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.

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.

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).

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