face a threat or alternatively escape from it, anxiety helps us to identify future threats and to guard against them.

Both play an adaptive role: when a person is in a stressful or threatening situation, the attack or escape response is automatically triggered, a physiological response that has been part of the biological makeup of humans for thousands of years and that prepares the body to defend itself through intense physical effort. Once the physical exertion is over, the physiological reactions quickly disappear, but when the physical exertion does not take place, the physiological changes can persist for a long time and be very disturbing.

Therefore, although a certain degree of anxiety is functional even in activities that require commitment, concentration, attention not to make mistakes and therefore, as the law of Yerkes and Dodson (1908) teaches us, a right degree of anxiety allows us to be more performant, it can override its adaptive aspects giving rise to anxiety disorders.

Physiological anxiety or pathological anxiety?

Normal anxiety – physiological or alarm – is a state of psychological and physical tension that involves a generalized activation of all the resources of the individual, thus allowing the implementation of initiatives and behaviors useful for adaptation. It is directed against a really existing stimulus, often well known, represented by difficult and unusual conditions.

Anxiety, on the other hand, is pathological when it disturbs, to a greater or lesser extent, the psychic functioning, determining a limitation of the individual’s ability to adapt. It is characterized by a state of uncertainty about the future, with the prevalence of unpleasant feelings.

Sometimes, pathological anxiety is vague, i.e. without a precise recognizable cause, or it may concern specific objects and events; it refers to an imminent future, or to the possibility of more or less distant events. It can accompany other psychological and psychiatric problems, as well as unresolved conflicts of the person who is affected; has an intensity that causes unbearable suffering; determines defense behaviors that limit the existence, such as the avoidance of situations considered potentially dangerous or control through the implementation of rituals of various kinds.

Pathological anxiety, as well as a disorder in its own right, can also be found in various psychiatric illnesses, such as schizophrenia, depression and mania, personality disorders, sexual and adjustment disorders.

Causes of anxiety

The causes of anxiety are not yet fully understood. However, it is agreed that there is the involvement of several factors that contribute to each other in giving rise to the disorder. Among these are:

  • Hereditary factors: some genetic studies have found that, in about 50% of cases, subjects with anxiety disorders have at least one family member affected by a similar pathology.
  • Biological factors: according to some studies carried out on the human brain, the onset of anxiety may be related to alterations in the amount of certain neurotransmitters, such as excessive production of norepinephrine, reduced availability of serotonin (which regulates the well-being) and GABA (an inhibitory neurotransmitter among the most important of our body).
  • Unconscious factors: according to Freud, the father of psychoanalysis, anxiety derives from an unconscious conflict that can date back to childhood or develop in adult life. This psychological conflict sets in motion defense mechanisms whose purpose is to remove this conflict from consciousness, relegating it to an inaccessible place of the psyche, which is the unconscious.

Anxiety symptoms

Anxiety encompasses a constellation of cognitive, emotional, and behavioral symptoms. Let’s look at them in detail.

Anxiety cognitive symptoms

The cognitive symptoms of anxiety are:

  • sense of mental emptiness
  • increasing feeling of alarm and danger
  • onset of negative images, memories and/or thoughts
  • adoption of cognitive protective behaviors
  • feeling of being watched and/or being the center of others’ attention.

Anxiety behavioral symptoms

Anxiety attacks are also characterized by behavioral symptoms, among the most frequent we find avoidance, that is, keeping away from all situations that may cause anxiety. This has a negative impact especially when the avoidance involves situations useful to the individual (e.g., taking public transportation, public speaking, taking an exam, etc.). At times, these limitations are obviated through the use of a chaperone or other types of protective behaviors such as taking anxiolytics as needed. In some cases, the anxious person may engage in passive and submissive behaviors.

Anxiety physical symptoms

More well-known are the physical symptoms of anxiety, including:

  • tension
  • tremors
  • increased sweating
  • palpitations
  • increased heart rate
  • dizziness
  • nausea
  • tingling
  • derealization and/or depersonalization

Some researchers divide the physical symptoms of anxiety into four clusters:

  1. Cardiorespiratory symptoms: tachycardia, chest tightness, feeling of drowning, dyspnea, etc.
  2. Gastrointestinal symptoms: nausea, vomiting, stomach pain, abdominal tension and/or pain, diarrhea, etc.
  3. Vestibular symptoms: feeling unsteady, dizziness, feeling faint, etc.
  4. Psychosensory symptoms: disorientation, derealization, depersonalization, etc.

Many of the components associated with anxiety attacks can be understood when read as responses to a threat in evolutionary terms: breathing becomes more frequent, increasing the amount of oxygen available to the muscles; heart rate and blood pressure increase so that the oxygen and nourishment required by the muscles is transported quickly; blood is diverted to the muscles of the lower limbs; less blood flows to the internal organs and also to the face and one may become ‘white with fear’; the muscles tense up preparing to contract quickly; the blood’s ability to clot increases, so that in the event of an injury, blood loss is reduced; one begins to sweat to counteract the overheating caused by physical activity; the mind focuses on a dominant thought: ‘am I really in danger and, if so, how can I avoid it? ‘; digestion stops, the mouth becomes dry and produces less saliva, food lingers in the stomach and may result in a feeling of nausea or ‘knot in the stomach’; sugar is released into the bloodstream, which serves to provide energy; the immune system slows down; the body for the moment focuses all its efforts on escape.

Palpitations

It is necessary to distinguish, as far as possible, several conditions that can be referred to as palpitations: palpitations, tachycardia and arrhythmia. The latter, for example, often occurs in healthy people with irregular beats during daily activities and is more likely to occur when the person is anxious. It can be caused by a variety of agents such as nicotine, caffeine, alcohol, and electrolyte imbalance.

Often the interpretation given to such a physical symptom during an anxious state is related to the idea of having a heart attack. This is true even though the underlying cause is an increased electrophysiological excitability of the heart muscle, which has no negative medical consequences.

Chest pain

This is a physical symptom that can occur during periods of high anxiety in the absence of a cardiac disorder. It can be caused by such diverse things as chest breathing and gastrointestinal disorders (e.g., esophageal reflux or spasm). If the person catastrophically interprets benign causes of pain, it is possible that the anxious state will increase, even leading to panic.

But in fact, we know that when a very high state of anxiety occurs, the body secretes adrenaline, which causes the heart rate to increase and the body to work faster. It is an evolutionary way to better prepare the person to deal with dangerous situations.

If adrenaline damaged the heart, how could humans have survived to this day? So the acceleration of the heart rate due to anxiety does not cause heart attacks; there must be something pathological for that to happen.

Shortness of breath

Breathing is an action that functions independently of what a person thinks or does; it is automatically controlled by the brain. In fact, the brain controls it even when you try to stop breathing.

The feeling of shortness of breath is very common in anxiety disorders and results from prolonged and repeated chest breathing.

In fact, one physical response to stress is the relative dominance of thoracic breathing over abdominal breathing, but this leads to fatigue of the intercostal muscles, which become tense and spasm, causing discomfort and chest pain, and causing the sensation of shortness of breath.

If one does not realize that these sensations are caused by thoracic breathing, they will appear sudden and frightening, causing the person to become even more alarmed.

Nausea or abdominal discomfort

The stomach contracts and relaxes regularly and evenly. When this rhythm is disturbed, nausea occurs. Several factors can cause this physical sensation, including ingestion of certain foods, vestibular disturbances, postural hypotension, or even previously neutral stimuli.

Feeding and digestive functions are the first to shut down in a state of alertness, but if the person misinterprets nausea as a sign of impending vomiting, anxiety is more likely to increase and lead to panic.

Fortunately, it is rare for nausea to lead to vomiting; people tend to overestimate this possibility.

Tremors and sweating

Tremors are involuntary, oscillating, rhythmic movements of one or more parts of the body caused by alternating contractions of opposing muscle groups. Sweating, on the other hand, helps control body temperature, which rises in anxious states.

In fact, stress stimulates the sympathetic nervous system with increased levels of adrenaline and norepinephrine, which stimulate an increase in metabolism, thus increasing heat production and consequent sweating, which is useful in lowering body temperature.

Again, the greater the alertness and catastrophizing about such physical symptoms, the greater the likelihood that they will increase in intensity.

Dizziness

Dizziness is the product of the illusion of movement of the self or the environment. It consists of feelings of confusion, dizziness, or lightheadedness. When information from the balance system (visual, somatosensory, and vestibular) conflicts, dizziness occurs.

Balance problems and related physical symptoms (unsteadiness, anxiety, cold sweat, palpitations) can also occur as a result of anxiety, hyperventilation, and common stress reactions such as clenching of the jaw and teeth.

Of course, the intensity of the dizziness may increase as more attention is paid to these sensations.

Derealization or depersonalization

Derealization or depersonalization are experiences that can be induced by fatigue, sleep deprivation, meditation, relaxation, or the use of substances, alcohol, and benzodiazepines.

There are also other more subtle causes related to brief periods of sensory deprivation or reduction of sensory input, such as staring at a spot on a wall for 3 minutes.
What is curious is that, again, the vicious cycle is established based on the interpretation given to these physical symptoms. When experiencing depersonalization or derealization (an experience that one third of the population has had), the more frightened a person becomes, the more he or she breathes, the more oxygen he or she takes in (eliminating carbon dioxide), the more the feeling of depersonalization or derealization increases.

Cardiorespiratory symptoms of anxiety

Palpitations are often the symptom that most alarms the anxious person, it is no coincidence that the person in the grip of anxiety attacks sometimes turns to their doctor or the emergency room.

Palpitations are also known as heart palpitations, and indicate the conscious perception of one’s own heartbeat, often felt on the precordium (part of the chest anterior to the sternum), throat or neck. Palpitations may give the impression of an abnormality of the heart; however, this manifestation is often transient.

Shortness of breath or shortness of breath is very common in anxiety disorders and is due to prolonged and repeated chest (pectoral) breathing. The body in fact responds to stress by increasing thoracic breathing at the expense of abdominal breathing. This, however, leads to fatigue of the intercostal muscles that, straining, spasm and cause chest pains that lead to the feeling of breathlessness.

Such cardiorespiratory symptoms can occur during periods of heightened anxiety. They may also have other causes attributable to gastrointestinal disorders for example. However, when such symptoms are interpreted catastrophically, the anxious person may experience them with greater intensity and have a panic attack.

Gastrointestinal symptoms of anxiety

Our stomach contracts and relaxes on a regular and constant basis. When this rhythm, for a variety of reasons, is altered, nausea occurs. The alterations are due to several factors including the ingestion of certain foods or disorders in some organs.

Nutrition and digestion are the first bodily functions to get stuck in a state of alertness. However, it may happen that the anxious person interprets nausea as a sign of impending vomiting, thus leading to increased anxiety and panic.

Vestibular disorders of anxiety

Dizziness can be described as sensations of spinning, oscillating, or lurching motion experienced while, in reality, standing still. Sometimes it may feel as if it is the environment around us that is moving and oscillating.

Dizziness occurs when information from the balance system (visual, somatosensory, and vestibular systems) conflicts. This can often occur in stressful situations. However, paying considerable attention to these lurching sensations (as frequently happens in anxious people), can increase the dizziness itself.

Psychosensory symptoms of anxiety

The term depersonalization is used to describe those experiences of unreality, detachment, or the feeling of being an outside observer with respect to one’s body or one’s thoughts, feelings, sensations, and actions. Derealization, on the other hand, refers to those experiences of unreality or detachment from an environment (e.g., people or objects are experienced as unreal, dreamlike, lifeless, or visually distorted).

These conditions can be induced by psychological trauma, fatigue, sleep deprivation, meditation, or the use of drugs or substances such as alcohol and benzodiazepines.

Again, derealization and depersonalization can increase the more you are afraid that you are experiencing them: fear leads to increased breathing and oxygen levels which, in turn, can increase these feelings of detachment from reality.

How does anxiety manifest itself?

Anxiety is characterized by general, psychological symptoms that are related to the activation of the autonomic nervous system, that is, that which is not under the control of the person’s will (sympathetic and parasympathetic), and are called neurovegetative disorders.

General symptoms of anxiety may be represented by:

  • Sense of fear and imminent danger;
  • Fear of dying;
  • Fear of losing control;
  • Fear of going crazy;
  • Avoidance;
  • Subjective internal tension;
  • Inability to relax;
  • Apprehension;
  • Hypervigilance;
  • Restlessness.

Psychological symptoms of anxiety, on the other hand, may be:

  • Excessive preoccupation with secondary issues;
  • Irritability and impatience;
  • Difficulty concentrating and poor attention;
  • Depersonalization;
  • Derealization;
  • Memory disturbances;
  • Sleep disturbances.

Neurovegetative symptoms may be represented by:

  • Difficulty breathing;
  • Sense of chest tightness;
  • Air hunger (dyspnea);
  • Shortness of breath;
  • Chest pain;
  • Feeling light-headed;
  • Dizziness;
  • Feeling of instability and lack of balance;
  • Impending fainting;
  • Tingling in different parts of the body;
  • Flushing of heat or cold;
  • Sensation of choking;
  • Difficulty swallowing;
  • “Knot in the throat” feeling;
  • Dry mouth;
  • Accelerated or irregular heartbeat;
  • Excessive sweating;
  • Sense of weakness and fatigue;
  • Muscle tension;
  • Tremors;
  • Frequent urination;
  • Diarrhea.

In any case, it should be pointed out that the symptoms that occur in the presence of anxiety may vary from one individual to another, both in terms of the type of symptoms and the intensity with which they arise.

The fear of fear

The physical symptoms of anxiety often frighten by generating vicious circles, i.e., the so-called “fear of fear.” However, they depend on the fact that, assuming it is in a situation of real danger, the anxious organism needs the maximum muscular energy at its disposal in order to escape or attack as effectively as possible, averting the danger and ensuring its survival.

Anxiety, therefore, is not just a limitation or a disorder, but constitutes an important resource. It is in fact an effective physiological condition at many times in life to protect us from risks, maintain alertness, and enhance performance (e.g., under examination).

When the activation of the anxiety system is excessive, unwarranted or out of proportion to situations, however, we are dealing with an anxiety disorder, which can greatly complicate a person’s life and render him or her unable to cope with even the most common situations.

Anxiety disorders

Known and clearly diagnosable anxiety disorders are as follows:

  • Specific phobia (airplane, enclosed spaces, spiders, dogs, cats, insects, etc.).
  • Panic disorder and agoraphobia (fear of being in situations from which there is no quick escape)
  • Obsessive-compulsive disorder
  • Social phobia
  • Post-traumatic stress disorder
  • Generalized anxiety disorder

These disorders are among the most frequent in the population, create great disability and often do not respond well to pharmacological treatment. It is therefore necessary to effectively intervene on them with targeted cognitive-behavioral oriented brief psychotherapeutic interventions, which have demonstrated high efficacy in hundreds of scientific studies.

Click on the individual disorders to learn more about them and learn about scientifically valid treatment modalities.

Anxiety psychotherapy

The treatment of choice for anxiety disorders is cognitive-behavioral psychotherapy (CBT). CBT intervenes by helping patients increase their ability to tolerate, cope with, and accept the inevitable uncertainty of everyday life (Dugas & Robichaud, 2007). Intervention differs depending on the disorder, but it is possible to identify some basic components: psychoeducation, cognitive restructuring, exposure, and relaxation.

Psychoeducation involves providing patients with information about the nature of anxiety, thereby increasing their understanding of the emotion and its mechanisms. People with anxiety disorders often automatically have catastrophic thoughts in triggering situations; during treatment, the thoughts that precede or accompany anxiety symptoms are made aware so that the person can learn to identify and modify them through cognitive restructuring. Finally, exposure consists in exposing the subject to the feared situation and preventing any avoidance response, while relaxation exercises allow to reduce activation and the most used are deep breathing and progressive muscle relaxation (Stein & Sareen, 2011).

In recent times, metacognitive therapy (MCT), which focuses on factors that contribute to the development and maintenance of the disorder, has also gained scientific evidence. These include positive and negative beliefs about brooding. MCT is based on the assumption that metacognition is of fundamental importance regarding what we believe and think and underlies our conscious experience and its emotional tone. Although it is part of the cognitive therapies, MCT differs from standard CBT because it attributes the causes of disorders to a particular cognitive style, called CAS (Cognitive-Attentive Syndrome), characterized by an excessive lingering on verbal thoughts in the form of brooding and / or rumination, which is accompanied by an attentional bias such that the patient focuses attention on the threat.

The traditional approach states that psychological disorders are determined by the interpretation of events and the patient needs to change the content of his thoughts. According to MCT, on the contrary, patients’ difficulties concern the recurrent and inflexible way of thinking that occurs in response to the appearance of negative thoughts, emotions, feelings and beliefs; therefore, it shifts the focus from the content to the process: the goal becomes to modify the way a person reacts to a thought, rather than the thought itself (Wells, 1999).

Psychotherapy for anxiety disorders is undoubtedly the most important treatment and one that is difficult to ignore. In particular, cognitive behavioral therapy has shown very high rates of efficacy and has been established in the scientific community as the strategy of first choice in the treatment of anxiety and its disorders.

Pharmacological treatment of anxiety

Anxiety medications, especially the “famous” benzodiazepines, are widely used, but they are useful only when used occasionally and for very short periods of time. Otherwise, they present major problems of addiction and withdrawal, making the situation worse rather than better.

Even the latest generation of antidepressants are readily prescribed with anxiolytic function in the treatment of anxiety disorders. They have some efficacy, but this is usually lost after discontinuation of therapy, as well as very often present side effects (drowsiness, sexual dysfunction, gastrointestinal problems, weight gain, etc.).

Remedies of other nature

Anxiety, especially when it does not reach the extreme levels typical of a true anxiety disorder, can be managed with relaxation techniques, mindfulness meditation strategies, and natural remedies such as valerian or other calming herbal products. These remedies for anxiety can be helpful and supportive of psychotherapeutic treatment, but they are unlikely to be definitive.

Anxiety crisis: symptoms and treatment

A panic crisis, or anxiety crisis, is an episode characterized by a sudden onset, apparently provoked by anything, usually lasting less than thirty minutes. Symptoms experienced by the person during the panic crisis may include: tachycardia, dizziness, extrasystole, sudden sweating, trembling, feeling of suffocation or choking, pain or weight in the chest, nausea, fear of dying or going crazy, chills or flushing.

People who have experienced an anxiety crisis describe it as a terrifying experience, often sudden and unexpected, at least the first time, so it is understandable that the fear of a new panic attack immediately becomes strong and dominant, partly because of the vicious cycle typical of panic attacks, in which physical symptoms reinforce psychological ones and vice versa.

It is therefore common for a single anxiety crisis to easily develop into a full-blown panic disorder, more out of “fear of fear” (anticipatory anxiety mechanism) than anything else; the person quickly finds himself or herself, without realizing it, in a powerful mechanism that often includes what is known as “agoraphobia”, that is, the fear of being in places or situations from which it would be difficult or embarrassing to escape, or where help might not be available in the event of an unexpected panic crisis.

All of this can also lead to severe disabilities in the person’s social and work life and functioning: it can become almost impossible to leave the house alone, to travel by train, bus or car, to stand in a crowd or queue, etc., for fear of being attacked by a new anxiety crisis.

Avoidance of all potentially anxiety-provoking situations (i.e., those capable of triggering the panic crisis) thus becomes the dominant mode of coping, and the person becomes a slave to his or her disorder, often forcing all family members and acquaintances to never leave him or her alone and to accompany him or her everywhere, with the inevitable sense of frustration that comes from being constantly dependent on others and that in many cases risks leading to secondary depression.

Panic attacks and related panic disorders, with or without agoraphobia, can be effectively treated with cognitive behavioral therapy, which has proven to be the most effective form of intervention in a relatively short period of time.

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