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Anxiety- Related Issues

About Anxiety

Anxiety, Fear and Worry

Anxiety has been associated with many things including, fear, worry, threat, fight/flight response, etc. However, these terms all mean different things. Fear is a reaction to a danger presently detected in the environment, which activates the stress (or survival) response called fight or flight – which is necessary in these genuinely dangerous situations. Anxiety on the other hand refers to the anticipation of some potential threat, that may or may not happen in the future; anxiety is also what persists after a significant stressor/danger has ended but the fight/flight system remains on. Worry is the unpleasant or uncomfortable thoughts that cannot be consciously controlled by trying to turn attention to other subjects

The reaction to fear is normal and necessary when a person is actually in a dangerous situation. Although most people do not want to feel anxious, anxiety can also be useful at times to prevent actual danger from happening. The problem with the anxiety system is when the response (i.e. the cognitive, emotional, behavioural and physical of fight/flight) continues after the threat is gone or when it is activated in other situation that are not actually dangerous but are perceived as dangerous. The system does not distinguish between real danger and perceived danger, so once the mind perceives a threat, and fear is activated, the systems involved get activated – preparing for fight or flight. Anxiety disorders are the outcome of inaccurate threat appraisal and worry is the cognitive component of the unnecessary anxiety.

The Science of Anxiety

The amygdala (part of the limbic system) is primarily responsible for regulating emotions such as fear and is thought to be responsible for detecting potential threats in the environment, as well as sounding the internal danger alarm. The hypothalamus is another very important part of the brain involved in anxiety – it serves to control the autonomic nervous system and several types of chemical messengers including many hormones and neurotransmitters. There are two components involved with the Autonomic nervous system:

  1. Sympathetic nervous system: triggers the fight/flight response which delivers a burst of energy to the body so it is prepared for running or fighting in response to perceived threat.
  2. Parasympathetic nervous system: promotes the rest and renewal response which helps the body to calm down and recuperate (i.e., regain balance or return to resting state)


When our bodies sense some sort of danger or threat, the amygdala, via the hypothalamus, sends a message to the autonomic nervous system to prepare for action (i.e. fight-or-flight). It does this by sending a message to the adrenal glands which increase the release of adrenalin into the bloodstream. This leads to a number of physiological changes such as increased respiration rate or rapid breathing, redirection of blood flow to our muscles and limbs, heightened sensory awareness; and expansion of the airways in the lungs.  More symptoms from this response are described in the next section.

Symptoms of Anxiety

Cognitive Symptoms

Cognitive symptoms of anxiety are those that involve our thinking processes, including:

  • Problem-focused thinking (therefore negative)
  • Attention difficulties (as anxiety hijacks frontal lobe functioning including attention)
  • Difficulty with decision-making (fear response can make the decision “dangerous” so the freeze response can cause decision-paralysis)
  • Racing thoughts/frequent worry
  • Focused on inner dialogue (can appear selfish)
  • Mind going blank

Emotional Symptoms

Emotional symptoms of anxiety include various feelings that can occur alongside an anxiety response, including feeling:

  • Fearful
  • Agitated
  • Irritable
  • Negativity/pessimism
  • Dread
  • Scared
  • Unsafe
  • Hopeless (when anxiety has been occurring for a long time people can become hopeless about fighting their fears)

Physical Symptoms

Physical symptoms experienced with anxiety are often referred to as “arousal” symptoms as they are a result of the :

  • Muscle tension
  • Nausea/vomiting/Diarrhoea
  • Fidgeting/Shaking/trembling
  • Heart racing/heart palpitations
  • Breathlessness/shallow breathing
  • Sweaty palms
  • Heat flush
  • Tingling (as blood rushes through to the extremities)
  • Bladder urgency
  • Dry mouth
  • Weakness/wobbly legs
  • Dizziness/lightheaded
  • Tunnel vision


Behavioural Symptoms

Behavioural symptoms of anxiety are are those we see in response to the anxious thoughts and feelings, including:

  • Avoidance
  • Procrastination
  • Overcompensation
  • Pacing
  • Cautious behaviours
  • Checking for signs of danger
  • Restlessness
  • Behaving timidly 
  • Being jumpy

Common Anxiety Disorders

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Social Anxiety

Social Anxiety is defined as marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. The individual fears that they will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).

Social Anxiety Disorder can take various forms: it can be about fear of talking to people, fear of judgement from others, fear of public speaking/performance fears, fear of group gatherings, fear of public places. Simply put, any situation that can elicit fear of scrutiny or judgement by others can be part of Social Anxiety.


Performance Anxiety

The current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recently added the “performance-only” specifier as part of Social Anxiety Disorder for individuals whose anxiety is limited to speaking or performing in public. Performance anxiety is therefore triggered specifically in situations that require the individual to perform in a certain way while being evaluated by others. 


Generalised Anxiety

GAD involves chronic worry which is diffuse; that is there is a general feeling of worry/unease/dread that spread to things in life generally. It is often about everything and anything (big or small); the main aim here is to help manage the worry more effectively while also facing certain anxieties that will help the person worry less about things in life.

Panic Attack

A Panic Attack is defined as an abrupt surge of intense fear or discomfort that peaks within minutes. It may be triggered unexpectedly (such as with Panic Disorder) or by a specific feared situation (which may arise due to other anxiety disorders). There are 13 symptoms categorised under a panic attack: racing or pounding heart, sweating, trembling or shaking, shortness of breath, choking feeling, chest pain or discomfort, nausea or abdominal distress, dizzy, unsteady or faint, feeling unreal or detached, numbness or tingling sensations, chills or hot flushes, fear of dying, fear of going crazy or losing control.


Panic Disorder

Panic disorder is the term used to describe when panic attacks are recurrent and disabling. Panic disorder can be characterised by: The presence of recurring and unexpected (‘out of the blue’) panic attacks. Worrying for at least a month after having a panic attack that you will have another one (i.e. the cycle becomes: panic about panic). Once a panic attack has occurred and especially if it happens multiple times, the misappraisal of the body signals as indicating a catastrophe causes further fear that is even more likely to escalate to panic. Panic can essentially perpetuate itself.


Agoraphobia

Agoraphobia is the excessive fear of situations such as public transportation, open spaces, enclosed spaces, lines and crowds, being outside of home alone – two or more must be feared in order to meet criteria for agoraphobia. It commonly develops after experiencing panic attacks as the person becomes afraid to leave safe environments for fear of having a panic attack or other incapacitating symptoms.

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Health Anxiety

Health Anxiety, also known as Illness Anxiety Disorder (IAD) and previously hypochondriasis, involves an unrealistic fear of having (or being at high risk of having) a serious medical health condition. People with IAD inaccurately assess normal bodily functions  as signs of illness. They may seek multiple medical tests from a variety of healthcare professionals and despite results showing no issues, the belief they are seriously ill persists. In fact, when doctors find no issues, this can cause further worry as they simply believe the issue has not been found yet. The fear is very real for people with IAD and can be very debilitating.

A variation of IAD is  somatic symptom disorder (SSD)– this involves obsessive worry about health (as with IAD), however, a person with SSD experiences actual physical symptoms. Despite true symptoms, tests and investigations are not able to pinpoint the reason for these symptoms. People who have had serious and real medical/health issues may also develop IAD as they can become hyper tuned into bodily symptoms, assessing them as another health threat.

Specific Phobias

For most phobias, the most common reaction to the feared object or situation is one of extreme fear or panic, which can include a wide range of physical symptoms (as described in previous sections). In addition to fearing the object or situation itself, people with phobias often are fearful of the anxiety symptoms they experience in the presence of their feared situation (e.g. someone with fear of heights feels fearful of the symptom of dizziness when in high places).

People with medical phobias (such as fears of blood, needles, doctors, and dentists) may also respond to their feared situations in a somewhat different way—one that includes fainting. When actually encountering the situation (for example, when they see blood or get an injection), heart rate and blood pressure drop very quickly, sometimes leading to fainting. It is believed that these changes are controlled by the vagus nerve, which affects activity in the chest and abdomen.

Treatment of Anxiety Disorders

Anxiety Disorders are commonly treated using Cognitive-Behavioural Therapy (CBT), Mindfulness-Based Cognitive Therapy (MBCT), Acceptance and Commitment Therapy (ACT), and Problem-Solving Strategies. Sometimes Dialectical-Behaviour Therapy (DBT) skills (rather than the full treatment) may be used to help a person who has a lot of physical arousal symptoms of anxiety that they find distressing.

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CBT may include: arousal management via breathing and relaxation techniques; cognitive strategies aimed at altering unhelpful thoughts that may be exaggerating the perception of threat; behaviour change such as reducing escape-type behaviours and safety behaviours; and graded exposure to anxiety provoking situations. MBCT incorporates mindfulness skills as a main component of the cognitive therapy.

ACT on the other hand focuses on dealing with anxiety in a different way using two processes: 1) accepting rather than fighting thoughts and emotions; 2) committing and acting according to core values. DBT skills teaches clients with anxiety distress tolerance skills, emotion regulation strategies, and de-arousal techniques.