What is anxiety?

Anxiety is the feeling of worry and stress in response to an on-going situation. Whilst worry and stress are common and can be helpful in situations, such as heightening our senses and triggering our fight or flight responses, prolonged and uncontrollable anxiety can become detrimental by interfering with our daily lives.

How is anxiety diagnosed?

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), anxiety disorders can be further specified based on the source of worry, for example:

Generalised anxiety disorder

1. Excessive anxiety and worry, occurring frequently for at least 6 months with regard to a number of events or activities
2. The individual finds it difficult to control the worry
3. Symptoms including:
   • Restlessness
   • Easily fatigued
   • Difficulties with concentration
   • Irritability
   • Muscle tension
   • Sleep disturbance
4. Anxiety/worry causes clinically significant distress/impairment in social, occupational functioning
5. Symptoms are not attributable to other physiological effects of substance use or medical condition

Separation anxiety disorder

1. Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures

• Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters or death
• Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure
• Persistent reluctance or refusal to go out, be away from home, go to school, go to work, or elsewhere because of fear of separation
• Persistent and excessive fear or reluctance about being alone or without major attachment figures at home or in other settings
• Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure
• Repeated nightmares involving the theme of separation
• Repeated complaints of physical symptoms (e.g., headaches, stomach aches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated

1. The fear, anxiety, or avoidance is persistent, lasting at least 4 weeks in children and adolescents and typically 6 months or more in adults
2. The disturbance causes clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning
3. The disturbance is not better explained by another mental disorder, such as refusing to leave home because of excessive resistance to change in autism spectrum disorder; delusions or hallucinations concerning separation in psychotic disorders; refusal to go outside without a trusted companion in agoraphobia; worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder

Social anxiety disorder

1. Persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating
2. Exposure to the feared situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally pre-disposed Panic Attack
3. The person recognizes that this fear is unreasonable or excessive
4. The feared situations are avoided or else are endured with intense anxiety and distress
5. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia
6. The fear, anxiety, or avoidance is persistent, typically lasting 6 or more months
7. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., drugs, medications) or a general medical condition not better accounted for by another mental disorder

Panic disorder

1. At least one attack is followed by one month or more of the person fearing that they will have more attacks. This causes them to change their behaviour, which often includes avoiding situations that might induce an attack

• The attacks are not due to the direct physiological effects of a substance (such as drug use or a medication) or a general medical condition
• The attacks are not better accounted for by another mental disorder. These may include a social phobia or another specific phobia, obsessive-compulsive disorder, post-traumatic stress disorder, or separation anxiety disorder

1. Defining Panic Attacks

• Palpitations, pounding heart, or accelerated heart rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breathor smothering
• A feeling of choking
• Chest painor discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, lightheaded, or faint
• Feelings of unreality (derealization) or being detached from oneself (depersonalization)
• Fear of losing control or going crazy
• Fear of dying
• Numbness or tingling sensations (paresthesias)
• Chills or hot flushes
• Specific phobia (Animal phobias, natural environment phobias, blood-injection-injury phobias, situational phobias, other phobias)

1. Marked fear or anxiety about a specific object or situation (In children fear or anxiety may be expressed by crying, tantrums, freezing, or clinging)
2. The phobic object or situation almost always provokes immediate fear or anxiety
3. The phobic object or situation is avoided or endured with intense fear or anxiety
4. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context
5. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more
6. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
7. The disturbance is not better explained by symptoms of another mental disorder, including fear, anxiety, and avoidance of situations associated with panic-like symptoms or other incapacitating symptoms; objects or situations related to obsessions; reminders of traumatic events; separation from home or attachment figures; or social situations

What causes anxiety?

Anxiety is not caused by a single factor, but rather a combination of multiple factors. These include family history, personality factors, number of stressors in one’s daily life, substance use, other comorbid mental health disorders and physical health problems.

Twin studies found the heritability of anxiety disorders to be at an estimate of 30-50% (Shimada-Sugimoto, Otawa & Hettema, 2015). A personality trait that has been extensively studied in anxiety disorders is neuroticism. Individuals who score high on neuroticism in personality inventories display heightened negative emotions such as, anxiety, fear, worry, frustration, anger and many more (Sen, Burmeister & Ghosh, 2004); and are more likely to develop an anxiety disorder.

 

How can anxiety be treated?

Anxiety can be treated with either pharmacological or psychological interventions; or a combination of both. Common pharmacological interventions include antidepressants, beta-blockers and benzodiazepines. All these medications aim to alleviate anxiety symptoms through relaxation. Common side effects may include:

 

• Nausea
• Fatigue
• Constipation
• Vomiting
• Confusion
• Dizziness
• Tremors
• Drowsiness
• Headache
• Diarrhoea

 

Psychological interventions:

There are many psychological interventions that have strong scientific evidence supporting its efficacy in the treatment of anxiety disorders. Randomised clinical trials have demonstrated strong evidence for the use of CBT (Hofmann & Smits, 2008) and psychodynamic psychotherapy (Bressi et al., 2010) in treating anxiety disorders. Some research suggested that CBT may be slightly more effective than PPT in chronically anxious patients (Durham et al., 1994), however this may depend on specific symptoms such as anxiety, worry and depression (Leichsenring et al., 2009).

• Cognitive Behavioural Therapy (CBT)

CBT with anxiety disorders involves the client working with a therapist to identify and modify negative automatic thoughts and behaviour that leads to or maintains anxiety. An example of unhelpful thinking pattern is catastrophising thinking patterns, where the individual always believes in the worst outcome when thinking about the future. This can lead to an increase in anxiety and avoidance behaviour (a maladaptive coping mechanism). Thought challenging is a major component in CBT, and this involves:

1. Identification of negative automatic thoughts
2. Challenging the negative thoughts; and
3. Replacing negative thoughts with more realistic thoughts

Depending on the type of phobia or source of worry, clients will be taught skills to appropriately appraise bodily sensations (e.g., shortage of breaths, sweating, increased heart rate) and how to manage these symptoms (e.g., breathing and relaxation techniques). For example, in panic disorders, there tends to be a catastrophic misinterpretation of bodily sensations (e.g., “an increased heart rate means I’m about to have a heart attack”) and this can result in a panic attack. CBT can address this faulty thinking pattern through thought challenging, cognitive restructuring and exposure therapy. On the other hand, the behavioural component of CBT involves graded exposure to the feared scenarios/objects. The idea behind exposure therapy is to provide a safe space for the client to confront their fear, build confidence and practice the skills that they’ve learnt from CBT sessions to cope with their fear. This allows people to experience the rise and fall of fear responses (e.g., increased heart rate, sweating) without the feared consequences (e.g., a heart attack). The key feature in graded exposure is the idea of a step ladder, graded from levels 1 – 10, where exposure starts small and gradually working upwards. The client and the therapist will work together to identify what each step consists of. It is important that each step should present in itself as a challenge, and it is through the accomplishment of each step that the client would steadily build confidence to eventually face the feared situation/object in the final step. For example, in spider phobia:

 

10 – Handling the big spider for 10 minutes on their own

9 – Handling the big spider for 5 minutes with the therapist

8 – Touching the big spider (that’s being held by the therapist)

7 – Being in a room with a bigger spider

6 – Touching a small spider (that’s being held by the therapist)

5 – Looking at a small spider in the open

4 – Looking at a small spider in a container

3 – Looking at videos of a spider

2 – Looking at pictures of a spider

1 – Imagining a spider

 

Exposure therapy is also a good opportunity for therapists to address and eliminate any negative coping mechanisms, such as avoidance behaviour, that indirectly maintains the phobia.

• Acceptance and commitment therapy (ACT)

The main values of ACT are to train people into accepting that maladaptive thoughts and/or sensations can happen beyond one’s control that does not require an action; and to choose a direction in life that one values and commit to taking actions towards achieving it. In the treatment of anxiety disorders, people are taught to come to terms with their anxiety-related discomfort by accepting them as sensations the way they are without the extensive interpretation of what it means. Adaptive behaviours and skills can be taught to people so that the act of engaging in these behaviours allows people to move closer to their life direction. Therefore, in ACT, the former provides relief while the latter encourages change.

• Positive Psychology (PP)

Positive psychology is a newly emerging branch of psychology that focuses on helping people flourish in life by empowering their strengths and positive traits. There is no one single way to implement positive psychology interventions, rather, there are several positive psychology programs that can be used in the treatment of anxiety disorders and these include:

• Increasing positive emotions/enhancing pleasure
  • Sharing with others: actively share positive emotions and engage with others to bring deliberate attention to positive emotions
  • Memory building: re-experience positive experiences with others by taking a mental photograph or a physical souvenir
  • Practicing gratitude: practice expressing a deep appreciation for someone/something
  • Self-congratulation: be proud of you and your achievements!
  • Sharpening perception: when experiencing pleasure, try to focus by tuning out other distractors
  • Absorption: allow yourself to be in a state of merely sensing the world and not thinking
• Enhancing coping skills and building resilience
  • Acceptance and Commitment Therapy (ACT)
  • Identifying and using your strengths: consider what your personal strengths are and how they can be applied across various settings
  • Practicing mindfulness: mindfulness is about being in the present moment and being focused. Mindfulness can be practiced through meditation or mindfulness-based therapies
• Finding meaning
  • Keep a gratitude diary/journal: by keeping a simple journal about things that you’re grateful for, this helps reminds us of all the positives in life and prevent rumination of negative events
  • Thank a mentor: write a letter of thanks to someone who you feel grateful for and read it to them
  • Learn to forgive: learning to let go of the past by writing a letter to the other person
  • Weigh up your life: consistent reflection of your life can be helpful in identifying where you’re at now in relation to your major life goals
  • Perform small acts of kindness: keeping a record of all the little acts of kindness/giving. These does not have to be grand gestures; all the little things count!
  • Write your future diary: keeping a future diary can help you keep track of your current progress and your ideal future. This can help you identify and solve any obstacles of problems in advance
• Building social support
  • Nurture relationships: life can get busy sometimes but don’t forget to take some time out to spend with friends and family. People who have a strong interpersonal relationship with others experience higher satisfaction with life

 

 

References:

Bandelow, B., Reitt, M., Röver, C., Michaelis, S., Görlich, Y., & Wedekind, D. (2015). Efficacy of treatments for anxiety disorders: a meta-analysis. International Clinical Psychopharmacology, 30(4), 183-192.

Bressi, C., Porcellana, M., Marinaccio, P. M., Nocito, E. P., & Magri, L. (2010). Short-term psychodynamic psychotherapy versus treatment as usual for depressive and anxiety disorders: a randomized clinical trial of efficacy. The Journal of nervous and mental disease, 198(9), 647-652.

Durham, R. C., Murphy, T., Allan, T., Richard, K., Treliving, L. R., & Fenton, G. W. (1994). Cognitive therapy, analytic psychotherapy and anxiety management training for generalised anxiety disorder. The British Journal of Psychiatry, 165(3), 315-323.

Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. The Journal of clinical psychiatry, 69(4), 621.

Jones, E. E., & Pulos, S. M. (1993). Comparing the process in psychodynamic and cognitive-behavioral therapies. Journal of consulting and clinical psychology, 61(2), 306.

Leichsenring D Sc, F., Salzer, S., Jaeger, U., Kächele, H., Kreische, R., Leweke, F., ... & Leibing D Sc, E. (2009). Short-term psychodynamic psychotherapy and cognitive-behavioral therapy in generalized anxiety disorder: a randomized, controlled trial. American Journal of Psychiatry, 166(8), 875-881.

Sen, S., Burmeister, M., & Ghosh, D. (2004). Meta‐analysis of the association between a serotonin transporter promoter polymorphism (5‐HTTLPR) and anxiety‐related personality traits. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics, 127(1), 85-89.

Shimada‐Sugimoto, M., Otowa, T., & Hettema, J. M. (2015). Genetics of anxiety disorders: genetic epidemiological and molecular studies in humans. Psychiatry and clinical neurosciences, 69(7), 388-401.