Anxiety

What Causes Anxiety?

Scientists don’t yet fully understand what causes anxiety. The condition’s precise cause likely varies depending on the underlying situation or disorder that triggers it. An individual’s risk for developing anxiety or an anxiety disorder is probably due to a complex interaction of genetic and environmental factors.

Risk factors for anxiety include:

• Exposure to traumatic or stressful situations
• Substance abuse
• Shyness or inhibition in childhood
• Serious physical illness
• Family history of anxiety or other mental illnesses

Is Anxiety Hereditary?

People with a family history of anxiety or associated mental disorders have a higher risk of developing anxiety themselves, suggesting that there is an inherited component to anxiety. However, scientists have not yet identified a single gene that is definitively associated with anxiety or anxiety disorders. Instead, anxiety is likely the result of a coincidence of multiple genetic and environmental factors.

How Is Anxiety Detected?

Anxiety is a normal reaction to the stresses of everyday life, but worsening, potentially debilitating anxiety can cause various behavioral and physical signs. Early warning signs of severe anxiety include:

• Avoidance of formerly pleasurable activities because they trigger anxiety
• Trembling
• Racing heartbeat
• Shortness of breath
• Tightness in the chest

How Is Anxiety Diagnosed?

Diagnosis of an anxiety disorder begins with determining that the patient has a cluster of symptoms that meet the diagnostic criteria for the disorder. A doctor will start with a physical exam to rule out biological problems that may be causing symptoms. This exam may include lab tests.

After these exams, if the doctor suspects that an anxiety disorder is the cause of the symptoms, they may recommend a psychological or psychiatric assessment to solidify the diagnosis further.

Diagnostic steps may include:

• A physical exam. This exam will be aimed at ruling out physical conditions that could be causing the symptoms.
• Blood tests. These tests will look at the patient’s blood chemistry for thyroid function and other potential causes of the symptoms. Screenings for drugs and alcohol may also be conducted to rule out symptoms caused by substance abuse.
• Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.

The results of the psychological assessments will be compared to the diagnostic criteria for anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM criteria for generalized anxiety disorder include:

• The anxiety has occurred on most days for at least six months.
• The anxiety is difficult to control.
• The patient has at least three of the disorder’s symptoms.
• Another mental illness does not explain the symptoms.
• The symptoms cause significant distress or impairment.
• The anxiety is not caused by substance abuse or a medical condition.

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is Anxiety Treated?

A combination of medications and psychotherapy is often used to treat the symptoms of anxiety and anxiety disorders.

Medication

Several different medications may be used to treat and manage anxiety. Individual medication plans depend on the patient’s age, responsiveness to treatments, and the severity of their symptoms.

• Benzodiazepines. These anti-anxiety medications work relatively quickly to control symptoms. However, they may lose their effectiveness over time.
• Buspirone. This medication may be used to treat chronic anxiety, but it is not effective for everyone.
• Selective serotonin reuptake inhibitors (SSRIs). These drugs work by increasing the levels of serotonin, a neurotransmitter chemical in the brain. Common SSRIs include citalopram, escitalopram, fluoxetine, paroxetine, sertraline, and vilazodone.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs). These drugs work similarly to SSRIs in that they increase serotonin levels, but they also increase the level of norepinephrine, another neurotransmitter.
• Beta-blockers. These medications are commonly used to treat high blood pressure, but they may be effective at controlling the physical symptoms of anxiety.

Psychotherapy

A combination of medication and psychotherapy is often the most effective approach to controlling anxiety. The most common therapeutic approach is cognitive behavioral therapy (CBT). This process focuses on helping the patient identify a pattern of harmful thoughts and construct strategies and solutions for dealing with them.

How Does Anxiety Progress?

Left untreated, anxiety can lead to many potentially severe mental and physical complications, including:

• Depression
• Relationship problems
• Problems at school or work
• Financial problems
• Isolation
• Insomnia
• Substance abuse
• Digestive problems

How Is Anxiety Prevented?

There is no known way to prevent the onset of an anxiety disorder, but some self-directed strategies may help control or prevent episodes of anxiety:

• Avoid using alcohol or drugs.
• Stay physically active, and eat a nutritious diet.
• Maintain your social relationships and activities.
• Seek help from a mental health professional.

Anxiety Caregiver Tips

Anxiety has many root causes, and it often exists alongside other mental health and brain-related conditions, a situation called comorbidity. Here are a few of the disorders commonly associated with anxiety:

• Depression and anxiety are among the most common comorbid mental disorders.
• Alcoholism and substance abuse may have anxiety as a symptom, and drug use can make anxiety worse.
• Bipolar disorder is commonly comorbid with anxiety disorders.
• Attention-deficit/hyperactivity disorder (ADHD) is associated with anxiety disorders in about half of adults with ADHD.
• Post-traumatic stress disorder (PTSD) shares many symptoms with other anxiety disorders.
• Bulimia, anorexia, and other eating disorders often have anxiety as a symptom.
• Alzheimer’s disease and other dementias are complicated by anxiety in the majority of cases.
• Strokes may have anxiety as a long-term complication.
• Multiple sclerosis patients have anxiety disorders three times more often than the general population.
• Creutzfeldt-Jakob disease is a degenerative brain disease that can have anxiety as an early symptom.
• Traumatic brain injuries can produce symptoms of anxiety.
• Certain types of epilepsy can have anxiety as a symptom.

Anxiety Brain Science

Scientists believe that anxiety symptoms come from activity in the parts of the brain that control emotions and our reactions to them. These parts of the brain are called, collectively, the limbic system. The limbic system is associated with anxiety in several ways:

• The amygdala, the part of the brain responsible for detecting threats, may be hyperactive and may misidentify causes for fear or worry when none exist.
• An overactive amygdala may persistently cause the hypothalamus to trigger the hormonal response that produces the physical symptoms of anxiety.
• Communication between the amygdala and the prefrontal cortex (PFC) may be impaired. The PFC is responsible for triggering a rational response to threats, and it may not be able to do so when it is unable to communicate with the amygdala effectively.
• The hippocampus, the part of the brain responsible for processing long-term memory, may be underdeveloped or dysfunctional in the case of anxiety. As a result, it may have a preference for retaining stress-related memories rather than more rational memories.

Anxiety Research

Title: Pharmacogenetically-guided Escitalopram Treatment for Pediatric Anxiety: Aiming to Improve Safety and Efficacy (PrEcISE) (PrEcISE)

Stage: Recruiting

Principal investigator: Jeffrey R. Strawn, MD

University of Cincinnati

Cincinnati, OH 

This randomized, controlled trial compares pharmacogenetically-guided and standard dosing of escitalopram in adolescents (12-17 years of age) with anxiety disorders. In this study, the investigators will examine these two dosing strategies in terms of efficacy (Aim 1) and tolerability (Aim 2).

The investigators propose to recruit 132 adolescents (age 12-17 years, inclusive) with generalized, separation, and/or social anxiety disorder (pediatric anxiety trial).1 This will allow investigators to evaluate whether pharmacogenetically-guided escitalopram dosing improves efficacy and tolerability in outpatient adolescents aged 12-17 years with anxiety disorders. Eligible patients will be randomized to (1) standard escitalopram dosing or (2) pharmacogenetically-guided dosing for 12 weeks.

Title: A Pragmatic Trial of Brief CBT for Anxiety in VA Primary Care

Stage: Not yet recruiting

Principal investigator: Terri L. Fletcher, PhD

Michael E. DeBakey VA Medical Center

Houston, TX 

This 4-year, multi-site trial (Houston, New Orleans, and San Antonio) will use a pragmatic randomized trial design to examine the effectiveness, and implementation potential of a brief cognitive behavioral therapy(bCBT) intervention for anxiety delivered either in-person or via VA Video Connect-Home (VVC-H), according to patient preference. Brief CBT will be delivered by existing Primary Care Mental Health Integration (PCMHI) providers at three large VAMCs (Houston, New Orleans, and San Antonio). Aim 1 will examine the clinical effectiveness of the bCBT intervention vs. Enhanced Usual Care (EUC) for anxiety at 4-, 8-, and 12-month follow-ups. Aim 2 will determine factors associated with bCBT response and explore Veteran demographic and clinical factors associated with VVC-H engagement. An exploratory aim will use mixed, qualitative, and quantitative methods to understand better implementation successes and challenges related to delivery and impact of bCBT anxiety and VVC-H use in the PCMHI setting. The primary hypothesis is that anxiety outcomes, as measured by the General Anxiety Disorder 7-item scale (GAD-7), will be superior at 4-, 8-, and 12-month follow-up for patients assigned to receive bCBT vs. EUC.

Title: Exercise for Anxiety

Stage: Recruiting

Principal investigator: Kristin Szuhany, PhD

NYU Langone Health

New York, NY

Ninety sedentary adults with a primary anxiety disorder and high anxiety sensitivity will be randomized to either eight weeks of 1) low-intensity exercise or 2) flexible titration to high-intensity exercise (HIE). Blinded, validated clinician-rated and patient-rated outcomes will be assessed over treatment and at 1- and 3-month follow-up. To better understand what mechanisms influence decisions to exercise in the real world, we will use heart rate (HR) as an objective mechanistic target for exercise intensity, examine changes in the valuation of exercise through a neuroeconomics task, examine changes in interoceptive sensitivity with a heartbeat detection task, and integrate of ecological momentary assessment (EMA) to measure effects of immediate changes in mood with exercise on anxiety outcomes and adherence.