Anxiety: Symptoms, Causes, and Treatment from Dr. Elaine Ryan, Psychologist

Anxiety is one of the most common mental health problems worldwide, with research undertaken just last year (2022) showing 42% of the adult population of Ireland have a mental health disorder, with 7% of those living with generalised anxiety disorder. The most recent UK survey in 2014 (a new survey is due this year) shows that 6% of the population has anxiety, accounting for over 8 million people.

Many people can recover through self-help, knowledge and psychoeducation, so I have written this detailed guide.

It is dense in parts, but I firmly believe that if you want to recover from anything, you must understand it first. This guide shall outline anxiety and cite possible reasons for what may cause it before moving on to options that help you recover.

What is anxiety?

Anxiety is an emotion; like all emotions, it has a purpose. I shall give a quick explanation of this as I find it helps people to understand anxiety better.

All emotions serve a purpose, i.e. they have a function.

• Fear keeps you safe by alerting you to possible danger.
• Disgust stops you from eating a rotting apple that could make you ill.
• Anger helps you to stand up for yourself.
• Sadness signals to others that you need support.

You can read more on emotions here.

Anxiety is an emotional response to anticipated or perceived threats. From an evolutionary perspective, feeling anxious keeps you on your toes and heightens your awareness to check for danger; anxiety evolved to keep you safe.

Anxiety is an emotion. Some people find relief in being able to label what they are feeling as an emotion, just the way sadness and anger are emotions. Anxiety is scarier due to how it makes you feel and what it can do to your thought processes, but it is an emotion nonetheless and like all emotions, it can change. It occurs in response to stress and is the body’s natural fight-or-flight response. It can sometimes be helpful, making you more alert and ready for action, but when it becomes excessive and difficult to control, an anxiety disorder may be present.

How do I know if I have an anxiety disorder?

Some signs and symptoms are common to emotion, and all anxiety disorders, but some are unique to specific anxiety disorders. The ability to differentiate between them can help signpost whether your anxiety is normal or more indicative of a disorder.

The National Institute of Mental Health explains how everyone can have temporary anxious feelings about life events such as health and finances. But with anxiety disorders, this feeling does not go away, and the symptoms start interfering with your life and ability to get things done.

As a rule of thumb, appropriate anxiety is temporary. It is related to a unique event, such as an interview or change in finances, and does not interfere with your ability to live your life.

If your anxiety is interfering with your quality of life. For example, changes in your sleep pattern, changes in your behaviour such as avoiding things, and the feeling does not go away or gets more intense; you should meet with a mental health professional to see if you have an anxiety disorder.

Signs and symptoms

All anxiety disorders can include the following symptoms.

For a detailed account of anxiety symptoms, please see this post.

Diagnosis

If you suspect you might have an anxiety disorder, a psychologist or psychiatrist can undertake an assessment and tell you not only if you have anxiety, but what type you have.

The clinician will use a tool called the Diagnostic and Statistical Manual of Mental Disorders (DSM). According to the DSM, the criteria for anxiety include the following;

• excessive anxiety and worry most days about many things for at least six months
• difficulty controlling your worry
• the appearance of three of the following six symptoms: restlessness, fatigue, irritability, muscle tension, sleep disturbance, and difficulty concentrating
• symptoms significantly interfering with your life
• symptoms not being caused by the direct psychological effects of medications or medical conditions
• symptoms aren’t due to another mental disorder (e.g. anxiety about oncoming panic attacks with panic disorder, anxiety due to a social condition, etc.)

You might also complete a self-report questionnaire like the Beck Anxiety Inventory (BAI). 

Following the assessment, they can tell you what type of anxiety disorder you have.

Types of anxiety disorders

It is estimated that around 12 to 15% of the population of Ireland has an anxiety disorder.

A 2019 report by the Mental Health Commission of Ireland estimated that 14.4% of the Irish population had experienced a mood or anxiety disorder in the past year. The same report noted that anxiety disorders were the most common mental health problem reported by Irish adults.

In light of the sheer number of the Irish population suffering from anxiety disorders, effective prevention is necessary to reduce the likelihood of developing anxiety disorders. Some effective strategies for preventing anxiety disorders include:

1. Early intervention and treatment: Addressing anxiety symptoms early on can prevent them from escalating into full-blown anxiety disorders. This can involve seeking professional help from a mental health provider or utilizing self-help techniques such as mindfulness, relaxation, and stress reduction techniques.
2. Stress management: Stressful life events can trigger anxiety disorders, so it’s essential to develop effective stress management strategies such as exercise, yoga, meditation, and relaxation techniques.
3. Healthy lifestyle choices: Maintaining a nutritious diet, getting regular exercise, getting adequate sleep, and avoiding or limiting the use of substances such as alcohol and drugs can help prevent anxiety disorders.
4. Building resilience: Developing skills to manage life’s challenges and setbacks can build resilience and reduce the impact of stressors on mental health. This can involve developing problem-solving skills, cultivating positive relationships, and seeking social support.

What causes anxiety disorders?

A complex interaction between genetic, environmental, and psychological factors causes the disorders.

Biological factors

Neurotransmitters

1. Serotonin: Serotonin is a neurotransmitter that helps regulate mood, sleep, appetite, and other bodily functions. Low levels of serotonin have been linked to anxiety and depression.
2. Gamma-aminobutyric acid (GABA): GABA is an inhibitory neurotransmitter that helps to reduce the activity of neurons in the brain. Low levels of GABA have been associated with anxiety disorders.
3. Norepinephrine: Norepinephrine is a neurotransmitter that helps to regulate the “fight or flight” response. High levels of norepinephrine can increase anxiety and panic.
4. Dopamine: Dopamine is a neurotransmitter that helps to regulate mood, motivation, and reward. Abnormal levels of dopamine have been linked to anxiety disorders.
5. Glutamate: Glutamate is an excitatory neurotransmitter that helps activate brain neurons. Abnormal levels of glutamate have been associated with anxiety disorders.

Genetics

Genetics play a role in the development of anxiety disorders, although the exact genes involved and how they contribute to the disorder is still not fully understood. Research has shown that the disorders tend to run in families, suggesting a genetic component.

Twin studies have also provided evidence that anxiety disorders are heritable. For example, one study of twins found that the heritability of generalised anxiety disorder (GAD) was around 30-40%, meaning that 30-40% of the variation in GAD symptoms can be attributed to genetic factors.

Studies have also identified specific genes that may be involved in developing anxiety disorders. For example, genes involved in regulating serotonin, a neurotransmitter that plays a role in mood regulation, have been linked to anxiety disorders. Other genes implicated in anxiety disorders include those involved in regulating the stress response, such as the hypothalamic-pituitary-adrenal (HPA) axis.

It’s important to note that genetics alone do not determine whether or not someone will develop an anxiety disorder. Environmental factors, such as exposure to stress or trauma, also play a role in the development of anxiety disorders. Additionally, the interaction between genetic and environmental factors may be complex and multifaceted.

While the role of genetics in anxiety disorders is still being studied, understanding the disorder’s genetic basis may help guide the development of new treatments and therapies. For example, identifying specific genes that contribute to anxiety disorders may lead to the development of new medications that target those genes or their associated pathways.

Brain structure

Research has shown that there are differences in brain structure and function between individuals with anxiety disorders and those without.

One area of the brain that has been linked to anxiety is the amygdala, which is responsible for processing emotional stimuli, including fear. Studies have found that individuals with anxiety disorders tend to have a hyperactive amygdala, meaning that the amygdala is more responsive to emotional stimuli. This heightened response may contribute to the exaggerated fear and anxiety experienced by individuals with anxiety disorders.

Another brain region that is involved in anxiety is the prefrontal cortex, which is responsible for cognitive processes such as decision-making and impulse control. Studies have found that individuals with anxiety disorders may have reduced activity in the prefrontal cortex, contributing to the difficulty in regulating emotions and making decisions often seen in these disorders.

Neurotransmitters also play a role in brain function and anxiety. As I mentioned earlier, low levels of the neurotransmitter serotonin have been linked to anxiety disorders. Additionally, abnormal levels of other neurotransmitters, such as norepinephrine and GABA, have also been associated with anxiety disorders.

Research has also shown that the brain is plastic and can change in response to experiences and interventions. For example, studies have found that cognitive-behavioural therapy (CBT) can lead to brain structure and function changes in individuals with anxiety disorders, such as increased prefrontal cortex activity and decreased amygdala activity.

Overall, the relationship between brain structure and function and anxiety is complex and multifaceted. While much is still to be learned about this relationship, understanding the neural mechanisms underlying anxiety can help guide the development of new treatments and therapies.

• One study published in the journal Nature Neuroscience used functional MRI (fMRI) to measure brain activity in individuals with generalised anxiety disorder (GAD) and healthy controls. The study found that individuals with GAD had increased activity in the amygdala and reduced activity in the prefrontal cortex when viewing pictures of threatening faces, compared to healthy controls (Etkin et al., 2010).
• Another study published in the Journal of Neuroscience used structural MRI to measure the amygdala volume in individuals with social anxiety disorder (SAD) and healthy controls. The study found that individuals with SAD had larger amygdalae than healthy controls and that the amygdala volume was positively correlated with the severity of social anxiety symptoms (Phan et al., 2006).
• A review article published in the journal Current Psychiatry Reports summarised the findings of multiple studies investigating the role of neurotransmitters in anxiety disorders. The article noted that low levels of serotonin, as well as abnormalities in other neurotransmitters such as norepinephrine and GABA, have been associated with anxiety disorders (Pittenger & Duman, 2008).

These studies and many others prove the link between brain structure and function and anxiety.

Psychological factors

 Personality traits and anxiety 

Research has shown that certain personality traits are associated with an increased risk of developing anxiety disorders. Here are some examples:

• Neuroticism: This personality trait is characterised by the tendency to experience negative emotions such as anxiety, depression, and worry. People who score high in neuroticism are more likely to develop anxiety disorders, and this relationship has been found in both cross-sectional and longitudinal studies (Lahey, 2009).
• Behavioural inhibition refers to a tendency to be cautious and avoidant in new or uncertain situations. Children who exhibit high levels of behavioural inhibition are more likely to develop anxiety disorders later in life (Caspi et al., 1996).
• Perfectionism is a personality trait characterised by setting high standards for oneself and being overly self-critical when those standards are not met. Perfectionism has been found to be associated with various anxiety disorders, including generalised anxiety disorder and social anxiety disorder (Stoeber & Otto, 2006).

It is important to note that personality traits do not necessarily cause anxiety disorders, but instead they may increase vulnerability to developing anxiety under certain circumstances. Additionally, the relationship between personality traits and anxiety is complex and may involve various interacting factors such as genetics, environment, and life experiences.

Coping styles

Coping styles are how individuals deal with stress and adversity. Research has shown that coping styles can play a role in developing and maintaining anxiety disorders. Here are some examples:

• Avoidant coping: This involves efforts to avoid or suppress anxiety-provoking stimuli or situations. While avoidance may temporarily relieve anxiety, it can also interfere with learning that anxiety is not always dangerous and can exacerbate anxiety symptoms in the long run (Meyer & Carver, 2000).
• Emotion-focused coping: This involves efforts to manage the emotional distress associated with anxiety. Examples include seeking social support, engaging in relaxation techniques, and engaging in distracting activities. While these strategies may help reduce immediate distress, they do not address the underlying causes of anxiety and may not be effective in the long run (Compas et al., 2001).
• Problem-focused coping: This involves efforts to address the underlying causes of anxiety by taking action to change the situation or one’s own behaviour. Examples include seeking information, making a plan of action, and engaging in problem-solving activities. Problem-focused coping is generally considered to be more effective than emotion-focused coping or avoidance (Lazarus & Folkman, 1984).

It is important to note that coping styles are not necessarily fixed and can be influenced by various factors such as personality, life experiences, and the nature of the stressor. Furthermore, effective coping strategies may vary depending on the type and severity of anxiety disorder.

Learning

Learning plays a vital role in the development and maintenance of anxiety disorders. According to learning theory, anxiety disorders can be seen as a result of maladaptive learning. Here are some examples:

• Classical conditioning is a type of learning in which a neutral stimulus becomes associated with a previously meaningful stimulus (such as a feared object or situation) and elicits a similar response. For example, a person who has experienced a panic attack in a crowded elevator may start to feel anxious even when they see an elevator door or hear the sound of an elevator bell.
• Operant conditioning is a type of learning in which behaviours are reinforced or punished based on their consequences. For example, a person who avoids a feared object or situation (such as flying on an aeroplane) may experience an anxiety reduction and be more likely to avoid the situation.
• Observational learning: This is a type of learning in which individuals learn by observing the behaviors of others. For example, a child who sees their parent react with fear or anxiety to a certain stimulus (such as a spider) may learn to react similarly to that stimulus.

Cognitive theory

According to cognitive theory, anxiety occurs when a false assumption is made about a situation, i.e., that it is dangerous, without having direct evidence to prove the threat.

For example, someone with social anxiety may believe that an upcoming event is something to be feared. This appraisal of the event leads to a myriad of cognitive errors, resulting in faulty thoughts, such as I cannot do this, I will make a fool of myself, which affects future behaviour; they may avoid the event.

Behavioural learning theory

According to behavioural theories, anxiety is acquired through learning. For example, someone who had been anxious while shopping might pair the experience of shopping with feelings of anxiety; this pairing is inadvertent learning that shopping results in stress.

New theories on anxiety

Dr Ellen Vora (3) makes a critical distinction between what she calls true and false anxiety and notes that a lot is going on in our world that we can be afraid of, which ultimately gives us a fear response. According to Vora, false anxiety is something we can do something about; it is avoidable. It can be from a blood sugar crash, too much stimulus, caffeine, diet or lack of sleep.

I can concur with some of her theories after restricting sugar and caffeine from my diet, focusing on an anti-inflammatory diet and prioritising sleep.

It is important to note that not all individuals who experience anxiety develop anxiety disorders, and factors such as genetics and life experiences can also play a role in the development of anxiety disorders.

Environmental

Life events

Stressful life events can trigger anxiety, disrupting an individual’s sense of safety, security, and control. When faced with a stressful life event, individuals may feel overwhelmed and uncertain about how to cope, which can lead to anxiety.

For example, if an individual experiences a traumatic event such as a car accident or physical assault, they may develop anxiety because the event has shaken their sense of safety and security. They may constantly worry about their safety and become hypervigilant to potential threats, which can cause them to experience anxiety symptoms such as panic attacks, avoidance, and intrusive thoughts.

Similarly, if an individual experiences a major life change such as a job loss or a divorce, they may feel a loss of control and uncertainty about their future, which can trigger anxiety. They may worry about their financial stability, relationships, and ability to adapt to new situations.

It is important to note that not all individuals who experience stressful life events develop anxiety disorders.

Childhood experiences

Studies have shown that traumatic or stressful experiences during childhood, such as abuse, neglect, or exposure to violence, can increase the risk of developing anxiety later in life.

Some examples of childhood experiences that may contribute to anxiety include:

• Parental separation or divorce: Children whose parents separate or divorce may experience significant stress and uncertainty, which can contribute to the development of anxiety.
• Childhood abuse or neglect: Children who experience physical, sexual, or emotional abuse or neglect may develop anxiety as a result of the trauma they have experienced.
• Family conflict: Children who grow up in households with high levels of conflict and tension may experience chronic stress, which can contribute to the development of anxiety.
• Overprotective parenting: Children who are overly sheltered or protected by their parents may not develop the coping skills necessary to manage anxiety and may be more vulnerable to developing anxiety disorders.

Do I need to see a doctor or therapist, and what will they do?

If you follow a stepped-care approach, you may not need treatment by a psychologist, as you can start with self-help.

The National Institute for Health and Care Excellence (NICE for short) gives guidance on a Stepped Care Approach, which suggests

Stepped Care Approach for treatment of anxiety

1. Assessment, education and discussion of treatment options
2. This could be a meeting with your local GP, who diagnoses anxiety or refers you to a psychologist for psychological assessment. Your GP or mental health consultation will explain anxiety to you and recommend treatment options, which may start with self-help.
3. Self Help
4. This can be self-help that you undertake alone or may include psycho-educational group sessions.
5. Psychological intervention CBT or medication
6. If self-help does not work for you, you might be referred for CBT with a psychologist or prescribed medication to help manage your anxiety.
7. Highly specialised treatment
8. This can include psychological intervention, medication and multidisciplinary teams or inpatient care.

Treatments

The primary treatment for anxiety is

• psychological therapy, or
• medication.

Psychological therapy is where you meet with a licensed mental health professional and are offered Cognitive Behavioural Therapy, CBT.

Your GP or psychiatrist can prescribe medications for anxiety.

Psychological therapy

Their G.P. often refers people to psychologists for Cognitive Behavioural Therapy when a diagnosis of anxiety has been given.

If you are considering therapy for anxiety, this series of articles explains in more detail how CBT helps with anxiety. 

Anxiety counselling

I shall start by talking to you about the most well-known therapy option for anxiety, which is CBT, but (and this is important) I also want to talk to you about how to get the right treatment based on the kind of anxiety that you have.

You might not be aware that different pathways in your brain can cause anxiety, and understanding how your anxiety is created affects the type of treatment you need.

People come to see me after trying many things or attending for counselling or CBT.

CBT is excellent but not a one-stop cure-all for the many forms of anxiety.

Many treatments do not focus on how your brain works or the pathways that exist in your brain that create anxiety. The key to my success in helping people with anxiety is understanding the different pathways to anxiety in your brain and being an expert in CBT.

CBT is beneficial for the thought processes involved in anxiety and great for changing any anxious behaviours you have (e.g., overworking, always predicting the worse). But you will feel anxiety in certain places or ways with little thought processes present for many of you. This is because your brain remembers to be anxious!

Your brain remembering to be anxious is explained in the video below, taken from my online course.

Recap: CBT is tremendous for the thought processes associated with your anxiety and is helpful in helping with anticipatory anxiety, where you create anxiety over events that have not yet happened.

However, if you can relate to feeling anxious in situations where no thoughts are present or can relate to the video above, where your brain remembers to be anxious, we need to look at your brain; in particular, we need to look at the role of your amygdala in anxiety.

• It would help if you learned to react differently to situations.
• You need to know to activate the rest and digest response more often
• It would help if you changed the way you interact with the thoughts in your head
• You must calm down your nervous system.

  The way your brain works for you needs to be changed.

You don’t need to see me in person to get help with anxiety. Self-help is enough for most people.

Recovering from anxiety is not about what you say to the therapist but what you are told to do.

Let me explain. There are tried and tested models of therapy that are shown to work with anxiety. These are highly directive (you are told what to do, what to change, and what not to do.)

But what about making it personal? If you were in session with me right now, I would have to tailor any treatment to suit you. How I do this is to explain what I need from you to make it personal. Give instructions on how to do this, and collect all of this information between sessions. We do it this way because you must be out and about daily to see what is.

• triggering your anxiety,

• how you react,

• what you do that needs changing.

And the changes you make, based on all the information you collect between sessions, are undertaken by you outside therapy sessions.

Most of the therapy for anxiety, if you are working within, for example, CBT, is the therapist explaining what to do, and most of your work is a practice between sessions.

This is what I mean when I say you don’t need to come to see me. I can take you through this process, in your own time, at your own pace.

My course covers everything I have talked to you about in this article.

How to deal with anxiety right now

Short-term ways to manage anxiety.

If you are feeling anxious right now, the following brief videos will help you manage your current anxiety.

Controlled breathing

The following video will help you to control your breathing.

7-11 breathing

Breathing

• It will allow your breathing to settle and calm your nervous system
• It will stop you from focusing on everything else that may increase or contribute to your anxiety.

Outlook

Anxiety, although debilitating, can be effectively treated with the right help. Whether you start my Retrain Your Brain® course or meet with a therapist, getting help is the first step to recovering from anxiety.

Sources

References

1. Ekman P. Basic Emotions. Handbook of Cognition and Emotion. 2005:45-60. doi:10.1002/0470013494.ch3
2. Hockenbury, D. and Hockenbury, S.E. (2007). Discovering Psychology.New York: Worth Publishers.
3. Vora, E. (2022) The anatomy of anxiety.  Orion Spring