Anxiety Disorders

Anxiety vs. an anxiety disorder

Anxiety is an emotion we all experience that tells us something bad is going to happen. Anxiety also helps us get ready for things we need to prepare for. For example, a bit of anxiety it often the emotional force that motivates a child to study for a test or a job applicant to prepare for an interview. 

An anxiety disorder is when a person feels anxious often and intensely, to the extent that it is no longer helping them.  For example, if a child is so anxious about an upcoming test that they cannot sleep during the nights leading up to the test, this might be an expression of an anxiety disorder.

Fear vs. anxiety

Fear and anxiety are related emotions. Fear is the emotion associated with a threat that is right in front of you. It is often more reactive to something bad that is just about to happen (for example, you might feel afraid or fearful when you start a speech, discover a big nasty spider, or when there is a terrible storm outside).

Anxiety is the emotion associated with a threat that is a bit further away, in someone's head, or something with lower-grade stakes. For example, people are more likely to feel anxious when thinking about an upcoming life change like starting a new school year or a new job, when getting prepared for something they care about, or when getting ready to have a conversation where they might be judged. 

Because fear and anxiety are so related, we often think about them together and are both hallmarks of many anxiety disorders.

How are anxiety disorders diagnosed?

The gold standard approach to diagnosing anxiety disorders involves a comprehensive psychological or psychiatric assessment to evaluate all possible contributors to a person's anxiety and to understand whether a person's difficulties can be best explained by excessive fear or anxiety. This typically involves a detailed interview with an expert therapist or doctor and completion of questionnaires. 

What causes anxiety disorders?

A combination of factors lead to anxiety disorders. Every person's experience is unique, but a few psychological, biological, and social/environmental factors have stood out.

• Psychological factors include both cognitive factors, or the way people think and how they pay attention to different parts of their world, and behavioral factors, or how they react to anxiety-provoking or scary situations. For example, people who struggle with anxiety tend to believe that "neutral" situations, or situations that could be understood as scary or not scary, are likely to be dangerous. They are also likely to pay closest attention to potential threat in their world. For example, in a crowd of approving or smiling faces, people with social anxiety will be the quickest to find a neutral face, and are more likely to believe that person is judging them. People who struggle with anxiety are less likely to believe in their ability to cope with challenges and are especially sensitive to situations in which something bad happens to them. They might also have exaggerated expectations about the likelihood of bad outcomes or how impactful they will be. For example, someone who is afraid of crowds might mistakenly believe the chances of a disaster happening in a crowded place are higher than they really are.

Behaviorally, people with anxiety disorders are more likely to avoid situations that bring up anxiety or leave situations where they feel anxious. Although avoiding the source of anxiety helps them feel less anxious in the short-term, it does not give them an opportunity to test out their fears, learn about their own ability to handle difficult situations, or to get used to their anxiety. For these reasons, anxiety is likely to grow when someone relies on avoiding the source of their anxiety too much. They might also turn to "quick fixes," like checking things over and over, seeking lots of reassurance, or doing lots of research on the Internet about their fears. Although these things also help them feel less anxious at first, they work like avoidance, in that they do not give a person the opportunity to face their fears directly and get all the benefits that can provide.

• Biologically, there seem to be certain characteristics people are born with that leaves them more likely to have an anxiety disorder later in life. This is often highlighted in an anxious "temperament," which you can see even among babies. This temperament refers to how young people tend to act in new situations, which can be more negative emotional reactions in young infants and shyness in toddlers. Infants and toddlers with this "anxious temperament" are much more likely to have anxiety disorders later in life. Because you can see this trait so early on, it suggests that there are certain genetic and biological factors that explain why people go on to experience anxiety disorders.

A specific part of the brain is especially related to anxiety is the amygdala, or the deep part of the brain that is triggered during a "fight or flight" situation. A person with an anxiety disorder tends to have an overactive amygdala, which corresponds with physical symptoms of anxiety like increased heart rate, sweating, or shakiness. Research also suggests problems with connections between the amygdala and other deep parts of the brain that process emotions with parts of the "frontal cortex," or the part of the brain that is in charge of reasoning, planning, and organizing. 

• There are also factors in a person's environment that can make them more likely to have an anxiety disorder. The primary factor that has been studied is trauma and adversity. This makes sense, as when bad things happen to a person, they are more likely to feel anxious about bad things to continuing to happen. Beyond major difficult life situations, other factors like how well a person gets along with peers or how much social support they feel can also play a part.

How common are anxiety disorders?

Anxiety disorders are the most common mental health conditions among children. During any given year of childhood, 5-10% are estimated to have an anxiety disorder. Phobias, separation anxiety, and nighttime fears tend to be more common among school-age kids, while social anxiety and excessive day-to-day worries become more common in adolescence.

Anxiety disorders are also very common in adults, with about 3-16% of adults experiencing one of the anxiety disorders during their lifetime. The most common anxiety disorders are specific phobias and social anxiety disorder.

Different anxiety disorders 

Although there are lots of different anxiety disorders, each of which having a focus on different parts of fear and anxiety, Most mental health professionals (myself included) believe they are all more related than different.  All these disorders are characterized by frequent or excessive experiences of fear or anxiety and tend to stick around for the same reasons. The main difference is in where this fear or anxiety is focused.  Because of this, people with anxiety disorders often have more than one of these disorders. They are caused by similar genetic, biological, psychological, and environmental factors. For this reason, the treatment approach is really similar across these disorders, and are best addressed together rather than separately. The most powerful psychological tool is in finding ways to face these fears instead of avoiding them. The different anxiety disorders are:

1. Separation anxiety disorder - significant anxiety about being away from an "attachment figure" (usually a parent or romantic partner)

2. Selective mutism - being able to speak in one situation but not being able to speak in others. This is more common in young children and can be due to anxiety but also can be related to difficulties with language development

3. Specific phobia - intense fears about specific things or situations, like spiders, animals, needles, heighted, or enclosed places (to name a few common phobias)

4. Social anxiety disorder - excessive anxiety about being judged in social situations

5. Panic disorder - having recurring panic attacks out of the blue, where fear and anxiety spike within minutes out of no where, and being very afraid of these attacks continuing to happen. This is different from having panic attacks; unfortunately, many people with anxiety disorders struggle with panic attacks, but they might not have panic disorder. This disorder is more about being afraid of having panic attacks.

6. Agoraphobia - avoiding being in public spaces because of fears that they will have a panic attack or some other crisis without being able to escape 

7. Generalized anxiety disorder - excessive worries about day-to-day stressors, like family, friends, school, work, or the future

Obsessive-compulsive disorder and posttraumatic stress disorder both used to be considered anxiety disorders as well, and it is often useful to continue to think of them this way, as the gold standard therapy techniques and frameworks overlap a lot between anxiety disorders and these conditions.