CHAPTER 1

What Is Anxiety?

Don’t worry about the world coming to an end today; it’s already tomorrow in Australia.

—Charles Schulz

LINDA HEARD THE CLOCK ticking as the second hand slowly lurched forward. She tried to slow her breathing—in, out, in, out—but she just couldn’t get enough air. Her heart pounded like it might burst out of her chest, and she could feel her sweat soaking through her dress. “Okay,” she told herself, “it’s just a job interview—not so scary.”

Avoiding eye contact with the other applicants in the waiting room, Linda stared at her résumé, but her eyes couldn’t focus. “I’ll never get this job,” she thought. “Why did I come? No way do I have as much experience as these other girls.”

She felt a sudden urge to urinate just as the receptionist called out, “Linda Fuller?”

Linda stood up quickly but got dizzy and had to sit back down.

“Are you Linda?”

She tried to answer, but her mouth was too dry.

“Well, you’re next,” the receptionist said impatiently. “Down the hall on the right.”

Linda got up more slowly this time and started walking down the hall, but she felt her throat closing up and she froze in fear. “If I don’t get out of here,” she thought, “I’m going to die.” She felt a wave of nausea coming up and bolted for the exit.

***

Anxiety is a normal human emotion that everyone feels from time to time, and it’s very common to feel a bit anxious before a job interview. In Linda’s case, however, her anxiety escalated so much that she had a panic attack, and that is relatively rare.

Most people experience anxiety as a state of unease or apprehension over an upcoming event or an uncertain outcome. It can manifest itself in various ways, and although it is usually an unpleasant feeling, most of us can either channel our anxiety into actions that dissipate the concern or accept that we can’t control the outcome. People who suffer from panic attacks and other anxiety disorders often misinterpret nervousness or stress as actual physical danger that must be avoided at all costs. And although many people think of fear and anxiety as the same thing, they are actually very different.

Fear is generally an emotional response to a real and imminent threat. It is characterized by a fight-or-flight response, where the person feeling fear either confronts the source or flees from it, and the fear usually dissipates as soon as the threat is gone. Anxiety, on the other hand, is worry and anticipation of a possible threat or conflict in the future and can linger or become chronic.

Today, we face few situations that call for a fight-or-flight response. Most of our day-in, day-out worries are more mundane, like whether traffic will make us late for an appointment or whether the boss will be in a bad mood today. In recent years, however, a growing sense of impending danger from terrorism, environmental concerns, political upheaval, and disease epidemics has crept into our consciousness and left many feeling persistently apprehensive. Instead of focusing chiefly on achieving their best, many people now worry more about preventing the worst. Although this type of ongoing, low-level anxiety can be a bothersome distraction, most of us don’t allow these worries to erode our overall sense of well-being.

When we say we feel anxious, we are usually describing feelings of nervousness, worry, excessive concern, or apprehension. But some people, such as Linda at the job interview, experience anxiety so intensely that it causes physical and emotional symptoms that disrupt their lives. These people suffer from an anxiety disorder—their worries and fears have gotten so severe that they are unable to live normally.

The physical and emotional symptoms that characterize anxiety disorders can become so excruciating that left untreated, the patient’s life can become severely restricted and intolerable. Germophobes can become too paranoid to dine out, fear of panic attacks can keep people from going out in public, and anxiety-induced chest pains can be mistaken for life-threatening heart attacks.

Linda’s inability to deal with her anxiety made her physically ill and sabotaged her job interview. As her anticipation of rejection overwhelmed her, it manifested itself in acute physical symptoms. When her anxiety escalated, her thinking became distorted to the point that she felt she was going to die. People with extreme anxiety disorders can often feel like they are in a life-or-death situation when they are not.

Linda is among millions of people of all ages and backgrounds that struggle with anxiety disorders and often suffer unnecessarily—usually because they assume that nothing can be done to relieve their symptoms. This is simply not true. Anxiety disorders are highly treatable: several successful medical interventions, lifestyle strategies, and alternative therapies are available, yet currently, only about one out of every three sufferers receives proper treatment.

THE ANXIETY EPIDEMIC

Anxiety disorders are the most frequent of all psychiatric diseases. As the problems in our world seem to worsen every year, there has been a corresponding increase in the prevalence of anxiety disorders. In 1980, only 4 percent of Americans were thought to be suffering from anxiety, but today, that number has risen to 18 percent. Approximately one in five Americans age eighteen or older, or about forty million people, suffer from them. In comparison, only one in ten of us suffers from a mood disorder like depression, the second most common type of psychiatric problem.

The economic burden that anxiety places on society is considerable, totaling $42 billion each year, or a third of our entire mental health bill. About half of these health care expenses go to the assessment and treatment of medical symptoms and consequences of anxiety.

If you have an anxiety disorder, you are five times more likely to go to the doctor or six times more likely to be hospitalized for a psychiatric condition than someone without an anxiety disorder. Severe symptoms of anxiety can lead to other conditions like ulcers and substance abuse, which take their own physical, emotional, and financial toll on sufferers. Chronic anxiety disorders also disrupt marriages and other relationships and have adverse effects on a person’s education, job, and social life.

WHY AM I SO ANXIOUS?

Sometimes we feel anxiety and are not sure why. No single cause can explain the many forms of anxiety, but past experiences and genetic predispositions will determine each individual’s risk of developing a disorder. These factors have an impact on our brain chemistry, personality style, and tolerance for stress, which ultimately determine who will develop normal, mild anxiety symptoms or a full-blown disorder.

If one of your parents was high strung or suffered from an anxiety disorder, your own risk increases. For the average person, genetic inheritance accounts for about 30 to 40 percent of the risk.

In addition to passing on their DNA or genetic material to us, our parents’ behavior impacts our ability to cope and adapt to fearful situations, beginning at a very young age. Whether our parents modeled healthy responses to stress or taught us their own anxious reactions will shape our own coping ability and temperament. A person who has a personality that is rigid, volatile, pessimistic, or insecure will likely have greater difficulty with anxiety than a more resilient, optimistic, and self-confident individual.

Physical illnesses and medication side effects can also lead to anxiety symptoms. For instance, patients with diabetes who take too much insulin will often experience an acute anxiety attack from a sudden drop in blood sugar.

Sometimes an anxiety disorder can be confused for a physical illness. In studies of patients who go to the emergency room complaining of chest pain and fearing cardiac disease, more than 40 percent of them are suffering from a panic disorder or panic attack rather than a heart problem. Also, heavy coffee drinkers are at risk of experiencing heart palpitations and other anxiety symptoms due to excess caffeine consumption.

If you are a woman, you are 60 percent more likely to suffer from an anxiety disorder than if you are a man. Your age will influence your risk as well. One of the upsides of getting older is that we tend to experience less anxiety. Young people live with greater peer pressure and increased worry about the future: building a career, finding a partner, having a family, and facing the unknown. As years pass, we gain more perspective on these concerns and they don’t seem as urgent or important. We also learn better ways to cope with our anxiety. It’s not surprising that the prevalence of anxiety in people ages eighteen to fifty-nine is about 30 percent but only 15 percent in people ages sixty and older.

It’s also true that as we get older, we experience different forms of anxiety. A majority of older people develop chronic physical illnesses, which can trigger considerable anxiety. As people age, they also worry more about their memory, and patients with Alzheimer’s disease and other dementias commonly suffer symptoms of anxiety.

THE ANXIOUS BRAIN

Several brain areas are involved in controlling our anxiety responses. The amygdala, a tiny region that resides beneath the temples of the forehead, serves to regulate our feelings of anxiety and fear. The amygdala interacts with another deeper brain region, the nucleus accumbens, and when this neural network becomes overstimulated, we experience anxiety and fear.

Anxious people often have hypersensitive amygdalae. When facing unfamiliar situations, they may experience exaggerated stress that results in physical symptoms (rapid heart rate, increased blood pressure) and amplified emotional responses.

The hippocampus, which resides near the amygdala, converts these exaggerated experiences into long-term memories. Over time, these memories can heighten one’s sensitivity to other similar situations that are benign and set off the amygdala’s inflated anxiety response unnecessarily.

Another brain region activated by anxiety is the frontal lobe, also called the “thinking brain.” This part of the brain processes uncomfortable emotions and attempts to put them into perspective. Sometimes heightened anxiety can overload the frontal lobe’s capacity to regulate emotional responses.

Chronic or even intermittent stress can cause wear and tear on the brain regions that control our responses. For example, research indicates that the hippocampus is actually smaller in people who were abused as children or were in military combat.

Regardless of the form of anxiety, when a person perceives danger, his or her brain triggers the body’s sympathetic nervous system, which responds by releasing adrenaline, cortisol, and other stress hormones into the blood. This then sets off the fight-or-flight response.

As anxiety escalates, it can lead to an imbalance of specific brain messengers—called neurotransmitters—such as gamma-aminobutyric acid (GABA), dopamine, and epinephrine. Various anxiety-related genes have been discovered that influence how our brain’s chemical messengers (e.g., adrenaline and serotonin) and hormones (e.g., cortisol) can alter our emotional states. For example, serotonin is essential to our well-being, and when it declines, it can lead to anxiety and even depression. In conditions such as panic disorder, the amount of the stress hormone cortisol in the brain rises, increasing feelings of fear and dread.

TECHNOLOGY ANXIETY

Advances in technology in recent years have made our lives more efficient and created simple and immediate ways to communicate with others. And although the emergence of the internet and twenty-four-hour news cycles helps keep us informed and connected, receiving a constant flow of information can serve to continually remind us of things that make us anxious. Thanks to our smartphones and other handheld devices, we receive moment-to-moment updates on current events that can often be stressful or even terrifying.

Social media outlets like Facebook, Instagram, and Snapchat have become a dominant presence in our lives and provide a conduit for sharing our experiences with others. For many anxious people, however, they contribute to an unrelenting form of peer pressure—a need to be better, happier, richer, and more successful than the others on our friends list.

These sites are distracting as well. Technology expert Linda Stone described the concept “continuous partial attention,” in which people constantly keep tabs on several things at once while never truly focusing on much of anything. When we bombard our brains with data, information overload can lead to anxiety.

PSYCHOLOGICAL VERSUS PHYSICAL ANXIETY

Most of us think of anxiety as an emotion, but anxiety symptoms and disorders can have prominent physical components. Your first clue that you are feeling anxious may be your racing pulse, pounding heart, or a sensation that you can’t catch your breath. Some people suffer an upset stomach or sweaty palms.

We all experience situational stress and worry, but these are usually transient states that get resolved. People who experience chronic stress or extreme worry for an extended time may be living in a persistent fight-or-flight state, which continually triggers the body to release increased amounts of the stress hormone cortisol. Persistently high cortisol levels can lead to a variety of physical symptoms ranging from difficulty swallowing to muscle aches, shortness of breath, and sweating. Cortisol also increases levels of blood sugar and fats, which are meant to fuel the body to take quick action under conditions of acute stress. Unfortunately, when stress or worry drag out or become chronic, the resulting physical changes can suppress and weaken the immune system, leading to infection and illness.

This overlap of physical and psychological symptoms of anxiety can be confusing to patients and doctors, especially when physical symptoms of anxiety are mistaken for a medical illness. A rapid heart rate caused by an oncoming panic attack may be construed as a life-threatening heart arrhythmia.

Other times a physical illness may be causing psychological symptoms. Poor concentration or irritability could be due to decreased oxygen to the brain from pneumonia or another infection. Some patients suffer from both an anxiety disorder and physical illness at the same time, which makes it even more challenging to figure out the true underlying source of anxiety symptoms.

THE DANGERS OF UNTREATED ANXIETY

There are a variety of reasons that one out of every three people suffering from an anxiety disorder never receives adequate treatment. Anxiety patients generally avoid stressful situations, and most patients find it stressful to see the doctor about their symptoms. A shortage of mental health professionals, difficulty diagnosing anxiety disorders, denial about the severity of symptoms, and the perception that nothing can be done to help also contribute to undertreatment. Many people play down the impact of mental symptoms on their health, but research has shown that untreated anxiety disorders can diminish a person’s ability to function even more than many medical conditions such arthritis, diabetes, and heart disease.

Clearly, not getting help can be dangerous to your health and well-being. Untreated anxiety disorders increase the risk of depression and even suicide. As anxiety-driven physical symptoms and illnesses worsen, the patient’s health care costs tend to rise—often due to frequent emergency room visits when panic attacks and physical symptoms overwhelm them.

Relationships suffer as well. Patients frequently feel misunderstood and become isolated from family and friends. Anxiety disorders can disrupt or ruin a patient’s professional life too. The symptoms distract the patient from completing tasks, increase their number of sick days, and can lead to significant financial losses.

The good news is that anxiety disorders can be effectively treated. The first step toward treatment is for patients to admit that their symptoms are disrupting their lives and to seek help. Whether a person is suffering from a full-blown anxiety disorder or less severe symptoms, determining the type of anxiety disorder will help clarify the most effective treatment for the condition.

ANXIETY SYMPTOMS CAN TRIGGER SUICIDAL THOUGHTS

Although most of us think of depression as the most likely trigger for suicidal thinking, people suffering from untreated anxiety disorders can also develop thoughts of suicide and act upon those thoughts. The recent tragic suicides of designer Kate Spade and celebrity chef Anthony Bourdain has brought greater awareness to the growing problem of suicide.

In the United States, suicide rates have risen by 25 percent during the last two decades. In 2016, there were almost forty-five thousand suicides in the United States, which is twice the number of deaths compared with homicides. Major risk factors for suicide include chronic depression, history of alcohol or substance abuse, access to lethal weapons, impulsivity, feelings of hopelessness, social isolation, and barriers to mental health treatment. Although suicidal individuals may not ask for help, they often do want it.

One of the greatest myths about suicide is that discussing the topic will plant the idea in someone’s mind. Stay alert to some of the warning signs of suicidal risk:

Anyone having thoughts of suicide should consult with a mental health professional. Help is also available through the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).

TAMING ANXIETY

Regardless of the type of anxiety symptoms or disorder you or your loved one may be experiencing, effective treatments and self-help strategies are available. Interventions vary depending on the specific disorder. For example, patients with panic disorder often benefit from both antidepressants and desensitization therapy. The antidepressants reduce the acute symptoms of panic, and the desensitization therapy helps patients overcome the phobias they may have developed to avoid the attacks. Many approaches, however, such as meditation, physical exercise, and psychotherapy can be useful for taming nearly all forms of anxiety.

Psychotherapy. Different forms of talk therapy can reduce anxiety symptoms and contribute to remission of disorders. By talking regularly with a mental health professional (psychiatrist, psychologist, social worker, or other counselor), patients are able to better understand their behaviors, emotions, and ideas that contribute to their symptoms and learn how to make positive changes. Cognitive behavioral therapy helps people identify and challenge negative patterns of thought about themselves and the world in order to alter unwanted behavior patterns. Supportive psychotherapy helps a person explore troubling issues and provides emotional support, while desensitization therapy exposes patients to their anxiety-provoking fears for brief periods in a supportive environment to increase their tolerance to those fears.

Medications. Antianxiety medicines, such as Ativan, Xanax, and other benzodiazepines, can reduce the acute psychological and physical symptoms of anxiety. Although they are usually the first medication choice for treating depression, antidepressant medications are also effective in treating many of the symptoms of obsessive-compulsive disorder and panic disorder.

Lifestyle strategies. Adopting and maintaining healthy behaviors can reduce anxiety symptoms. Regular physical exercise and a balanced diet not only improve mood and reduce symptoms; they also benefit memory and cognitive abilities. Relaxation methods and mindfulness techniques, such as meditation, hypnosis, yoga, tai chi, deep breathing, and other forms will lower stress levels and anxiety symptoms and even rewire neural circuits in the brain.

Other therapies. Various supplements (e.g., kava, valerian, St. John’s wort) and innovative treatments (eye movement desensitization and reprocessing [EMDR], neurofeedback, transmagnetic stimulation [TMS]) have been used to relieve anxiety. Some of these interventions show promise and are still under scientific investigation, while others have not yet been shown to be more effective than placebo but are still used by many people.