Causes and symptoms

Anxiety can have a number of different causes. It is a multidimensional response to stimuli in the person’s environment, or a response to an internal stimulus (for example, a hypochondriac’s reaction to a stomach rumbling) resulting from a combination of general biological and individual psychological processes.

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Physical

In some cases, anxiety is produced by physical responses to stress, or by certain disease processes or medications.

THE AUTONOMIC NERVOUS SYSTEM (ANS). The nervous system of human beings is “hard-wired” to respond to dangers or threats. These responses are not subject to conscious control, and are the same in humans as in lower animals. They represent an evolutionary adaptation to the animal predators and other dangers with which all animals, including primitive humans, had to cope. The most familiar reaction of this type is the so-called “fight-or-flight” response. This response is the human organism’s automatic “red alert” in a life-threatening situation. It is a state of physiological and emotional hyperarousal marked by high muscle tension and strong feelings of fear or anger. When a person has a fight-or-flight reaction, the level of stress hormones in their blood rises. They become more alert and attentive, their eyes dilate, their heartbeat increases, their breathing rate increases, and their digestion slows down, allowing more energy to be available to the muscles.

This emergency reaction is regulated by a part of the nervous system called the autonomic nervous system, or ANS. The ANS is controlled by the hypothalamus, a specialized part of the brainstem that is among a group of structures called the limbic system. The limbic system controls human emotions through its connections to glands and muscles; it also connects to the ANS and “higher” brain centers, such as parts of the cerebral cortex. One problem with this arrangement is that the limbic system cannot tell the difference between a realistic physical threat and an anxiety-producing thought or idea. The hypothalamus may trigger the release of stress hormones by the pituitary gland, even when there is no external and objective danger. A second problem is caused by the biochemical side effects of too many “false alarms” in the ANS. When a person responds to a real danger, his or her body gets rid of the stress hormones by running away or by fighting. In modern life, however, people often have fight-or-flight reactions in situations in which they can neither run away nor lash out physically. As a result, their bodies have to absorb all the biochemical changes of hyperarousal, rather than release them. These biochemical changes can produce anxious feelings, as well as muscle tension and other physical symptoms associated with anxiety. They may even produce permanent changes in the brain, if the process occurs repeatedly. Moreover, chronic physical disorders, such as coronary artery disease, may be worsened by anxiety, as chronic hyperarousal puts undue stress on the heart, stomach, and other organs.

DISEASES AND DISORDERS. Anxiety can be a symptom of certain medical conditions. Some of these diseases are disorders of the endocrine system, such as Cushing’s syndrome (overproduction of cortisol by the adrenal cortex), and include over- or underactivity of the thyroid gland. Other medical conditions that can produce anxiety include respiratory distress syndrome, mitral valve prolapse, porphyria, and chest pain caused by inadequate blood supply to the heart (angina pectoris).

A study released in 2004 showed that people who had experienced traumatic bone injuries may have unrecognized anxiety in the form of post-traumatic stress disorder. This disorder can result from witnessing or experiencing an event involving serious injury, or threatened death (or experiencing the death or threatened death of another.)

MEDICATIONS AND SUBSTANCE USE. Numerous medications may cause anxiety-like symptoms as a side effect. They include birth control pills; some thyroid or asthma drugs; some psychotropic agents; occasionally, local anesthetics; corticosteroids; antihypertensive drugs; and nonsteroidal anti-inflammatory drugs (like flurbiprofen and ibuprofen).

Although people do not usually think of caffeine as a drug, it can cause anxiety-like symptoms when consumed in sufficient quantity. Patients who consume caffeine rich foods and beverages, such as coffee, tea, chocolate, cocoa, or carbonated soft drinks (especially cola beverages), can sometimes lower their anxiety symptoms simply by reducing their intake of these substances.

Withdrawal from certain prescription drugs, primarily beta blockers and corticosteroids, can cause anxiety. Withdrawal from drugs of abuse, including LSD, cocaine, alcohol, and opiates, can also cause anxiety.

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Learned associations

Some aspects of anxiety appear to be unavoidable byproducts of the human developmental process. Humans are unique among animals in that they spend an unusually long period of early life in a relatively helpless condition, and a sense of helplessness can lead to anxiety. The extended period of human dependency on adults means that people may remember, and learn to anticipate, frightening or upsetting experiences long before they are capable enough to feel a sense of mastery over their environment. In addition, the fact that anxiety disorders often run in families indicates that children can learn unhealthy attitudes and behaviors from parents, as well as healthy ones. Also, recurrent disorders in families may indicate that there is a genetic or inherited component in some anxiety disorders. For example, there has been found to be a higher rate of anxiety disorders (panic) in identical twins than in fraternal twins.

CHILDHOOD DEVELOPMENT AND ANXIETY. Researchers in early childhood development regard anxiety in adult life as a residue of childhood memories of dependency. Humans learn during the first year of life that they are not self-sufficient and that their basic survival depends on the care of others. It is thought that this early experience of helplessness underlies the most common anxieties of adult life, including fear of powerlessness and fear of being unloved. Thus, adults can be made anxious by symbolic threats to their sense of competence and/or significant relationships, even though they are no longer helpless children.

SYMBOLIZATION. The psychoanalytic model gives considerable weight to the symbolic aspect of human anxiety; examples include phobic disorders, obsessions, compulsions, and other forms of anxiety that are highly individualized. The length of the human maturation process allows many opportunities for children and adolescents to connect their experiences with certain objects or events that can bring back feelings in later life. For example, a person who was frightened as a child by a tall man wearing glasses may feel panicky years later by something that reminds him of that person or experience without consciously knowing why.

Freud thought that anxiety results from a person’s internal conflicts. According to his theory, people feel anxious when they feel torn between desires or urges toward certain actions, on the one hand, and moral restrictions, on the other. In some cases, the person’s anxiety may attach itself to an object that represents the inner conflict. For example, someone who feels anxious around money may be pulled between a desire to steal and the belief that stealing is wrong. Money becomes a symbol for the inner conflict between doing what is considered right and doing what one wants.

PHOBIAS. Phobias are a special type of anxiety reaction in which the person’s anxiety is concentrated on a specific object or situation that the person then tries to avoid. In most cases, the person’s fear is out of all proportion to its “cause.” Prior to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), these specific phobias were called simple phobias. It is estimated that 10-11% of the population will develop a phobia in the course of their lives. Some phobias, such as agoraphobia (fear of open spaces), claustrophobia (fear of small or confined spaces), and social phobia, are shared by large numbers of people. Others are less common or unique to the patient.

Social and environmental stressors

Anxiety often has a social dimension because humans are social creatures. People frequently report feelings of high anxiety when they anticipate and, therefore, fear the loss of social approval or love. Social phobia is a specific anxiety disorder that is marked by high levels of anxiety or fear of embarrassment in social situations.

Another social stressors is prejudice. People who belong to groups that are targets of bias are at higher risk for developing anxiety disorders. Some experts think, for example, that the higher rates of phobias and panic disorder among women reflects their greater social and economic vulnerability.

Some controversial studies indicate that the increase in violent or upsetting pictures and stories in news reports and entertainment may raise the anxiety level of many people. Stress and anxiety management programs often suggest that patients cut down their exposure to upsetting stimuli.

Anxiety may also be caused by environmental or occupational factors. People who must live or work around sudden or loud noises, bright or flashing lights, chemical vapors, or similar nuisances, which they cannot avoid or control, may develop heightened anxiety levels.

Existential anxiety

Another factor that shapes human experiences of anxiety is knowledge of personal mortality. Humans are the only animals that appear to be aware of their limited life span. Some researchers think that awareness of death influences experiences of anxiety from the time that a person is old enough to understand death.

Symptoms of anxiety

In order to understand the diagnosis and treatment of anxiety, it is helpful to have a basic understanding of its symptoms.

SOMATIC. The somatic or physical symptoms of anxiety include headaches, dizziness or lightheadedness, nausea and/or vomiting, diarrhea, tingling, pale complexion, sweating, numbness, difficulty in breathing, and sensations of tightness in the chest, neck, shoulders, or hands. These symptoms are produced by the hormonal, muscular, and cardiovascular reactions involved in the fight-or-flight reaction. Children and adolescents with generalized anxiety disorder show a high percentage of physical complaints.

BEHAVIORAL. Behavioral symptoms of anxiety include pacing, trembling, general restlessness, hyperventilation, pressured speech, hand wringing, or finger tapping.

COGNITIVE. Cognitive symptoms of anxiety include recurrent or obsessive thoughts, feelings of doom, morbid or fear-inducing thoughts or ideas, and confusion, or inability to concentrate.

EMOTIONAL. Feeling states associated with anxiety include tension or nervousness, feeling “hyper” or “keyed up,” and feelings of unreality, panic, or terror.

DEFENSE MECHANISMS. In psychoanalytic theory, the symptoms of anxiety in humans may arise from or activate a number of unconscious defense mechanisms. Because of these defenses, it is possible for a person to be anxious without being consciously aware of it or appearing anxious to others. These psychological defenses include:

• Repression. The person pushes anxious thoughts or ideas out of conscious awareness.
• Displacement. Anxiety from one source is attached to a different object or event. Phobias are an example of the mechanism of displacement in psychoanalytic theory.
• Rationalization. The person justifies the anxious feelings by saying that any normal person would feel anxious in their situation.
• Somatization. The anxiety emerges in the form of physical complaints and illnesses, such as recurrent headaches, stomach upsets, or muscle and joint pain.
• Delusion formation. The person converts anxious feelings into conspiracy theories or similar ideas without reality testing. Delusion formation can involve groups as well as individuals.

Other theorists attribute some drug addiction to the desire to relieve symptoms of anxiety. Most addictions, they argue, originate in the use of mood-altering substances or behaviors to “medicate” anxious feelings.

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