Our understanding of anxiety disorders is shaped by multiple psychological perspectives. Researchers are finding that both genetic and environmental factors contribute to the risk of developing an anxiety disorder. Although the risk factors for each type of anxiety disorder can vary, some general risk factors for all types of anxiety disorders include

• temperamental traits of shyness or behavioral inhibition in childhood;
• exposure to stressful and negative life or environmental events in early childhood or adulthood;
• a history of anxiety or other mental illnesses in biological relatives; and
• some physical health conditions, such as thyroid problems, heart arrhythmias, or caffeine or other substances/medications, can produce or aggravate anxiety symptoms; a physical health examination is helpful in the evaluation of a possible anxiety disorder.

The Biological Perspective

The biological perspective seeks to understand the neurological and biological connections to anxiety. As mentioned above, some physical conditions can lead to anxiety. Researchers have concluded that several specific neurotransmitters are also connected with anxiety: gamma-aminobutyric acid (GABA), serotonin, and norepinephrine (noradrenalin).

When the balance of gamma-aminobutyric acid (GABA) is disrupted in the body, there is a correlated change in anxiety levels. Because of this, benzodiazepines, drugs that exert their effect through gamma-aminobutyric acid (GABA) receptors, are used to help people suffering from acute anxiety.

Serotonin is greatly important in anxiety. It is a monoamine neurotransmitter involved in controlling a wide range of behaviors by affecting the neural system, including emotions connected with fear and anxiety. Knockout studies on animals (called that because a certain receptor on the genetic code is knocked out) have shown that animals that have had their serotonin re-uptake transporters knocked out show abnormal responses to fear and anxiety in a number of behavioral conflict tests. These responses confirm the role of serotonin in modulating anxiety. Animals that had their serotonin receptor knocked out showed an increased heart rate and anxiety in a large variety of tasks such as eating and locomotion.

The best proof of the function of the serotonergic system in fear and anxiety is the pharmacological evidence. Drugs that change the function of serotonin have beneficial effects on various forms of anxiety. The best pharmacological treatment of anxiety is serotonin re-uptake inhibitors that allow greater levels of serotonin to accumulate and in that way help in treatment of anxiety.

Norepinephrine is also an important neurotransmitter in anxiety. Neurons which carry Norepinephrine rise from the locus coereuleus (LC), and these are also a center associated with warnings or alarms. The locus coereuleus (LC) secretes directly into the brain causing an immediate response. Increased levels of norepinephrine cause higher levels of anxiety. In pharmacology, norepinephrine blockers lower the levels of norepinephrine and do the same to a patient as do serotonin re-uptake blockers. Among adults, agents that alter noradrenergic functioning are powerful anxiolytics. Similarly, agents, such as yohimbine, that increase firing of the locus coeruleus (LC) are potent anxiogenic compounds.^[1]

Due to these connections between anxiety and neurotransmitters, medication is commonly used to treat anxiety. In terms of treating anxiety with medication, it is important to note medication is one option of treatment and not always a one-stop treatment plan. Anti-anxiety medications are not cures for anxiety disorders, but they can help manage some of the symptoms. Medications (anti-anxiety drugs and antidepressants) have been found to be beneficial for disorders other than specific phobia, but relapse rates are high once medications are stopped (Heimberg et al., 1998; Hollon et al., 2005), and some classes of medications (minor tranquilizers or benzodiazepines) can be habit forming.

Anti-Anxiety Drugs

Benzodiazepines

Anti-anxiety medications help reduce the symptoms of anxiety, such as panic attacks, or extreme fear and worry. The most common anti-anxiety medications are called benzodiazepines (such as Valium and Xanax). Benzodiazepines can treat generalized anxiety disorder and are known to be fast-acting and have a calming effect. In the case of panic disorder or social anxiety disorder, benzodiazepines are usually second-line treatments, behind SSRIs or other antidepressants.

Benzodiazepines are effective in relieving anxiety and take effect more quickly than the antidepressant medications (or buspirone) often prescribed for anxiety. However, people can build up a tolerance to benzodiazepines if they are taken over a long period of time and may need higher and higher doses to get the same effect. Some people may even become dependent on them. To avoid these problems, doctors usually prescribe benzodiazepines for short periods, a practice that is especially helpful for older adults, people who have substance abuse problems, and people who become dependent on medication easily. If people suddenly stop taking benzodiazepines, they may have withdrawal symptoms or their anxiety may return. Therefore, benzodiazepines should be tapered off slowly.

Like other medications, anti-anxiety medications may cause side effects. Some of these side effects and risks are serious. The most common side effects for benzodiazepines are drowsiness and dizziness. Other possible side effects include

• nausea,
• blurred vision,
• headache,
• confusion,
• tiredness, and
• nightmares.

SSRIs and SNRIs

Anti-depressant medications such as selective serotonin reuptake inhibitors (SSRIs, like Prozac and Zoloft) and serotonin-norepinephrine reuptake inhibitors (SNRIs, like Effexor), are also commonly used to treat generalized anxiety disorder and other anxiety disorders, such as panic disorder. These interact with serotonin in the brain and can help to reduce worry and elevate mood. Anti-depressants are safer than benzodiazepines for long-term use.

Benzodiazepines used to treat anxiety disorders include the following: clonazepam, alprazolam, and lorazepam. Short half-life (or short-acting) benzodiazepines (such as lorazepam) are used to treat the short-term symptoms of anxiety. Beta-blockers also treat the short-term symptoms.

Beta-Blockers

Beta-blockers (like Propranolol) help manage physical symptoms of anxiety, such as trembling, rapid heartbeat, and sweating, that people with phobias experience in difficult situations. Beta-blockers block the effects of epinephrine and reduce heart rate and blood pressure. Taking beta-blockers for a short period of time can help a person keep physical symptoms under control and can be used as needed to reduce acute anxiety.

Common side effects of beta-blockers include

• fatigue,
• cold hands,
• dizziness or light-headedness, and
• weakness.

Beta-blockers generally are not recommended for people with asthma or diabetes because they may worsen symptoms related to both conditions.

Busiprone

Buspirone (which is unrelated to benzodiazepines) is sometimes used for the long-term treatment of chronic anxiety. In contrast to benzodiazepines, buspirone must be taken every day for a few weeks to reach its full effect. It is not useful on an as-needed basis.

Possible side effects from buspirone include

• dizziness,
• headaches,
• nausea,
• nervousness,
• lightheadedness,
• excitement, and
• trouble sleeping.

Biofeedback

Biofeedback is a technique that can be used to track and monitor physiological changes in the body in order to learn to control them. During biofeedback, a person may be connected to sensors to monitor heart rate, temperature, and other biological changes in order to practice controlling their reactions to various situations.

Cognitive and Behavioral Perspectives

Because anxiety disorders are connected to the way people perceive situations, cognitive therapies are particularly effective in thinking about and treating anxiety disorders. Some anxiety disorders, such as phobias, also stem from learned experiences, such as traumatic events. Cognitive theories suggest that anxiety disorders develop through thought patterns that overestimate threats to safety, therefore anxiety is caused by cognitive misinterpretations and can be treated by developing strategies to combat these thoughts. Therapies include cognitive behavioral therapy, acceptance and commitment therapy, and intolerance of uncertainty therapy. Behavioral theories contend that anxiety disorders are mostly caused by conditioning, by modeling, or through experiences triggering their development, such as in specific phobias. Behavioral therapies often work in conjunction with cognitive therapies (such as in CBT), but they may also include behavior therapy, exposure treatment, systematic desensitization, and flooding.

Cognitive-Behavioral Therapy

CBT is an example of one type of psychotherapy that can help people with anxiety disorders. CBT teaches people different ways of thinking, behaving, and reacting to anxiety-producing and fearful objects and situations.

CBT has three phases: education, application, and relapse prevention. In the education phase, the individual is informed on the different effects anxiety can have physically and more importantly mentally. Understanding and being able to recognize their reactions will help the person to manage and eventually reduce their overall response.

CBT can also help people learn and practice social skills, which is vital for treating social anxiety disorder. CBT can be conducted individually or with a group of people who have similar difficulties. Often “homework” is assigned for participants to complete between sessions.

Exposure-based CBTs are effective psychosocial treatments for anxiety disorders, and many show greater treatment effects than medication in the long term (Barlow, Allen, & Basden, 2007; Barlow, Gorman, Shear, & Woods, 2000). In CBT, patients are taught skills to help identify and change problematic thought processes, beliefs, and behaviors that tend to worsen symptoms of anxiety, and practice applying these skills to real-life situations through exposure exercises. Patients learn how the automatic appraisals or thoughts they have about a situation affect both how they feel and how they behave. Similarly, patients learn how engaging in certain behaviors, such as avoiding situations, tends to strengthen the belief that the situation is something to be feared. A key aspect of CBT is exposure exercises, in which the patient learns to gradually approach situations they find fearful or distressing, in order to challenge their beliefs and learn new, less fearful associations about these situations.

Typically 50–80% of patients receiving drugs or CBT will show a good initial response, with the effect of CBT more durable. Newer developments in the treatment of anxiety disorders are focusing on novel interventions, such as the use of certain medications to enhance learning during CBT (Otto et al., 2010), and transdiagnostic treatments targeting core, underlying vulnerabilities (Barlow et al., 2011). As we advance our understanding of anxiety and related disorders, so too will our treatments advance, with the hopes that for the many people suffering from these disorders, anxiety can once again become something useful and adaptive, rather than something debilitating.

Among the cognitive-behavioral orientated psychotherapies the two main treatments are cognitive behavioral therapy and acceptance and commitment therapy (ACT). Intolerance of uncertainty therapy and motivational interviewing are two new treatments for GAD that are used as either stand-alone treatments or additional strategies that may enhance CBT.

Acceptance and Commitment Therapy

Acceptance and commitment therapy (ACT) is a behavioral treatment based on acceptance-based models. ACT is designed with the purpose to target three therapeutic goals:

• Accept emotions—reduce the use of avoiding strategies intended to avoid feelings, thoughts, memories, and sensations;
• Choose goals and directions—committing to these plans will decrease a person’s literal response to their thoughts (e.g., understanding that thinking “I’m hopeless” does not mean that the person’s life is truly hopeless), and
• Take action—increase the person’s ability to keep commitments to changing their behaviors.

ACT’s goals are attained by switching the person’s attempt to control events to working towards changing their behavior and focusing on valued directions and goals in their lives as well as committing to behaviors that help the individual accomplish those personal goals. ACT psychological therapy teaches mindfulness (paying attention on purpose, in the present, and in a non-judgmental manner) and acceptance (openness and willingness to sustain contact) skills for responding to uncontrollable events and therefore manifesting behaviors that enact personal values.

Intolerance of Uncertainty Therapy

Intolerance of uncertainty therapy (IUT) refers to the idea that those with anxiety often experience consistent negative reactions to uncertain and ambiguous events regardless of their likelihood of occurrence. Central to the idea of intolerance of uncertainty is that someone with a high level of intolerance to uncertainty will feel that a new or uncertain situation is stressful and threatening. IUT focuses on helping patients in developing the ability to tolerate, cope with, and accept uncertainty in their life in order to reduce anxiety.

IUT is based on the psychological components of psychoeducation, awareness of worry, problem-solving training, re-evaluation of the usefulness of worry, imagining virtual exposure, recognition of uncertainty, and behavioral exposure. Past research has shown support for the efficacy of this therapy with GAD patients with continued improvements in follow-up periods.^[2]

The Humanistic Perspective

According to the humanistic perspective, anxiety may develop if people do not see themselves honestly or do not practice self-acceptance. In this model, client-centered therapy is encouraged to help patients accept themselves and not be so self-judgemental. One humanistic type of treatment for anxiety is motivational interviewing.

Motivational Interviewing

A promising innovative approach to improving recovery rates for the treatment of GAD is to combine CBT with motivational interviewing (MI). Motivational interviewing (MI) is a strategy centered on the patient that aims to increase intrinsic motivation and decrease ambivalence about change due to the treatment. Motivational interviewing (MI) focuses on expressing empathy, encouraging self-efficacy, and heightening the dissonance between behaviors that are not desired and values that are not consistent with those behaviors.

Motivational interviewing (MI) is based on asking open-ended questions and listening carefully and reflectively to patients’ answers, eliciting “change talk,” and talking with patients about the pros and cons of change. Some studies have shown the combination of CBT with MI to be more effective than CBT alone.^[3]

While there are as many differences in technique, the underlying spirit of the method remains the same and can be characterized in a few key points:

• Motivation to change is elicited from the client and is not imposed from outside forces.
• It is the client’s task, not the counselor’s, to articulate and resolve the client’s ambivalence.
• Direct persuasion is not an effective method for resolving ambivalence.
• The counseling style is generally quiet and elicits information from the client.
• The counselor is directive, in that they help the client to examine and resolve ambivalence.
• Readiness to change is not a trait of the client, but a fluctuating result of interpersonal interaction.
• The therapeutic relationship resembles a partnership or companionship.

The Sociocultural Perspective

Globally, in 2010, approximately 273 million (4.5% of the population) had an anxiety disorder. It is more common in females (5.2%) than males (2.8%).

In Europe, Africa, and Asia, lifetime rates of anxiety disorders are between 9 and 16%, and yearly rates are between 4 and 7%. In the United States, the lifetime prevalence of anxiety disorders is about 29% and between 11 and 18% of adults have the condition in a given year. This difference is affected by the range of ways in which different cultures interpret anxiety symptoms and what they consider to be normative behavior. In general, anxiety disorders represent the most prevalent psychiatric condition in the United States, outside of substance use disorder.

Cultural Factors and Anxiety

Cultural factors that have been related to social anxiety disorder include a society’s attitude towards shyness and avoidance, affecting the ability to form relationships or access employment or education, and shame. One study found that the effects of parenting are different depending on the culture: American children appear more likely to develop social anxiety disorder if their parents emphasize the importance of others’ opinions and use shame as a disciplinary strategy (Leung et al., 1994), but this association was not found for Chinese/Chinese-American children. In China, research has indicated that shy-inhibited children are more accepted than their peers and more likely to be considered for leadership and considered competent, in contrast to the findings in Western countries. Research indicates that Asian cultures have lower rates of social anxiety when compared with samples from the United States or Russia.^[4]

Problems in developing social skills, or social fluency, may be a cause of some social anxiety disorder, through either inability or lack of confidence to interact socially and gain positive reactions and acceptance from others. The studies have been mixed, however, with some studies not finding significant problems in social skills while others have. What does seem clear is that the socially anxious perceive their own social skills to be low. It may be that the increasing need for sophisticated social skills in forming relationships or careers, and an emphasis on assertiveness and competitiveness, is making social anxiety problems more common, at least among the middle class. An interpersonal or media emphasis on “normal” or “attractive” personal characteristics has also been argued to fuel perfectionism and feelings of inferiority or insecurity regarding negative evaluation from others. The need for social acceptance or social standing has been elaborated in other lines of research relating to social anxiety.

In contrast to the individualistic views of the Western culture, which emphasize individual thought, achievement, and well-being, Eastern cultures operate on collectivism, which focuses on the group and the interdependency of its members rather than any one person. The collectivism view of the self is that it can only be understood through one’s social relationships and affiliations. These relationships and affiliations make up a network where the nuclear family shares the closest bonds, followed by the extended family and close friends.

Although the collectivism of Eastern cultures creates a strong support system for the group, it produces many stressors that can lead to depression and anxiety. For example, the overwhelming focus on the group rather than the individual can result in feelings of a lost individual identity and sense of self. Moreover, many rules and social norms exist in collective cultures than in individual cultures to maintain the harmony of the group. This combined with the cohesiveness of the group can make social mistakes very public and result in feelings of shame and embarrassment by the individual at fault. Research indicates that these feelings are associated with social anxiety within collectivistic societies. A bigger mistake that affects an individual’s reputation or results in the loss of honor has more severe consequences because of the stress associated with maintaining that honor. Taijin kyofusho, a Japanese term for those who are embarrassed about their appearance or bodies or are fearful of displeasing others, is a possible culture-specific expression of social anxiety.^[5]

Race and Anxiety

Racial trauma or race-based traumatic stress, is the cumulative effects of racism on an individual’s mental and physical health. It has been linked to feelings of anxiety, depression, and suicidal ideation, as well as other physical health issues.

Racial trauma is not included in the most recent edition of the Diagnostic and Statistical Manual on Mental Disorders (DSM-5), since it does not meet the current criteria. However, researchers such as Robert T. Carter, Thema Bryant-Davis, and Carlota Ocampo have lobbied for its addition. According to them, racial trauma evokes symptoms similar to that of post-traumatic stress disorder (PTSD), hence the push for its recognition as a viable mental health concern. The effects of race-based traumatic stress on individuals depends on their experiences, and the ways in which it can manifest itself can vary significantly as well. Individuals who are exposed to race-based trauma or stress may experience dissociative symptoms following the event. Dissociative symptoms include depersonalization, in which an individual feels disconnected from their body or mind, and derealization, in which an individual has an unreal or distorted sense of experiences.

Race-based traumatic stress is a traumatic response to stress following a racial encounter. Robert T. Carter’s (2007) theory of race-based traumatic stress implies that there are individuals of color who experience racially charged discrimination as traumatic, and often generate responses similar to post-traumatic stress. Race-based traumatic stress combines theories of stress, trauma, and race-based discrimination to describe a particular response to negative racial encounters.

Despite the limited research that examines race-based traumatic stress specifically, trauma research suggests that an individual’s response to a stressor is highly dependent on that person’s perception of the stressor; what one person may experience as traumatic, another person may not experience as such. These differing responses have been found to be strongly associated with each individual’s ability to cope with the said stressor. According to Carter, a professor at Columbia University, race-based traumatic stress is an individual’s response to racial discrimination as traumatic or outside of their ability to cope. Race-based traumatic stress can be experienced both directly and indirectly and can occur on an interpersonal level, institutional level, or cultural level. As such, research indicates that race-based traumatic stress can be demonstrated as a number of negative outcomes, including psychopathological symptoms, social inequities, and internalized racial oppression.

Research has indicated that children, as well as adults, can experience and be impacted by the reaches of race-based traumatic stress. Through direct experience from peers and/or authority figures, as well as indirectly through media exposure and/or bearing witness to the racial discrimination of their parents, research suggests children of color are particularly vulnerable to race-based traumatic stress.

Poverty and Anxiety

As of 2017, 12.3% of Americans were considered in poverty, according to the official poverty measure.^[6] People who are in poverty have different health risks than those who are not considered in poverty, as well as different outcomes associated with those risks. People who are in poverty grapple with varying outcomes in physical health, mental health, and access to health care. Examining divergences in health between those above and below the poverty line gives insight into conditions for those who live in poverty.

Poverty has a complex relationship with mental health. Being in poverty may itself provoke a condition of elevated emotional stress, known as poverty distress. Poverty is also a precursor or risk factor for mental illness, particularly anxiety or mood disorders. Schizophrenia is also strongly associated with poverty, occurring most frequently in the poorest classes of people all over the world, especially in more unequal countries. In a sort of reciprocating relationship, having a mental illness is also a major risk factor for being in poverty, as having a mental illness may inhibit a person’s ability to work or deter employees from hiring them.

A hypothesis known as the drift hypothesis posits that people with psychiatric disorders (primarily schizophrenia) tend to fall further down the socio-economic ladder as their condition reduces their functionality. The drift hypothesis is an effort to establish that people with profoundly limiting psychiatric symptoms are more likely to descend economically, not that the financially challenged are more likely to present severe psychiatric disorders. People experiencing less severe symptoms are less likely to be affected by “drift.”

The social causation theory is an older theory with more evidence and research behind it. This hypothesis states that one’s socioeconomic status (SES) is the cause of weakening mental functions. As Perry writes in The Journal of Primary Prevention, “members of the lower social classes experience excess psychological stress and relatively few societal rewards, the results of which are manifested in psychological disorder.”^[7] The excess stress that people with low socioeconomic status (SES) experience could be inadequate health care, job insecurity, and poverty, which can bring about many other psycho-social and physical stressors like crowding, discrimination, crime, etc. Thus, lower socioeconomic status (SES) predisposes individuals to the development of a mental illness.

Social risk factors for anxiety include a history of trauma (e.g., physical, sexual or emotional abuse or assault), bullying, early life experiences and parenting factors (e.g., rejection, lack of warmth, high hostility, harsh discipline, high parental negative affect, anxious childrearing, modelling of dysfunctional and drug-abusing behavior, discouragement of emotions, poor socialization, poor attachment, and child abuse and neglect), cultural factors (e.g., stoic families/cultures, persecuted minorities including the disabled), and socioeconomics (e.g., uneducated, unemployed, impoverished although developed countries have higher rates of anxiety disorders than developing countries). A 2019 comprehensive systematic review of over 50 studies showed that food insecurity in the United States is strongly associated with depression, anxiety, and sleep disorders. Food-insecure individuals had an almost threefold risk increase of testing positive for anxiety when compared to food-secure individuals.

Contextual factors that are thought to contribute to anxiety include gender socialization and learning experiences. In particular, learning mastery (the degree to which people perceive their lives to be under their own control) and instrumentality, which includes such traits as self-confidence, self-efficacy, independence, and competitiveness fully mediate the relation between gender and anxiety. That is, though gender differences in anxiety exist, with higher levels of anxiety in women compared to men, gender socialization and learning mastery explain these gender differences.

Our review suggests that the prevalence and expression of social anxiety depend on the particular culture. Asian cultures typically show the lowest rates, whereas Russian and U.S. samples show the highest rates of social anxiety disorder. Taijin kyofusho, a Japanese term for those who are embarrassed about their appearance or bodies or are fearful of displeasing others, is a possible culture-specific expression of social anxiety, although the empirical evidence concerning the validity of this syndrome has been mixed. It is concluded that the individual’s social concerns need to be examined in the context of the person’s cultural, racial, and ethnic background in order to adequately assess the degree and expression of social anxiety and social anxiety disorder.

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