Written by Eva Hamrud
August 3, 2020
26 min read
Topic Review: Anxiety
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INTRODUCTION
In March 2020 toilet paper was flying off the shelves. The uncertainty and fear of the spreading coronavirus spilled into shopping isles – with serious shortages. Researchers have since found people who felt more threatened and anxious about COVID-19 were found to ‘panic buy’ more toilet paper.
Everyone feels anxious or uneasy from time to time. Whether it’s pressure from work, taking a test, heading out to bat in a game or COVID-19. Worrying, jitteriness, sweating, an increased heart rate, rapid breathing can also be symptoms of anxiety. Anxiety is the most common mental health condition in the world – with about 284million people experiencing an anxiety disorder in 2017. It can be caused by an event (like COVID-19) or it can be an underlying trait for individuals.
But what separates normal anxiety from unhealthy levels? Do certain foods help reduce anxiety? How do I know if my anxiety is unhealthy? Are there ways to manage or treat anxiety? What about for children? We asked 30 top mental health researchers around the world to share the facts on Anxiety. Our goal in this review is to help you better understand one big area of mental health and science-backed ways to manage or treat it.
Here’s what we found…
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NUMBERS
Meta-Index
34% Population affected by anxiety disorders at sometime in their lifetime
63% Proportion of those with anxiety disorders that don’t seek treatment
7% Proportion of children aged 3-17 years who have diagnosed anxiety in the USA
284,000,000 Number of people globally who experienced an anxiety disorder in 2017
$44,000,000,000 Annual cost from Anxiety disorders in US alone
6 Number of anxiety disorders: Generalized anxiety, Panic Disorder, Post-traumatic Stress, Social Phobia, Specific Phobia, Obsessive-Compulsive Disorder
7 Average age when phobias tend to begin (height, spiders, planes etc)
50 The age when anxiety tends to ‘disappear’
ORIGIN STORY
Hippocrates and fear of the ‘flute girl’
The word anxiety comes from the latin verb ango – to distress or constrict. In French, Anxiété is described as the psychological and cognitive aspects of worrying. Anguish and worry is common for people to experience when attending social gatherings. Do I fit in? What do these people think of me? What if I do something embarrassing? Going back thousands of years, social anxiety was described in ancient reports.
A man named ‘Nicanor’ was described by Hippocrates as ‘having a fear of the flute girl’ when attending parties in Ancient Greece (400BC). Parties are gatherings that bring out social anxieties and whenever Nicanor heard the voice of the flute begin to play, ‘masses of terrors rose up’ wrote Hippocrates. Although mood disorders were commonly written about, anxiety wasn’t described until 1621, when Robert Burton described the symptoms of anxiety attacks in socially anxious people in his book The Anatomy of Melancholy. Since then a variety of forms of anxiety have been documented, with it being the most common mental health condition in humans.
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EXPLAINER QUESTIONS
What is Anxiety? And is it Genetic?
Anxiety is the brain’s response to stress that generally occurs when events and occurrences do not meet expectations writes Neuroscientist Dr Laura Schrader from Tulane University. “That response depends on an individual’s perception and reaction to that stressor”.
People use different words for anxiety writes Professor Edwin de Beurs, psychologist from the Netherlands. “Nervousness, apprehension, concern, worry, fear, dread, fright, horror, panic, to mention a few which tells us something about the importance of this emotion in our lives, but it is generally viewed as a single basic emotion. Various things may provoke anxiety: one may fear snakes, spiders, social interactions, illness, losing control, experiencing emotions, or one’s own bodily reactions to fear (aka fear of fear)” says Professor de Beurs.
Anxiety disorders, however, are an umbrella term used by doctors when anxiety is common enough to impact day-day activities and life. The 6 most common anxiety disorders are: generalised anxiety disorder, social phobia, specific phobias, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disored and panic disorder.
Uncertainty plays a role in shaping anxiety in our lives writes Dr Sherman Lee, a psychologist from Christopher Newport University. “It is the looming threat of harm (e.g., physical; interpersonal; spiritual; financial) behind the unknown that drives anxiety. Another important component to this is a sense of uncontrollability that makes the uncertainty feel even more threatening and anxiety inducing” he writes.
Is Anxiety Genetic or Environmental?
Both, depending on the type of anxiety. “There is ample evidence to suggest that anxiety has a genetic component in humans” writes Dr Alasdair Mackenzie, geneticist from University of Aberdeen. “This has been backed up by work in animal models where there are strains of mice who are significantly more anxious than other strains. Also, deleting specific genes from the mouse genome, or regions of DNA that control where genes are expressed, has been shown to change the anxiety status of these animals” he writes.
The environment however, also plays a role writes Professor Milena de Barros Viana from the Federal Univeristy of Sao Paulo “Anxiety is both genetically and environmentally determined. Some types of anxiety rely heavier on genetic factors than others (for instance panic relies heavier on environmental factors than generalized anxiety).”
Is fear the same thing as anxiety?
No they are not interchangeable writes psychiatrist Dr Jerome Palazzolo from Université Côte d’Azur in France. “ Even though symptoms typically overlap, a person’s experience with these emotions differs based on their context. Fear relates to a known or understood threat, whereas anxiety follows from an unknown, expected or poorly defined threat. In general, fear is seen as a reaction to a specific, observable danger, while anxiety is seen as a diffuse, a kind of unfocused, objectless, future-oriented fear” he says.
What are phobias?
“Anxiety is a normal and useful emotion” writes Professor Anthony Jorm, psychologist from the University of Melbourne. “It functions to protect us from danger and prepares us for action. For example in the current COVID-19 pandemic, anxiety will help to prevent infection. However, sometimes it is possible to have too much of a good thing” which leads to phobias he writes.
“If anxiety becomes extreme, so that it disrupts a person’s ability to work, study or have social relationships, then it is getting to the point where it may be labelled a ‘phobia’ and some intervention to reduce the level of anxiety might be warranted….A phobic level of anxiety to any danger is where what is usually a useful emotion becomes a hindrance to everyday functioning” writes Professor Jorm.
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THE CONSENSUS
Is anxiety healthy?
86% Affirmative via 7 experts
Read the full answers to this question here. All experts agree that a certain amount of anxiety is not only healthy, but needed for our own survival. “Anxiety is a fundamental emotion experienced by all organisms,” writes Professor Ronald Rapee, psychologist from Macquarie University. “It’s primary purpose is to protect the organism from harm. Therefore, the typical level of anxiety that most people experience is healthy. In fact, it is more than that – it is critical to our survival” he says.
At the evolutionary level, anxiety is important to help us ward off threats. Jordan Davis from Temple University uses a lion as an example “If a lion walks into a room we’re in, we will likely react intensely. We might jump up, run, hide, try to get out of the room. In this example, anxiety helps to protect us. If we just sat in the room, the lion might attack us. Similarly, in daily life, some amount of anxiety helps to protect us and to drive us. If we aren’t nervous for a test, we might not study.”
When does anxiety become unhealthy?
“When anxiety levels become higher than usual and they last longer than usual, it is no longer healthy” writes Professor Ronald Rapee. “In other words, excessive and chronic anxiety can be harmful in two major ways: first, it can affect quality of life and interfere with functioning, and second, long term and very high levels of anxiety can actually begin to affect physical health and have been linked to problems such as heart disease, high blood pressure, and gastrointestinal problems.”
How do I know if I have an anxiety problem?
Most experts suggest that when your anxiety consistently interferes in your daily functioning. In the case of an anxiety disorder, the feeling of fear may be with you all the time. It is intense and sometimes debilitating. This type of anxiety may cause you to stop doing things you enjoy. In extreme cases, it may prevent you from entering an elevator, crossing the street, or even leaving your home. If left untreated, the anxiety will keep getting worse.
Anxiety disorders can be noticed via a few things Professor Ronald Rapee writes:
1) Occurs more often, in more places, and at higher levels than the average person;
2) Is out of proportion to the objective level of danger;
3) Interferes with daily life.
It is the third point that is most critical – anxiety is a mental disorder when it affects functioning and stops someone from doing the things that they want or need in life.”
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THE CONSENSUS
Is anxiety a lifelong condition?
60% Negative via 7 experts
Read the full answers to this question here. Anxiety itself is a very normal experience that is critical for life. Therefore, by definition, anxiety as a normal human experience is lifelong” writes Professor Ronald Rapee, Psychologist from Macquarie University. “We also know that anxiety levels are very much a part of someone’s basic personally – some people simply experience more anxiety than others”. However the question can be viewed in relation to anxiety disorders like phobias or generalized anxiety. Once you get an anxiety disorder, is it permanent?
No. “Anxiety disorders can be successfully treated and people can also “lose” their anxiety disorder through self-help, maturation, changed lifestyles, or simply the passage of time. So an anxiety disorder does not necessarily have to be lifelong” writes Professor Rapee. Some people however are “high anxiety sensitivity” writes Professor Edwin de Beurs who have the tendency to become easily or quickly anxious. This is a rather stable trait he writes and is a risk factor for developing clinical anxiety or an anxiety disorder.
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THE CONSENSUS
Are there effective ways to treat anxiety?
100% Affirmative via 4 experts
Read the full answers to this question here. All experts agree there are a lot of different and highly effective ways to treat anxiety – but there isn’t a one-size fits all approach.
“Yes, there are lots of good treatments” writes psychologist Professor Anthony Jorm from the University of Melbourne. “Medical, psychological, and complementary and lifestyle treatments are available. I have recently worked with colleagues to comprehensively review what works for anxiety disorders and we have written a booklet on this for Beyond Blue [called A guide to what works for Anxiety: An Evidence-based Review]. This booklet looks at every treatment that has ever been evaluated for anxiety disorders— there is a large number of them—and gives a rating to each one for the strength of supporting scientific evidence. The booklet is available for free here”.
Talking with a therapist that includes relaxation training and some form of exposure (facing the feared thoughts, feelings, sensations, places, people, etc.), have been shown in many research studies to be effective for reducing anxiety symptoms writes Dr Julia Strait, psychologist who specializes everyday stress. Beyond seeking a therapist, there are ways to help reduce anxiety if people can better understand the stressors that trigger anxiety in their lives and how to handle them writes writes Neuroscientist Dr Laura Schrader. “Exercise and meditation are common ways to deal with anxiety. Furthermore, if a person is relieved of that stressor (ie retirement from a job), anxiety levels decrease” writes Dr Schrader.
For COVID-19, visiting a doctor may be difficult, but the good news is that online therapies have been shown to be effective to help writes Dr Sherman Lee. “While quarantine and social distancing measures are in place, using a telehealth type of therapy may be the most practical of psychological services to aid those suffering from anxiety during the COVID-19 pandemic. For instance, internet-based cognitive behavior therapy (ICBT) has been shown to work effectively in reducing anxiety and neurotic symptoms”.
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THE CONSENSUS
Is anxiety increasing in prevalence for children and teens?
50% Uncertain via 6 experts
Read the full answers to this question here. Anxiety disorders are the most common psychiatric disorders affecting children and adolescents. The worldwide-pooled prevalence for anxiety disorders among youth is 6.5%. “Although anxiety disorders are common, they are not increasing among children and teens” writes child mental health expert Professor Tracy Vaillancourt from the University of Ottawa.
Other experts suggest there is some data suggesting an increase: “Large datasets and surveys are showing a trend of increased anxiety and mental illness in general in young people over the last decade” writes mental health expert Dr Aliza Werner-Seidler from UNSW Sydney, but “there is still some debate as to whether this is a true trend or due to increased awareness and assessment of anxiety”. Other experts agree.
Anxiety associated with COVID-19 seems to have increased as “There has now been one good study from the UK suggesting that anxiety has increased substantially for young people in the context of the pandemic and lockdown” writes Paediatric mental health expert Professor George Patton from the Royal Children’s Hospital.
Are there effective methods to help parents reduce anxiety in kids?
100% Affirmative via 5 experts
Read the full answers to this question here. We found universal agreement from experts that there are options to help at home and beyond for young people with anxiety. “Definitely,” writes Professor Ronald Rapee. “There are a number of scientifically demonstrated treatments that have been shown to reduce anxiety disorders in young people. These include psychological treatments (most often what is called cognitive behavior therapy – CBT) and medications (most often selective serotonin reuptake inhibitors – SSRI)”.
Parents can be intimately involved in the treatment he says, even over the internet. “Many of the CBT programs include parents and in some cases they are run entirely through the parents (in other words, parents learn to help their own child). More recently, some of the CBT programs are now delivered over the internet. One example of a proven child anxiety program is our own program called, Cool Kids – you can access here”.
Other experts suggest more general ways to help at home by talking with your child and encouraging them to remain actively engaged with friends and activities writes Professor George Patton.
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THE CONSENSUS
Does alcohol help ease anxiety?
50% Uncertain via 4 experts
Read the full answers to this question here. It’s common for people to have a glass of wine after a stressful day at work. Alcohol has a “depressive effect on the brain… so it often feels like anxiety is helped after a few drinks” writes Mental Health geneticist Dr Alasdair Mackenzie. But it’s a temporary “fix” he says and not really a viable treatment for anxiety. Indeed, after the effects of alcohol wear off, not only are many people back to square one, but their feelings of anxiety can often be multiplied by the after effects of excess alcohol intake.
Alcohol is an anxiety trap writes psychologist Professor Anthony Jorm “because high levels of alcohol use are known to increase anxiety. Alcohol can also lead to social and health problems which can increase anxiety. In general, it is better for people who experience high levels of anxiety to avoid using alcohol” he writes.
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THE CONSENSUS
Are there ways to manage anxiety related to COVID-19?
100% Uncertain via 4 experts
Read the full answers to this question here. All experts agree there are ways to help manage anxiety at home. Dr Claudia Finkelstein, Mental Health expert from Michigan State University shares a number of things people can do for themselves:
Keep a healthy routine: Using humor, exercising, eating right, regulating sleep and keeping a routine as best you can will strengthen your body and mind to manage these very real stressors.
Practice ‘self-kindness’: “Research suggests that talking to yourself – the way a friend would talk to you, with accurate and helpful phrases – reduces anxiety”. Say to yourself: “I’ve been through scary and uncertain things in the past and made it through.” Or “These past few weeks and months have been filled with uncertainty, but I’m still surviving.”
Find distance between yourself and your thoughts: When experiencing an anxious thought, notice it, name it, then release it. You don’t need to “buy in” to the thought; instead, stay focused on the present moment.
Don’t read the news too much: Be mindful of the quality and quantity of information you take in. In uncertain times, we try to calm our fears by gathering as much information as we can. Recent research suggest that lower COVID-19 news consumption and healthy lifestyle (e.g., eating a balanced diet; exercise) may lower anxiety.
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QUICK ANSWERS WITH CONSENSUS
Are women more anxious then men? Yes – women are twice as likely as men to develop a mood disorder, including anxiety. These studies suggest women are generally more anxious than men, with higher prevalence rates for anxiety disorders, greater susceptibility to stress, and significant impacts from factors like brain structures, genetics, and hormonal fluctuations.
Is diet linked to anxiety? Yes. Some studies suggest that unhealthy diets are linked to increased anxiety, while other studies indicate that healthy diets may reduce anxiety, though more research is needed to confirm these effects.
Do certain foods (eg salmon or dark chocolate) help lower anxiety? There is no evidence. These studies suggest that certain foods like salmon, dark chocolate, fruits, vegetables, and foods rich in omega-3 fatty acids and dietary fiber may help lower anxiety.
Are grateful people less anxious? Yes. These studies suggest that grateful people are generally less anxious.
Are rich countries more anxious than poor countries? Uncertain. The research indicates that both rich and poor countries experience anxiety, but the sources and nature of this anxiety differ. In rich countries, anxiety may stem from subjective perceptions and historical contexts of wealth and poverty. In contrast, in poorer countries, economic instability and concerns such as inflation are significant contributors to anxiety. Therefore, it is not straightforward to conclude that rich countries are more anxious than poor countries; rather, the nature and sources of anxiety vary between them.
Can anxiety be detected from brain imaging? Sort of. These studies suggest that anxiety can be detected from brain imaging by identifying increased activity and structural/functional alterations in regions such as the amygdala, insula, prefrontal cortex, and limbic areas.
Do Gratitude interventions help lower anxiety? The evidence so far seems to be unlikely. These studies suggest that gratitude interventions can help lower anxiety by reducing negative thinking, stress, and promoting a more compassionate self-relationship, although the effect size may be small.
Is anxiety linked to weight gain? Uncertain. Some studies suggest anxiety is linked to weight gain, while other studies show no significant association or even weight loss in certain populations.
Do hormone levels impact anxiety? Uncertain. Some studies suggest that hormone levels, including testosterone, cortisol, estradiol, estrogen, progesterone, and androstenedione, impact anxiety by influencing serotonin synthesis, sex differences, and vulnerability factors, while other studies indicate that dysregulated sex steroid hormones and genetic factors also play a role in anxiety disorders.
Is anxiety always linked to depression? No, they can be quite different. Some studies suggest anxiety and depression are highly comorbid and bidirectionally linked, while other studies indicate they are distinct emotional states with overlapping but not identical symptoms.
Does exercise help with anxiety? Yes. Some studies suggest exercise significantly reduces anxiety symptoms and is effective as an adjunctive treatment, while other studies indicate its effectiveness is less than that of antidepressants or show no significant effect for aerobic exercise.
TOP ANSWER
It’s time to stop dreading anxiety.
Bethany Teachman: An expert from University of British Columbia in Gastroenterology
Few things motivate escape and avoidance more than the feeling of anxiety, the sense of apprehension and worry that a catastrophic outcome may lie ahead. Sometimes we can name it – tomorrow is the big test, the first online date, a telemedicine check-up by Zoom. Other times, we are unsure of the source of our unease. Of course, few words promote anxiety more than “coronavirus.”
Embracing uncertainty and risk
What we know is we want anxiety to go away, and we’ll do almost anything to get rid of the feeling – avoid studying for the test, cancel the date, skip the check-up. This desire to escape or avoid anxiety is very natural. After all, anxiety is meant to function as an alarm or warning signal to let us know that dangers lurk ahead so we can protect ourselves. It is a tremendously adaptive system and the associated bodily responses do a fantastic job at helping us manage objective dangers. So, if a bear is chasing us in the woods, then an acute fear response with a racing heart and shortness of breath that prepares the body to flee, fight or freeze is just what we want to help escape the danger.
The problem is, many people have come to fear the anxiety response itself; when we routinely have “false alarms” going off, then situations that are not objectively dangerous – but make us feel anxious – come to be feared and avoided. When we become intolerant of uncertainty and risk, and come to fear the experience of anxiety itself, our world becomes smaller. It is true we don’t know for sure how the test, the date, or the check-up will turn out, but rarely is our life better by avoiding or not preparing for these events.
The benefits of some anxiety
As a clinical psychologist, I teach my clients that anxiety is uncomfortable but not dangerous. In fact, moderate levels of anxious arousal can improve our performance, when we think about the arousal in a healthy way – it’s hard to give a good, lively speech when we feel absolutely no arousal, and some anxiety about the coronavirus can remind us to take needed precautions. Even high levels of anxiety are not themselves imminently harmful; a panic attack does not cause a heart attack. Rather, it is the sustained experience of anxiety and stress over time that can contribute to coronary heart disease and other negative health outcomes. And one of the significant risk factors for developing chronic anxiety is fearing the experience of anxiety, termed anxiety sensitivity, and repeatedly avoiding situations that trigger those feelings.
In contrast, when we come to see anxiety as signaling a challenge instead of a threat, our world gets bigger. We try new things, we surprise ourselves with what we can do, and we learn that failing is not actually the end of the world.
Of course, when an objective danger is present, it makes sense to escape that situation, but usually there is no bear chasing us in the woods – we just feel that way. Certainly, it makes sense to minimize risks in ways that don’t interfere with us living a full life; I always wear my seatbelt to reduce risks associated with driving. But what doesn’t make sense is to avoid driving altogether because I might have a car accident one day. There are so many places to see and go.
Don’t stop living, but wear a ‘Coronavirus Seatbelt’
What does this mean for managing our anxiety about the coronavirus? It means we wear the equivalent of a “coronavirus seatbelt” – we do the recommended hand washing, physical distancing, wearing masks in public, and other recommended healthy precautions from reliable sources like the Centers for Disease Control. But we don’t stop living; we get creative about how to meet our goals as much as possible while still physical distancing (virtual dates are an option!) and we don’t make decisions based on panic (you probably don’t need 50 rolls of toilet paper for just your household). Of course, this is a confusing time and it can be hard to know which advice to follow. The key is to ask yourself what factors you want to guide your decisions (e.g., What is the evidence to support the advice? Is it consistent with my values and the person I want to be? How will it affect others?). Anxiety is not a good decision-maker – it’s too inflexible.
Too many people are letting anxiety make decisions for them. Approximately one in four Americans will have an anxiety disorder in their lifetime, and still more experience clinically significant anxiety symptoms that lead them to turn down opportunities and undermine their own potential. Even for those who do not struggle with clinical levels of anxiety, the messages about fear and anxiety in our society are not healthy ones. Long before coronavirus, the repeated message has been that the world is a dangerous place and we are vulnerable. And more than that, we are fragile and can’t handle feelings of anxiety.
The risk of coronavirus infection is objectively dangerous, and we need to take the appropriate steps to mitigate that specific vulnerability, but that shouldn’t generalize to a belief that the world more generally is dangerous or that we are perpetually vulnerable and weak. Managing the insidious consequences of coronavirus, in terms of jobs and lives lost, is going to require all of our strength and resilience, as individuals and communities; this is not the time to overestimate threat and underestimate ourselves.
Anxiety is uncomfortable, but not dangerous
We need to change this narrative and embrace anxiety as the signal that a challenge lies ahead. We can shift the thinking pattern that screams in our heads that the situation portends a threat we cannot manage to a quieter voice that empowers us to handle a challenge and recognize that we can get back up even when something doesn’t go well. It is time to develop a new mantra: Anxiety is uncomfortable, but not dangerous. Anxiety can be tolerated, so we don’t need to escape or avoid situations that make us anxious when no objective danger is present.
We can shift these patterns through cognitive behavior therapy or other evidence-based approaches to treat anxiety or, for those who want to try shifting their anxious thinking on their own, try one of the online approaches. For instance, our lab is testing free, new web-based programs to train less anxious thinking.
Ironically, when we stop dreading anxiety, it’s amazing how much calmer we feel!
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TAKEAWAYS
- Anxiety is a healthy and important human emotion. Anxiety disorders are common and occur when anxiety impacts daily life.
- No evidence that certain foods can help reduce anxiety. Alcohol gives a short reprieve but can increase anxiety in the long-term.
- There are many effective treatments and methods to help anxiety. Even online therapy has been shown to work effectively.
- Evidence suggests anxiety in young people is on the rise due to COVID-19, but many treatments available.
- To help manage anxiety during COVID-19, keep a healthy routine, use humor, exercise, eat a well-balanced diet and get regular sleep. Practice ‘self-kindness’ and find distance between yourself and your thoughts. Finally don’t read the news too much.
If you have read something in this review that raises issues for you, or if you’re concerned about someone you know, call a healthcare professional or mental health organisation that operates in your country.
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