Anxiety
Anxiety is a mental health condition involving anxiousness, fear, and worry, often accompanied by physical signs such as tension, sweating, and increased pulse rate. Anxiety can take many forms and can often overall be characterized by a feeling of unease in the body or in the mind.
In 2018, 18% of the US population was affected by an anxiety disorder of some kind
Anxiety currently affects approximately 40 million Americans, and general symptoms are on the rise.
Anxiety impacts physical health and wellbeing. In addition to increasing the risk of insomnia, avoidance behaviors, and chronic stress, it has been associated with an overall increase in mortality.
Symptoms and Causes
What are some of the different ways that anxiety shows up in people?
Anxiety presents in a variety of ways. Some people experience anxious thoughts, excessive worry, panic attacks, social anxiety, or specific phobias.
OCD symptoms, such as intrusive thoughts or compulsive behaviors, and PTSD symptoms—such as flashbacks, hyper-arousal, and avoidance behaviors—are also forms of anxiety.
Furthermore, some people’s anxiety appears in more body-based, somatic ways, such as digestive issues, migraines, headaches, fatigue, muscle tension, dizziness, lightheadedness, tunnel vision, or rapid heart rate.
What is the underlying biology of anxiety?
Anxiety has a variety of potential causes. For some, ongoing symptoms result from a dysregulation of the stress response, either from prolonged stress or a predisposition to drop into a “fight or flight” reaction too readily. In these cases, the hypothalamic pituitary adrenal axis is involved in excessive or inappropriate release of adrenaline and cortisol.
For others, the body seems to have a deficiency or dysregulation of the neurotransmitter GABA (gamma amino butyric acid). In these cases, the brain simply can’t feel calm or relaxed. Potential causes of GABA dysregulation are an imbalance of bacteria in the digestive tract (it seems that gut bacteria play a role in the synthesis of GABA), chronic stress, and a consequence of consuming GABA-modulating agents, such as benzodiazepines and alcohol.
Finally, serotonin signaling can play a role in anxiety. In these cases, anxiety typically coexists with depression. Potential underlying causes of serotonin dysregulation include inflammation, chronic stress, chronic sleep deprivation, and nutritional deficiencies.
When does anxiety typically start for people?
Anxiety can begin at various phases of life, from childhood—where it more typically manifests with stomach aches or headaches—to puberty and adulthood.
If someone experiences an onset of anxiety in adulthood that’s uncharacteristic for their temperament, this can be an indication that there’s a physical basis for the anxiety, such as a medication side effect, inflammation, dysbiosis (microbial imbalance), or nutrient deficiency. It may also be a reflection that the person is experiencing an excessive amount of stress.
Types of Anxiety
Why are some people more prone to being anxious?
This is due to a combination of genetic vulnerability and epigenetic changes, stress, nutrition, history of trauma, and current lifestyle factors. There are also subtler factors, such as disconnection from nature and from a sense of purpose in life.
Are panic attacks the same as anxiety?
Panic attacks are a subset of anxiety, where a person experiences discrete episodes of intense anxiety that come on quickly without apparent cause, lasting about 10-30 minutes.
They are characterized by symptoms such as a feeling of dizziness or lightheadedness, rapid heart rate, palpitations, sweating, trembling, shortness of breath, tunnel vision, a feeling of unreality or detachment, and a sense of impending doom or that you’re going to die or go crazy.
People can develop a fear of having another panic attack, which can cause them to want to avoid returning to situations that have caused panic in the past.
What about social anxiety?
Social anxiety is another subset of anxiety, where everyday social interactions illicit significant self-consciousness, embarrassment, and fear of being scrutinized or judged by others.
Distinct from the normal amount of anxiety that most people feel with public speaking or meeting new people, social anxiety disorder involves fear and avoidance behaviors that interfere with activities of daily life, such as work, school, or daily routine.
Diagnosis and Treatment
How is anxiety typically diagnosed?
In diagnosing anxiety, it’s important to make sure that medications, substances, and/or underlying medical conditions (such as impaired thyroid function) are not causing the symptoms.
A thorough history and detailed questioning is important, and sometimes physical examination and/or testing is needed.
There are several validated questionnaires that are widely used for anxiety screening and tracking, and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association serves as the gold standard for diagnostic criteria.
How is anxiety generally treated?
There are a variety of ways to treat anxiety, from cognitive behavioral therapy (CBT) to traditional psychotherapy to medication to a more holistic or mind-body approach (which might include yoga, meditation, acupuncture, breathing exercises, and dietary changes). There’s even an approach to treating anxiety that involves a functional medicine exploration of potential root causes, such as micronutrient deficiencies or a gut flora imbalance.
Medications
Are medications effective?
For some people, medications can be beneficial. There are two main categories of medications used to treat anxiety.
The SSRI/SNRI medications, such as Lexapro, Prozac, and Effexor, work by modulating serotonin activity in the brain. They take about six-to-eight weeks to work (defined as at least 25% improvement), and can lower overall anxiety levels.
Between one-third and one-half of patients on a modern antidepressant do not achieve sustained remission from anxiety. For some people, these antidepressants can exacerbate anxiety in the short term before they begin to work. They can also be very difficult to get off of, causing a worsening of anxiety in that process.
The benzodiazepine medications, such as Xanax, Klonopin and Ativan, are only approved for panic attacks, but many prescribers and patients lean on them as daily medication for anxiety. These work by increasing levels of a particular chemical messenger in the brain called GABA, and they provide instant relief for many people.
However, they can exacerbate anxiety, panic, and insomnia in the long-term; are associated with a shortened life span; and can contribute directly to the development of depression and dementia.
There are a few other medications used to treat anxiety, such as gabapentin (neurontin), buspirone (buspar), and beta blockers (such as propranolol). These work by a variety of different mechanisms.
Other Interventions
What have you found to be the most helpful interventions for people who have anxiety?
For just about anyone with anxiety, I suggest spending some time focusing on mind-body practices, such as yoga, meditation, breathing exercises, pranayama, qi gong, and acupuncture.
Additionally, for most people, I begin by recommending that they decrease (or eliminate) caffeine gradually. I also recommend making dietary adjustments to stabilize blood sugar, since swings in blood sugar can induce or exacerbate anxiety symptoms.
After this, I usually focus on gut healing for anyone with digestive disturbances. This might involve using herbal antimicrobials to kill off bad bacteria, repopulating the gut with beneficial bacteria (using probiotics, fermented foods, and starchy tubers), and healing the gut lining with substances like glutamine, collagen, ghee, and bone broth. It's also essential to remove potential dietary intolerances. This is different for everybody, but might include eliminating gluten or dairy.
Does counseling work? Are certain approaches more effective than others?
Counseling and psychotherapy play a very important role in the treatment of anxiety disorders. Cognitive Behavioral Therapy (CBT), which involves addressing cognitive distortions and doing homework assignments like facing feared situations, is the most validated approach and is considered as effective as medication.
Other forms of therapy can be effective as well, including somatic experiencing, eye movement desensitization and reprocessing (EMDR), psychodynamic psychotherapy, and acceptance and commitment therapy (ACT).
Are there any promising new treatments or approaches? What research are you most excited about?
There are always new and interesting approaches to mental health. I’m personally most excited about an increased understanding of the physical basis for anxiety, such as the role that gut health plays, better detection of thyroid disorders and other autoimmune conditions, awareness of micronutrient deficiencies such as B12 deficiency, and a growing appreciation for the role that diet plays in anxiety.
I’m also excited that more and more people are exploring mind-body approaches, such as yoga, meditation, breathing exercises, and acupuncture. There are particular meditation techniques, such as Heartmath, that are especially promising as approaches for anxiety.
Prevention
Why does the gut matter for anxiety?
More serotonin is manufactured in the gut than in the brain. When our gut is healthy, we are absorbing the nutrients we need to build the neurotransmitters (such as GABA) that are necessary for a stable mood and a sense of calm.
When our gut flora has been compromised, such as after a course of antibiotics, we can begin to develop dysbiosis, or an imbalance of gut bacteria. This can adversely impact our micronutrient and neurotransmitter levels.
A final aspect of gut health that affects anxiety is the competence of the gut lining. If there’s intestinal permeability or “leaky gut,” contents of the digestive tract can “leak” into the bloodstream, creating systemic inflammation. This inflammation impacts the brain and contributes to anxiety.
What about diet?
The most fundamental impact diet has is that it provides the nutritional building blocks for neurotransmitters and receptors in the brain. We need these building blocks in order to have an optimally functioning brain. Conversely, a diet low in nutrients compromises brain health by not providing the necessary building blocks.
Systemic inflammation can create an inflammatory state in the brain. This can lead to a state of unease, which can manifest as anxiety. Inflammatory foods vary on an individual basis, but some common culprits include gluten, dairy, sugar, and grains. People can also have allergies to foods like tree nuts, eggs, soy, tomatoes, and shellfish.
What’s the role of sleep/sleep deprivation and anxiety?
Sleep deprivation contributes to anxiety, and consistently getting adequate quantity and quality of sleep is one of the most effective treatments. For some people, the necessary change is to simply prioritize sleep. Frequently, someone may have difficulty falling and staying asleep in spite of making it a priority.
Can resilience be learned?
Resilience is a key concept with anxiety, as not everyone who experiences severe or prolonged stress develops anxiety or other mood disorders. The good news is that resilience can absolutely be learned. A lot of the most important research on this topic comes out of positive psychology labs like that of Martin Seligman.
Seligman’s approach involves reframing how one experiences life by changing one’s exploratory style from internal to external, from global to specific, and from permanent to impermanent. His research has also demonstrated that an internal locus of control (i.e. feeling a sense of autonomy and control over the events of our lives) improves resilience.
I also help my patients build their mental resilience by cultivating physiological resilience. This involves eating real food, keeping blood sugar stable, reducing caffeine, going to bed early and getting enough sleep, and practicing daily mindfulness meditation.
What’s the research about connecting anxiety to a sense of loneliness or having a lack of purpose?
Though there isn't much evidence to support this, it makes sense that a diminished sense of community, meaning, and purpose in life can contribute to anxiety. For anyone suffering from anxiety, it’s important to recognize the role that these play, and to make a priority of investing in these aspects of life.
Related Topics
Can anxiety cause chest pain? What does it feel like and how long does it last?
What are some ways to deal with anxiety at work?
What’s the difference between an anxiety attack versus a panic attack?
Can anxiety cause dizziness, nausea, or blurred vision?
Useful Links
Diagnosis and Management of Anxiety and Panic (American Family Physician)
Anxiety Resources (Anxiety and Depression Association of America)
Tips to Manage Anxiety and Stress (Anxiety and Depression Association of America)
Connect with our physicians
Jamila Schwartz, MD and Natalie Albanese, MD are both members of the Galileo Clinical Team. Connect with one of our physicians about Anxiety or any of the many other conditions we treat.