Anxiety
Anxiety is a state of apprehension or unease, usually about something uncertain that has not yet happened, accompanied by physical symptoms such as a racing heart, muscle tension, sweating, or a churning stomach. As an abnormal emotional reaction it is the ordinary, universally recognisable feeling of anxiety taken to an excessive or disproportionate degree, whether in intensity, duration, or how readily it is triggered.
Anxiety has traditionally been distinguished from fear by its object: fear is directed at something specific and identifiable, while anxiety is a more diffuse apprehension that may have no single clear focus, though in everyday clinical use the two terms are often used loosely and interchangeably.
Recognition features
- A subjective feeling of apprehension, dread, or unease, often about something uncertain or anticipated rather than a specific present danger
- Accompanied by physical (autonomic) symptoms: tachycardia, sweating, tremor, dry mouth, muscle tension, gastrointestinal discomfort
- May be free-floating (not attached to any particular object) or focused on a specific worry
- Present out of proportion to any real threat, or persisting well beyond the situation that provoked it
Eliciting it at interview
- Ask directly: "Do you find yourself feeling anxious or on edge? How often, and how bad does it get?"
- Screen systematically for the physical accompaniments of anxiety, since patients sometimes report only the somatic symptoms and not the emotional label
- Ask whether the anxiety is attached to anything specific or feels more constant and free-floating, and how it compares with the person's usual baseline
Distinguishing features
- Differs from a phobia, in which the anxiety is specifically and consistently triggered by a particular object or situation, and can be avoided by avoiding that trigger
- Differs from a panic attack, which is a discrete, time-limited episode of intense anxiety with a rapid onset, rather than a more sustained state
- Differs from anxious foreboding, which is anxiety specifically focused on the sense that something bad is about to happen, often without a clear object
Common misconceptions
- That anxiety always has an obvious external trigger; free-floating anxiety with no clear focus is a recognised and common pattern
- That anxiety is purely psychological; its physical, autonomic symptoms are often what brings a person to a doctor in the first place
Related phenomena
Abnormal Emotional Reaction · Panic Attack · Phobia · Anxious Foreboding · Morbid Anxiety · Distractibility
Practice this
A patient describes weeks of persistent apprehension and unease, not tied to any particular object or situation, accompanied by a racing heart, muscle tension, and a churning stomach that come and go but never fully settle. What is this? · A patient describes sudden episodes, several times a week, in which within a couple of minutes her heart pounds, she feels she cannot breathe, and she is gripped by a fear that she is about to die — each episode passing within about twenty minutes, after which she feels essentially back to normal until the next one. Before revealing the answer: is this simply anxiety? · A patient describes apprehension along with physical symptoms such as a racing heart and sweating. Before revealing the answer, decide what distinguishes anxiety from a panic attack. · A patient reports feeling anxious much of the time. Before revealing the answer, decide what distinguishes morbid anxiety from anxiety as an ordinary emotional reaction. · A patient describes a fear response. Before revealing the answer, decide what distinguishes a phobia from generalised anxiety. · A patient reports feeling on edge much of the time. Before revealing the answer, decide how you would explore this. · Explain why anxiety is described as an abnormal emotional reaction only when it is out of proportion to, or persists beyond, whatever provoked it, rather than simply by its presence.
Illustration
In the days leading up to a routine performance review at work, a 29-year-old woman notices her heart pounding, her palms sweating, and a persistent knot in her stomach that does not ease even when she reminds herself the review is unlikely to go badly, and the feeling lingers well past the meeting itself.
References
- Casey, P. & Kelly, B. (2019). Fish's Clinical Psychopathology, 4th ed. Ch. 6, 'Disorders of Emotion'.