Anxiety
Anxiety is the mind and body’s anticipatory response to uncertainty, perceived threat, or lack of control — marked by a persistent sense of unease, tension, and hypervigilance that becomes disconnected from immediate danger. It is the suffering of what might happen, not what is happening — a looping internal narrative that magnifies doubt, catastrophizes possibility, and hijacks presence.
“Anxiety is like a smoke alarm that keeps going off — even when there’s no fire.”
Signs and Symptoms of Anxiety.
Two syndromic clusters often arise in the context of an event that produces anxiety symptoms, roughly organized into the activities of the two main branches of the peripheral nervous system (sympathetic and parasympathetic):
(1) The sympathetic overdrive symptoms (PANICS):
Palpitations
Abdominal pain
Nausea and altered gastrointestinal motility (e.g., constipation, diarrhea)
Intense fear (of death or losing control, among other things)
Chest tightness and difficulty breathing
Sweating
(2) The parasympathetic underdrive or adrenal axis symptoms (MISERAble):
Muscle tension
Irritability
Sleep impaired
Energy decreased
Restlessness
Attention impaired
Oftentimes these two symptom clusters overlap and a mix of symptoms is present.
Screening and Evaluation.
First and foremost, anxiety should be differentiated from other potentially appropriate descriptors like fear, stress, excitement or mania, and hypervigilance:
Fear: A response to a known, immediate threat.
Stress: Tied to specific demands or pressures, often external.
Excitement: Similar physiology, but excitement feels energizing and positive. This should be further differentiated from mania.
Hypervigilance: This may occur in trauma, often with anxiety, but not always.
A common acronym to help differentiate anxiety experiences is ONSTAGE. This includes the following:
Obsessive-Compulsive Disorders: Includes obsessions and/or compulsions and includes disorders such as obsessive-compulsive disorder, hoarding disorder, and body dysmorphic disorder, among others.
Normal life changes: Anxiety may naturally occur during life adjustments. It’s important to note that life adjustments can sometimes lead to significant changes in the body, leading to a state of anxiety.
Somatoform: These are conditions where anxiety carries the theme of physical symptom presence and concern. These conditions include pain disorder, somatization disorder, conversion disorder, and illness anxiety disorder, among others.
Trauma: Anxiety symptoms occur in the setting of trauma, which may be an underlying psychological cause of anxiety. Please see my trauma blog for further details.
Attributable: Attributable anxiety conditions include a particular theme. For instance, social anxiety disorder carries the theme of social triggering, and specific phobias stem from particular things that induce an anxiety response. Anxiety can also be attributable to depression, executive impairment or ADHD, psychotic illness, and personality disorders.
Generalized: When anxiety stems from several sources not explained by the above categories, as occurs with generalized anxiety disorder.
Episodic: When anxiety and stress occur in distinct episodes not explained by the above categories and take on the form of panic attacks as seen in panic disorder. When anxiety is episodic, it should be differentiated from mania.
The use of screening tools depends on what “content” is associated with the syndromal features. So the appropriate screening tool depends on whether the condition looks like generalized anxiety disorder (GAD-7), panic disorder, obsessive-compulsive disorder (Y-BOCS), bipolar disorder (RMS/MDQ), PTSD (PCL-5), etc.
Just looking at DSM criteria for anxiety disorders, there are over 1,000 unique combinations of symptoms. 60-80% (600-800) of these symptom combinations that can be used to diagnose DSM-based anxiety disorders also occur in other conditions. Therefore, the majority of the “symptoms” used to describe anxiety do not uniquely point to an anxiety disorder.
Causes and Contributing Factors.
As with other psychiatric conditions, anxiety is multifaceted and includes several potential causes and contributing factors. Integrative (Holistic) Psychiatry goes beyond the conventional approach to explore this.
Psychological/Neurological Factors. Anxiety is experienced as changes in the way threats are perceived. This threat perception system involves an interplay of (1) the threat detection system, (2) subcortical activation, (3) autonomic nervous system activation, (4) cortico-striato-thalamo-cortical (CSTC) loop, and (5) the hypothalamic-pituitary-adrenal (HPA) axis.
Threat detection system. utilizes the senses (sight, see, smell, feel, taste) and the brain’s capacity to monitor the internal environment (interoception) and external environment (neuroception) for threat.
Subcortical Activation. Lower brain regions are then activated, including the amygdala and associated network projections. This system can overwhelm the capacity of the executive brain (prefrontal cortex) to manage the threat.
Autonomic Nervous System. The sympathetic (fight-flight) and parasympathetic (connect, immobilize, freeze) systems activate to mobilize energy in the body to neutralize the threat. The first thing that happens is an activation of the ventral vagal complex (part of the parasympathetic nervous system) to connect and attach to others to neutralize the threat. If significantly overwhelmed or if a safe other is not recognized quickly, then the sympathetic nervous system is activated. The sympathetic nervous system prepares us to fight or flee. If the threat is not quickly neutralized by this system, then the most primitive system is activated (the dorsal vagal complex of the parasympathetic nervous system). In response to threats, this system will induce freezing, numbing, and submitting.
Cortico-striato-thalamo-cortical (CSTC) Loop. This system carries the stressor beyond the actual stressful encounter when activated. This is the “worry” or “obsession” loop. Often, here, you’ll experience generalized avoidance or repetitive behaviors (e.g., compulsions) aimed at neutralizing the threat.
These changes may be set in motion by underlying trauma. Underlying disconnection leads to fragmentation of the system with diverse patterns of symptom expression that looks like different forms of anxiety. See the blog on Trauma for more information.
Biological Factors. Several biological factors related to body systems can contribute to and cause anxiety symptoms.
Hypothalamic-pituitary-adrenal Axis. This system also carries the stressor beyond the actual stressful encounter. This system releases a stress hormone (cortisol) that aims to mobilize energy in a chronically “activated” body. Think of it as an ongoing energy manager who tries to keep the energy going when there is a persistent threat. This system, while helpful to a degree, can cause damage to the amygdalae (making them chronically hyperactive, making them overly responsive to events), hippocampus (shrinkage, impairing memory), and prefrontal cortex (disconnection, impairing the executive functioning of the brain, i.e., planning, organizing, prioritizing, focusing, etc.).
Hypothalamic-Pituitary-Gonadal Axis. Certain estrogen metabolites interact with anxiogenic (anxiety-producing) estrogen receptors in the body. The clearance of these metabolites is contingent upon healthy detoxification. These metabolites and detoxification processes can be evaluated. Progesterone (in healthy concentrations) tends to combat this anxiogenic response from estrogen metabolites. Testosterone imbalances can contribute to anxiety in addition to irritability and agitation.
Gut-Brain Axis. There is a strong relationship between the activities of the gut and anxiety symptoms. Oftentimes, those who experience gut symptoms (nausea, cramping, diarrhea, constipation) that coincide with anxiety and stress symptoms have unaddressed abnormalities in the gut, such as bacterial or fungal overgrowth or impaired intestinal permeability. This is often diagnosed as “irritable bowel syndrome” in the conventional setting. Correcting these abnormalities tends to improve not only the gut symptoms but also the anxiety symptoms.
Hypothalamic-Pituitary-Thyroid Axis. The brain is very sensitive to the activities of thyroid hormone. When elevated, even in small quantities (often referred to as “subclinical”), these changes can contribute to anxiety symptoms.
Immune-Brain Axis. Immune dysregulation and even low-grade inflammation influence the metabolism of neurotransmitters (namely, serotonin), contributing to anxiety.
Micronutrients. Deficiencies in B complex, iron, magnesium, zinc, and vitamin D contribute to anxiety. These are crucial cofactors for neurotransmission, neurogenesis, and neuroplasticity.
Epigenetic. Underlying genetic abnormalities, especially in methylation, can contribute to anxiety. A common abnormality is in catechol-o-methyltransferase, which is strongly implicated in anxiety/stress resilience.
Lifestyle/Environmental Factors. Several lifestyle activities and environmental factors contribute to anxiety symptoms and actually structure themselves around the anxiety experience.
Anxiety Related to Routine. Anxiety that relates to social settings, relationships, work, and illness, among other things, commonly stems from underlying trauma.
Nutrition. Impaired metabolic activity and related imbalances in carbohydrate, fat, and protein concentrations all influence anxiety symptoms. A common culprit is high sugar intake. The variability among high and low blood sugar levels contributes to anxiety.
Exercise. A sedentary lifestyle or lack of exercise incorporation contributes to anxiety. In addition to nurturing a pro-inflammatory environment, it also causes deconditioning. In the context of deconditioning, internal cues can be misinterpreted by the threat detection system of the brain as a threat.
Sleep. Impaired sleep quantity and quality create a circadian imbalance, which would normally regulate the activity of neurotransmitters that maintain energetic balance. These fluctuations put the system at risk for experiencing anxiety symptoms.
Substance Use. What goes up must come down. What goes down must come up. The use of stimulating substances such as caffeine, cocaine, and methamphetamine, among others, can contribute to anxiety symptoms. Withdrawal from downers such as opioids and benzodiazepines, among others, can contribute to anxiety symptoms as well.
The Integrative Psychiatry Approach to Anxiety.
In the treatment of anxiety, a combination of treatments is likely to yield positive results, and this combination depends on the individual’s experience.
Medications.
Medications. Medications may help to bring balance to anxiety symptoms. This is best done in the context of further investigation to get to the underlying causes and contributing factors that perpetuate anxiety in the first place. Some common options include:
Selective-serotonin reuptake inhibitors (SSRIs) e.g., citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), etc.
Serotonin-norepinephrine reuptake inhibitors (SNRIs) e.g., venlafaxine (Effexor), desvenlafaxine (Pristiq), duloxetine (Cymbalta).
Tricyclic Antidepressants (TCAs) and adjunctive agents (e.g., buspirone)
“As Needed” Medications: Propranolol, hydroxyzine, clonidine, benzodiazepines
Nutraceuticals. Several nutraceutical options will help with anxiety. The most appropriate nutraceutical option(s) depends on your specific experiences but may include 5HTP, ashwagandha, Lavender oil capsules, L-theanine, inositol, and Saint John’s Wort, among others. A focused exploration into the impact of the hypothalamic-pituitary-adrenal (HPA) axis may indicate a need for a regimen to calm the stress response.
The Body. Targeting biological derangements with adrenal support, hormone support, gut evaluation and treatment, thyroid supplementation, immune support, B12/folate supplementation, iron, magnesium, zinc, and vitamin D can reduce anxiety symptoms. A multi-ingredient formula (MIF) such as EmPower+ or Daily Essential Nutrients may also be beneficial. These considerations are typically based on comprehensive evaluation and tailored to the individual.
Lifestyle. Several lifestyle modifications can help improve depressive symptoms:
Habits: Reducing and eliminating substance use and other addictions. Although easier said than done, this often involves multimodal treatment and exploration of root causes.
Sleep: Stabilization of sleep routines and patterns (e.g., reducing blue light exposure from screens 4 hours before bed, avoiding stimulating activity before bed, etc.) with a goal of 6-7 hours per night (sometimes medication or nutraceutical options are helpful here).
Exercise: Moderate-intensity exercise (e.g., walking) with a goal of 3-4 times per week has the best evidence for improving anxiety and stress. Interestingly, exercise works as a form of “exposure” therapy for anxiety by way of training your brain to monitor physical symptoms and neutralize the associated threat perception. It’s recommended to start with something you enjoy and build upon a routine and habit from there.
Nutrition: Dietary adjustments such as sugar reduction (<10% added sugar in products) and a goal of a Mediterranean diet with healthy fats and high fiber have been shown to improve anxiety symptoms.
Therapy. A goal of therapy is to establish a sense of safety (e.g., rewiring the networking of the brain regions described above) while exploring the alarm system (identifying areas where we can adjust the alarm to go off at appropriate times), and developing strategies to respond to the alarm (e.g., techniques and tools to keep the system calm while the alarm is investigated). This involves depth work to explore the nature of triggers and heal deeper-rooted issues.
Common therapy modalities used in the treatment of anxiety include cognitive-behavioral therapy (CBT), dialectical behavioral therapy (DBT), positive psychotherapy (PPT), and solution-focused or problem-solving therapy (SFT/PST), among others. Depth work may include Internal Family Systems (IFS), Compassionate Inquiry (CI), and Eye-Movement Desensitization and Reprocessing (EMDR), among others.
One overarching principle is that you can’t experience anxiety and stress in a relaxed body. If I were to recommend one thing to start with, I would encourage actively checking your body multiple times throughout the day (e.g., via scanning head-to-toe) and noticing where you are tensing muscle groups. As you notice, these tensed muscle groups actively release this tension. When I say multiple times a day, I mean 20, 30, or 60 times a day for a few weeks. The more you do this, the more reflexive this will become. You cannot experience stress and anxiety in a relaxed body. Set reminders in some way to cue you to relax muscle groups. Where there’s tension, pay attention.
Our clinicians can help you navigate these options safely and effectively to determine the best course of action for you.
