What is anxiety?

What is Anxiety?

Anxiety is a psychological state characterized by excessive fear, worry, or apprehension about perceived threats that is persistent, disproportionate to actual danger, and causes significant distress or functional impairment in daily life. 1

Core Psychological Features

Anxiety manifests as a clinically significant disturbance in cognition, emotion regulation, or behavior that reflects dysfunction in psychological, biological, or developmental processes underlying mental functioning. 1 The cardinal features include:

• Excessive, uncontrollable worry about multiple everyday situations or specific triggers that persists most days for at least 6 months 1, 2
• Fear responses that are disproportionate to the real dangers posed by the situation and its sociocultural context 1
• Anticipatory anxiety about future threats or negative outcomes, distinguishing it from acute fear responses 1
• Worry- or fear-laden thought content with perseverative or ruminative thinking patterns 2

Physical Manifestations

Anxiety produces distinct somatic symptoms that reflect autonomic nervous system hyperactivity: 3

• Cardiovascular symptoms: palpitations, accelerated heart rate, chest pain or discomfort 3
• Respiratory symptoms: shortness of breath, smothering sensations, feeling of choking 3
• Neurological symptoms: trembling, shaking, dizziness, lightheadedness, paresthesias (numbness or tingling) 3
• Gastrointestinal symptoms: nausea, diarrhea, abdominal distress, dry mouth 3
• Other autonomic symptoms: sweating, cold clammy hands, flushes or chills, frequent urination 3
• Muscle tension: aches, soreness, restlessness, easy fatigability 3

Behavioral Components

The behavioral dimension of anxiety centers on avoidance and safety-seeking behaviors: 1

• Active avoidance of feared situations or objects, or enduring them with intense fear or distress 1
• Vigilance and scanning behaviors: feeling keyed up or on edge, exaggerated startle response, difficulty concentrating 3
• Functional impairment: interference with normal routine, occupational or academic functioning, social activities, or relationships 1

Distinguishing Clinical Anxiety from Normal Worry

Clinically significant anxiety must be distinguished from everyday worries and fears, which are common to human experience and even normative at specific developmental stages. 1 The key differentiators include:

• Duration: symptoms typically lasting 6 months or more (versus transient worries) 1
• Controllability: inability to stop or control the worry despite efforts 2
• Functional impact: causes clinically meaningful distress or impairment in social, occupational, or other important areas 1
• Proportionality: fear or anxiety is excessive relative to actual threat 1

Neurobiological Basis

Anxiety disorders involve dysfunction in brain circuits that respond to danger, with risk influenced by genetic factors (30-50% heritability), environmental factors, and their epigenetic interactions. 4, 5 This includes:

• Autonomic hyperreactivity with exaggerated physiological stress responses 4
• Behavioral inhibition patterns characterized by temperamental fearfulness 4
• Negative affectivity or tendency toward negative emotional states 4

Common Pitfalls in Recognition

Clinicians must avoid several diagnostic errors: 6

• Dismissing symptoms as "normal" stress or shyness rather than recognizing pathological anxiety 6
• Missing medical mimics: hyperthyroidism, hypoglycemia, cardiac arrhythmias, asthma, caffeine excess, and medication side effects can all trigger or mimic anxiety 4
• Overlooking substance-induced anxiety: alcohol/drug withdrawal, stimulant use, and certain medications produce anxiety symptoms 4
• Failing to assess comorbidities: 56% of patients with major depression have comorbid anxiety, and anxiety frequently co-occurs with other psychiatric conditions 4

Clinical Significance

Anxiety disorders are the most prevalent mental health conditions with a lifetime prevalence of approximately 34% in the US, often starting before or in early adulthood. 5, 7 They are associated with:

• Chronic course: often persisting for years without treatment 5
• Significant burden: marked distress, functional impairment, and reduced quality of life 5, 7
• High comorbidity: frequently co-occurring with depression, other anxiety disorders, and somatic conditions 5
• Increased suicide risk: particularly when comorbid with depression 4